Memorandum submitted by BLISS (H&SC 23)
10 January 2008
1. BLISS, the premature baby charity, is dedicated to making sure that more babies born prematurely or sick in the UK survive and that each one has the best quality of life. BLISS aims to realise this by supporting parents and families, promoting new developments and innovations in care and campaigning for improvements in neonatal care.
2. BLISS has been the leading charity working for sick and premature babies for over twenty eight years. A major part of our work is the provision of support to parents and carers such as a telephone helpline, publications on specific issues when caring for sick and premature babies, online information and a website message board.
3. In addition to our board of trustees, our work is informed and monitored by a Nursing Advisory Panel, a Medical Advisory Panel and a Parent Advisory Panel.
4. We are submitting this evidence with regards to the Health in Pregnancy Grant in Part 4 of the Health and Social Care Bill. BLISS welcomes this measure as it vitally important that women eat healthily in order to promote the growth of their child, or to help them produce milk if they have already given birth, and this grant will help to ease the financial burden that many parents experience.
5. We are delighted that the Government has decided to make the Health in Pregnancy Grant available earlier in pregnancy, from the 25th week instead of the 29th week, as was announced in September 2007. It is extremely important that women who give birth before their baby has reached 29 weeks gestation do not lose out on this valuable additional income.
6. However, BLISS is concerned that the grant does not appear to take any consideration for women with a multiple pregnancy.
7. Compared to singleton pregnancies, multiple birth pregnancies have additional nutritional requirements and consequently there are additional costs to achieving healthy weight gain. To ensure this is addressed, BLISS propose that the grant be paid per expectant child rather than per pregnancy as this will help to ensure multiple birth babies have the greatest chance of survival. This amendment will ensure the Bill more closely resembles the eligibility criteria of the Sure Start Maternity Grant and the Healthy Start scheme which are also paid per expectant child rather than per pregnancy.
8. Improving access to information from health professionals, and increasing awareness of the added importance of good nutrition in multiple birth pregnancies among professionals also needs to be addressed. Although these pregnancies are high risk, the interim results of a recent survey of multiple birth mothers by Tamba (Twins and Multiple Births Association) found that only 9% were given advice on nutrition in multiple birth pregnancies. Of the 103 mothers whose babies required 'special care', less than five per cent were given this advice.
9. The requirement on expectant mothers (Part 4, section 121) to receive "advice on matters relating to maternal health from a health professional" in order to become eligible for this grant provides an excellent opportunity to ensure mothers and health professionals are better informed of the importance of good nutrition during pregnancy. We would welcome further clarification from the Government on how they intend to use this opportunity to improve awareness of the added importance of nutrition in multiple birth pregnancies.
Multiple birth pregnancies
10. In the UK, about one in every 67 pregnancies results in a multiple birth. This equates to just over 10,000 births a year (10,533 in 2005). It is widely acknowledged that multiple births are relatively high risk pregnancies and this is usually due to multiples being born prematurely or under weight. The average length of singleton pregnancies is 40 weeks and the average birth weight is 3.5kg. This compares to twin pregnancies which average 37 weeks and triplets which average 34 weeks and their average birth weights are 2.5kg and 1.8kg respectively.
11. Multiple births have a stillbirth rate over three times that of singleton births and a neonatal mortality rate nearly seven times that of singleton births.
12. There is a clear link between multiple pregnancy and preterm birth. Despite representing less than two per cent of all births, half of twins and almost all higher order multiples are born before 37 weeks.
13. In a study of a developed country in which 25 per cent of women smoke during pregnancy and a substantial minority are non-white, multiple birth is the second largest identifiable aetiological determinant for preterm birth. In the same study, low gestational weight gain (partially, but not exclusively, reflecting low energy intake) was identified to have a clear link to intrauterine growth restriction.
Nutrition and weight gain in multiple birth pregnancies
14. A singleton pregnancy requires weight gain of around 0.25kg per week, for an eventual total of about 13kg, while mothers of twins need to gain more, usually at least 18kg, acquired at the rate of at least 0.5kg a week.
15. The American Dietetic Association suggested that for twin pregnancy an extra 500 kcal should be added to the dietary reference values for non-pregnant women, as soon as the multiple pregnancy is detected. According to Professor Simon Langley-Evans, "It is generally accepted that a multiple pregnancy increases energy requirements, but the level of requirement has not been defined. Rosello-Soberon and colleagues suggested that the extra energy requirement for the whole of a twin pregnancy was 35,000 kcal, which works out at around 150kcal/day on top of the requirement for singleton pregnancy. The key element is achieving a healthy maternal weight gain."
16. The Health in Pregnancy Grant represents a genuine opportunity to improve outcomes for all babies. However if the grant is calculated per expectant child, for the reasons outlined above, there is a good chance the consequent improved dietary intake of mothers with multiple pregnancies will lead to reduced cases of intrauterine growth retardation, preterm birth, babies born with low birth weight, stillbirth and infant mortality.
17. According to the American Society for Reproductive Medicine, "The total cost of raising multiples is likely higher than the cost of raising the same number of singletons." Often families do not already have children and therefore cannot benefit from reusing existing resources. Although the Sure Start Maternity Grant and the Healthy Start scheme recognize the additional costs of raising a multiple birth family, Child Benefit and Child Tax Credit do not. As a result, multiple birth families receive an estimated £50 million less per annum from the Government towards the cost of living than other families and we are concerned that without amendment the Health and Social Care Bill 2007 will exacerbate this inequality.
 Tamba multiple birth families' survey, January 2008. Respondents were asked, "Were you given specific advice on your nutrition for a multiple pregnancy? 8.9% Yes, 91.1% No" (NB. Sample size 213 on 3 Jan 2008).
 HFEA Press release "HFEA calls for national strategy to reduce the biggest risk of fertility treatment - Multiple births" 4 December 2007.
 ONS, 2005.
 Confidential Enquiry into Maternal and Child Health. Stillbirth, Neonatal and Post-neonatal Mortality 2000-2003, England, Wales and Northern Ireland. London:RCOG Press; 2005.
 Joseph KS, Kramer MS, Marcoux S, Ohlsson A, Wen SW, Allen A, et al. Determinants of secular trends in preterm birth in Canada. New England Journal of Medecine 1998; 339:1434-1439.
 'Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly?' MS Kramer et al. Paediatric and Perinatal Epidemiology 2000, 14, 194-210.
 Email message between Professor Simon Langley-Evans, Chair in Human Nutrition in the School of Biosciences at the University of Nottingham and Keith Reed, CEO of Tamba, on 3 December 2007.