1. This work was undertaken in the Clinical Effectiveness Unit, Stockport NHS FT Funded by the Greater Manchester Supra District Audit Committee

2. How the audit came about Incline in rickets The inconsistent Vitamin D advice The many vitamin D projects across the North West Audit Objectives Results Survey Audit Results Case Note Audit Results

3. Method Step1; Provider Services Audit: sent to each PCT and Hospital Trust to answer questions on policies and personnel. Step 2; Case Note Audit: Health Visiting and Midwifery heads were asked to cascade a proforma on practice and knowledge to all health visitors and midwives Objectives Establish training needs of healthcare professionals to deliver advice on vitamin D Reduce the percentage of Vitamin D deficient prenatal and postnatal women in the Northwest Encourage and facilitate PCTs in providing free Vitamin D supplies to all pregnant women. Promote examples of good practice through local and regional lead networks

4. Hospital Trust Stockport FT Central Manchester FT North Manchester General Royal Oldham Hospital Heywood Middleton and Rochdale Fairfield General Hospital Liverpool women's Hospital

6. Enquire to whether women at greatest risk are following advice to take Vitamin D supplements. These include: women of South Asian, African, Caribbean or Middle Eastern family origin Evidence of vitamin D discussion with the client? EthnicityFALSETRUEGrand Total Bangladeshi5 5 British1914195 Chinese22 Far Eastern 11 Indian33 Irish11 Middle Eastern77 N.African66 Pakistani15217 S. European22 South East Asian11 Sub Sahara10212 W European11 Grand Total2449253

7. NICE: All women should be informed at the booking appointment (ideally by 10 weeks) about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. Evidence of vitamin D discussion with the client? FALSETRUEGrand Total Total25810268

8. NICE; Check if women at greatest risk are following advice to take Vitamin D supplements. These include: women with a pre-pregnancy body mass index above 30 kg/m2 Did the client receive literature? Pre-pregnancy BMI above 30 kg/m2FALSETRUEGrand Total TRUE362864 Evidence of vitamin D discussion with the client? Pre-pregnancy BMI above 30 kg/m2FALSETRUEGrand Total TRUE62264

9. NICE; Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care Did the client receive literature? FALSETRUEGrand Total Total162106268 Types of literature referencing vitamin D; Pregnancy book In house Leaflet Healthy Start Leaflet Other

10. 0 10 20 30 40 50 60 CMFTFFLWNMGRIROSFTWT TRUE FALSE Count of ID Hospital Trust Did the client receive literature?

11. Primary Care Trust NHS East Lancashire NHS Liverpool Community Health NHS Ashton Wigan and Leigh NHS Manchester

12. Enquire to whether women at greatest risk are following advice to take Vitamin D supplements. These include: women of South Asian, African, Caribbean or Middle Eastern family origin

13. Evidence of vitamin D discussion with the client? FALSETRUEGrand Total Total number of clients187111298 Overall discussing the implications of low Vitamin D and the importance of vitamin D supplementation was poor amongst all trusts Discussions of Vitamin D and healthy Start were low in 16-20 year old. Highest group to be informed about vitamin D were the above 35’s,

14. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CMELLPWN TRUE FALSE Count of ID PCT Evidence of vitamin D discussion with the client?

15. 1 1 TRUE 297142 155 FALSE Does the client have Coeliac disease 3 3 TRUE 295142 153 FALSE Does the client have family history of bone deformity 2 2 TRUE 296111 185 FALSE Grand Total FALSE TRUE Does the client have history of bone disorders Evidence of vitamin D discussion 2Does the client have history of bone disorders 1Does the client have Coeliac disease 0Does the client have Crohn's disease / hepatic or renal disease 3Does the client have family history of bone deformity Total

16. Did the client receive literature? %Total FALSE52 TRUE48 Clients with an associated medical condition did not receive any Vitamin D literature Audit results show literature informing women of vitamin D was distributed to 88% of women in East Lancashire The Birth to Five book was the most distributed source of literature

17. Percentage of clients who received literature 44.6% 5.7% 31.9% 31.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Referred to Birth to Five book? Referred to an in house leaflet? Referred to a Health Start Leaflet Referred to other literature Type of literature given to client

18. An assessment of the risk factors associated indicating vitamin D deficiency to be introduced Health professional are trained to advise to deliver verbal and written advice on vitamin D to pregnant/breast feeding women We suggest the training is incorporate this within an existing training session OR a stand alone session Introduce the Healthy Start Scheme to all clients Recording and auditing the uptake of vitamin D supplements by pregnant/breast feeding women is essential, we recommend Vitamin D discussions are recorded in notes

19. Central Manchester Foundation Trust Liverpool Women's Hospital Pennine Acute Trust Stockport Foundation Trust Wirral Trust NHS East Lancashire NHS Central Manchester NHS Liverpool NHS Heywood Middleton and Rochdale NHS Ashton Wigan and Leigh NHS Wirral We hope to reaudit next year If you would like to join the audit, please sign the participation form situated on your table.