Maternal and child health – a national and international perspective Dr Hora Soltani Health & Social Care Research Centre Sheffield Hallam University

What factors influence Maternal & Child Health (MCH): –Local & National –Global Current concerns & priorities in MCH from a national and global perspective Effective MCH promotion strategies – group activity –The role of health professionals in support of MCH –The role of communities –National and International Initiatives

Health promotion and preventive strategies/services to improve the health of mothers, infants, children and adolescents in order to maintain/enhance the health of families and communities as a whole. It is multidisciplinary. Objectives: –reduce maternal, neonatal and child mortality & morbidity –the promotion of the physical and psychosocial health and well-being of mothers and children/families in: reproductive health the maternity cycle (preconception, pregnancy & birth, PP) nutrition infection

UK specific

Changing Childbirth (1993) National Service Framework (NSF) 2004: for Children, Young People & Maternity Services Healthcare Commission Maternity Matters 2007 NICE guidance Centre for Maternal and Child Enquiries (CEMACE) [formerly CEMACH] –Maternal and Perinatal Health: National Maternal & Perinatal Mortality Surveillance Maternal Death Enquiry Obesity in Pregnancy Intrapartum Care Diabetes in Pregnancy Child death review [Jan-Dec 2006] (28 Children days-18yrs) (n=150) Head injury

Between the HCC investigated complaints about poor maternity care at Northwick Park Hospital in North London, New Cross Hospital in Wolverhampton and Ashford and St Peter’s NHS Trust in Surrey (HCC report 2006). 10 Maternal Deaths between ; Causes: 4 cases of Ecclampsia, 4 cases of Post Partum Haemorrhage, 2 post C/S - Cardiac Arrest & Liver Rupture Attributed to: Failure to recognise when progress in labour deviates from the expected, normal course of events. Delays in seeking medical advice. Lack of clear management plans for women whose pregnancies are classified as high-risk. Low staff numbers, high numbers of agency staff/locums and the impact on the safety of patients. Equipment failure, or a lack of equipment or facilities (baths & showers). Failure to record blood results in the clinical case notes. Commissioned a survey of maternity services (2007)

Woman-centred care: She must feel and be in control of what happens to her. She must be able to make informed decisions about her care, based on her own needs. She must have input into service planning and design (service user involvement). Maternity services should be based in the community, sensitive to the needs of the local population and easily accessed by that population. Women should have a choice of primary carer (NHS midwife, independent MW or Doctor) and place of birth (home, birth centre, hospital). There should be continuity of care and of the carer – a named midwife (team of midwives), a named obstetrician (if required).

NICE – Antenatal Care (ANC) guideline: a reduced no. of antenatal visits. Confidential Enquiries into maternal death (saving mothers’ lives) 2007 or CEMACE. –Maternal death (14/100,000) is a rare event. –More than half of women who died were overweight or obese. –Health inequalities: women from poor backgrounds were 7 times more likely to die than those from other demographic backgrounds. –A reduction in death from maternal suicide/mental health. Infant feeding survey (2005): 76% initiation but a dramatic reduction at 6 weeks and 6 months.

17% of the women who died booked for maternity care after 22 weeks or had missed over four antenatal visits VS 5% of women who were self-employed or had a partner in employment. Late ANC booking A third of all women who died were either single and unemployed or in a relationship where both partners were unemployed. Of the 360 existing children whose mothers died, 112 were already in the care of social services. Unemployment/Single Parents – Lack of (family) support Black African women, including asylum seekers and newly arrived refugees, have a mortality rate nearly six times higher than White women. To a lesser extent, Black Caribbean and Middle Eastern women also had a significantly higher mortality rate. Ethnicity In England, women who lived in the most deprived areas were five times more likely to die than women living in the least deprived areas. Deprivation

Of the women who died from any cause: 4% self-declared that they were subject to domestic abuse. Domestic Abuse 11% had problems with substance abuse, 60% of whom were registered addicts. Substance abuse 10% lived in families known to the child protection services. Vulnerable groups/Social deprivation

1/3 of all stillbirths and neonatal deaths were born to mothers in the most deprived quintile (compared with the expected 20%). Stillbirth and neonatal mortality rates for mothers resident in the most deprived areas were 1.7 times > than those in the least deprived area. Deprivation Compared with women of White ethnicity, ethnic- specific mortality rates showed significantly higher stillbirth, perinatal and neonatal death rates for women of Black ethnicity (2.4, 2.4 and 2.2. times higher, respectively) and Asian ethnicity (2.0, 1.9 and 1.8 times higher, respectively). Ethnicity CEMACH aims to further explore these differences by developing further analysis of specific causes of deaths by ethnic group.

Babies born to women from VG had a higher risk of: Mortality Morbidity Premature labour Intrauterine growth restriction Low Birth Weight Higher rates of neonatal complications Lower breastfeeding rates

Inter-disciplinary work A lack of cross-disciplinary or cross-agency working. Communication There was poor communication, particularly the risk of self-harm and child safety, between the health and social services, and there was an assumption by social services that their pregnant clients were receiving maternity care. Language Barrier Language barriers and unfamiliarity with the NHS, concerns about confidentiality, and a lack of provision of services to meet the individual needs of these women.

Social Disadvantag e Delayed Pregnancy Obesity Suboptimal Care UK Mortality Incidence: The mortality rate for maternal deaths from Indirect causes of death was 7.71 per 100,000 maternities. The mortality rate for maternal deaths from Direct causes of death was 6.24 per 100,000 maternities.

Midwifery-led versus other models of care – Cochrane review (11 trials: 12,276 women) – Women who were randomised to MLC were: Less likely to experience: - antenatal hospitalisation - the use of regional analgesia - Episiotomy and instrumental delivery - intra-partum analgesia/anaesthesia - fetal loss (<24wks) More likely to experience: - vaginal birth - a feeling of control during labour and childbirth - breastfeeding initiation - shorter baby hospitalisation Overall, there was no increased likelihood for any adverse outcome for women or their infants associated with having been randomised to MLC.

Pre-conception care: (Opportunistic and planned) for women of childbearing age with pre-existing serious medical or mental health conditions that may be aggravated by pregnancy. Migrant women who have not previously had a full medical examination in the UK should have a medical history taken and a clinical assessment should be made of their overall health, including a cardio-vascular examination at booking or as soon as possible thereafter by an appropriately trained doctor. Women with genital mutilation should be sensitively asked about this during their pregnancy and management plans for delivery should be agreed upon during the antenatal period. Accessible and welcoming ANC – full booking from 1 to 12 weeks gestation. Midwifery care should be offered to all women without complications.

International Perspectives

Maternal mortality ratios range widely, from an estimated 12 maternal deaths per 100,000 live births in North America to more than 700 per 100,000 in some parts of sub-Saharan Africa. For the developing world as a whole, maternal mortality is estimated at more than 400 deaths per 100,000 live births, while the ratio is below 30 per 100,000 in the developed world. One woman dies every minute (515,000/year). Global maternal mortality:

99% of maternal deaths occur in developing countries. Maternal mortality is the largest disparity between the developed and developing worlds. Pregnancy or birth complications are the leading cause of maternal disability and death (15-49 yrs old) in developing countries – 20 times more than Maternal Death (MD) for an average woman in Developed Countries (CDs). The huge implications for the child, family and community (e.g. care- giving, psychosocial and economic cost).

neonatal deaths (up to 1m perinatal (PN)) and stillborn babies/year, mainly due to: –Infection –Asphyxia –Prematurity and its complications –40-80% associated with Low Birth Weight (LBW) Almost all in developing countries. The mother and child’s health are inter-linked. Challenges – Interventions?

Investment Political commitment (war-peace) Establishing reliable audit systems Skilled birth attendants/Traditional Birth Attendants Empowering communities: support networks Facilitate access to care, prevent delayed referrals Nutritional interventions (Vit A supplementation has reduced MD by 40% by reducing infection) Emphasis on women’s health rather than just FP Care continuum

Improve mothers’ health, targeting women of childbearing age as early as possible. Support education and provide skilled attendance at birth. Improve health and nutrition, prevent infection. Keep babies warm after birth. Encourage (long-term) breastfeeding. Women and Children first available from

*Lawn JE, Tinker A, Munjanja SP, Cousens S. Where is maternal and child health now? Lancet, 2006; 368(9546): Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwifery-led versus other models of care delivery for childbearing women. Cochrane Database of Systematic Reviews, 2008 Lewis G. The Confidential Enquiry into maternal and child health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer UK, 2007 D'Souza L, Garcia J. Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal Mortality 2006: England, Wales and Northern Ireland. CEMACH: London, 2008 D'Souza L, Garcia J. Improving services for disadvantaged childbearing women. Child: Care, Health & Development 2004; 30: Maternity Matters. nce/DH_ Maternal Mortality. Centre for Maternal and Child Enquiries (CEMACE). Improving the health of mothers, babies and children.

Why psychosocial aspects are important An analysis of contributing psychosocial factors at the different stages: –(Pre-)conception –Deciding on parenthood –Antenatal –Intrapartum, birth & postpartum Professionals’ impact The psychosocial preparation for birth Conclusion

Pregnancy and birth are social as well as biological events. Pregnancy is a complex psychosocial event. Motivations for reproduction: – Genetic immortality. – Achieving true adulthood. – A desire to emulate parental care. – To actively explore a new object/source of love. – Cultural transmission: individual and societal goals intertwine to pass on knowledge, skills, etc., so cultures develop a means to promote this. – Not only as survival but (in some cultures) children constitute wealth.

Long-term commitment with irreversible effects. Contraception adds to the dilemma of choice and parenthood – it’s no longer possible to “leave it to fate.” Modern life –competing professional ambitions –social and economic responsibilities on women impacting on women’s inner desire “to be like mummy” Wanting to be pregnant: is it the same as wanting children?

Positive prenatal attachment: trust in the outcome; falling in love, chatting or daydreaming about the baby as well as imagining a particular infant: the child of her dreams. Neutral: a conscious effort to have no “feeling” or an expectation of fear of something going wrong (more common in cases of a previous baby loss) – protecting the self or family. Negative: it’s normal at times but some women are preoccupied with largely negative feelings.

Sometimes when I’m exhausted my baby seems so horrible, like a monster: vicious, greedy and bad. I end up like a monster myself, furious with my husband and with the pregnancy, just wanting to smash everything up, get rid of it all and force everyone out of my way. But I also feel desperate, like a screaming baby inside. What does all that do to the fetus? How will I bear its crying when it’s born, not to mention looking after it too? How will I cope without ever wanting to exterminate the baby the way I feel my mother would have liked to get rid of me?

There is evidence to suggest Fetus is sensitive and reactive Aware of maternal reactions and affected by: –Temperature –Pressure –Sound and light –The mother's respiratory and vascular systems i.e. There is a great responsibility for Professionals in dealing with women to protect them from unnecessary impingements during investigations.

Professionals appear to be the key holders. They should know that the “mother’s eagerness to know” is a sign of health (responsibility) rather than idle curiosity.

Profound psychological and physical changes occur during pregnancy. Respect the normality of alterations (e.g. anxiety, worry, mood changes, impaired concentration, regressive shifts and increased dependence). Be vigilant for increased psycho-socio-economic stressors: a study in south London 1 st ANC found: –35% negative GHQ (general health Q) –29% psychiatric “cases” – largely neurotic depression

Housing & financial difficulties Unemployment Poor social support Poor marital relationship Triggering hidden vulnerable areas in women who appear healthy – obtainable through looking at the AN/booking history Key steps Timely identification Referral Individual or group interventions

Test interpretation – the communication of results. Ultrasound scanning – the “Truth Test”: reliance on professionals. Controversial evidence should be rescanned: this is normal, informative, reassuring and popular but increases anxiety. There should be a balanced use of technology – rescanning should be kept to a minimum with detailed feedback. Amniocentesis: anxiety over –Awaiting Results –Fetal injury –Miscarriage –What to do if the fetus is abnormal… Mother Professional Scanning screen

Emotional preparation: talking to other women, reading about labour, discussing her fears with her friends, mother, etc. (Some) unconsciously work through their anxieties in repetitive dreams. Daydreaming about the ideal birth: the accompanying person, the type of birth, monitoring, the birth place. Preparation for disappointing realities rather than focusing solely on ideal situations.

1.Psychoprophylactic (distraction): –Introduced to the West by Dr Ferdinand LaMaze (from the Pavlovian method from Russia). –Distraction from contractions and conscious control in the 2 nd stage of labour (patterned breathing). –Other methods include: Singing songs Envisaging a relaxing pastoral scene

2.The body harmony range –By Dr Grantly Dick-Read (1940) (the father of natural childbirth?) The fear-tension-pain syndrome (a self-perpetuating syndrome). The ability to overcome fear, tension and pain by a better understanding of the labour process and deep breathing and relaxation. –Jacobson’s progressive relaxation –Sheila Kitzinger’s approach : Physical and psychical education to “foster a woman’s delight in the rhythmic harmony of her body’s functioning, and training to maintain her conscious & active participation, the power of self-direction.” –Active birth: a combination of the above with changes in position (kneeling, squatting or sitting), the use of gravity.

Maternal responsibility phases (assumptions): –Taking in: preoccupied with her own needs (2-3 days) –Taking hold: tries to be in control, eager to learn but this coincides with the “blues” – appropriate support –Letting go: accepting the baby’s separation (10 days) Blues (50%-75%): a transitory syndrome of weepiness – it coincides with rapid physiological & hormonal changes, incoming milk. Encourage the woman to make a bridge between her pregnant self and the mother-to-be to establish a new emotional identity; early bonding helps.

Keeping in mind the importance of maternal psycho- social well-being, the following skills/qualities are essential for health professionals: Effective communication (verbal and non-verbal), eye contact, gestures Appropriate questioning/sensitivity Listening skills Counselling abilities –Empathy –Acceptance –Genuineness

Raphael-Leff J. Psychological processes of childbearing. London: Chapman & Hall,1991 Raphael-Leff J. Pregnancy – The inside story. London: Karnac Ltd., 2003 DH: National Service Framework for Children, Young People and Maternity Services – Executive Summary, [Online] Available from: pics/ChildrenServices/fs/en pics/ChildrenServices/fs/en More references in your module guidebook