1. Measuring and Improving Vitamin D Promotion and Prescribing to Prenatal and Postnatal Women within the North West. Part 1: The Provider Services Audit Sept – Nov 2010 This work was undertaken in the Clinical Effectiveness Unit, Stockport NHS FT Funded by the Greater Manchester Supra District Audit Committee Sophie Jagatia Deborah Lee Charlotte Haynes

2. Aims Provider services audit was developed to gain an insight into:  Current local vitamin D policies in place  Current practice of midwives and health visitors regarding discussing/supplementing vitamin D  Training needs of midwives and health visitors

3. Methods: Participants Acute Trusts:  Central Manchester University Hospitals NHS FT  Liverpool Women’s NHS FT  Pennine Acute Hospitals  Stockport NHS FT  Wirral University Teaching Hospital NHS FT  East Lancashire Hospitals NHS FT (staff survey only)  Royal Bolton Hospitals NHS FT (staff survey only) Primary Care Trusts:  Liverpool Community Health NHS Trust  NHS East Lancashire  NHS Ashton, Leigh and Wigan  NHS Heywood, Middleton and Rochdale  NHS Manchester  NHS Wirral

4. Methods: Data collection Provider Services Trust Proforma One proforma sent to lead contacts at each Trust Establish current vitamin D practice and policy in place (e.g. local guidelines, training programmes, in- house leaflet, Healthy Start) Staff Survey Online/paper based survey sent to all midwives and health visitors at participating Trusts Establish current knowledge, practice and training needs relating to vitamin D supplementation with pre/postnatal women.

5. Findings: Provider Services Trust Proforma  Only 1 Acute Trust and 1 PCT reported a vitamin D policy in place  1 Acute Trust and 3 PCTs reported having vitamin D representative/coordinator/team in place.  3 Acute Trusts and 3 PCTs reported having incorporated vitamin D into training policies.  Majority of Trusts reported providing midwives/health visitors with some information on vitamin D

6. Findings: Staff survey Response rate:  Total of 178 health visitors and 206 midwives across the 6 PCTs and 8 Acute Trusts participated in the survey.  Gives an overall response rate of 44% health visitors 14% midwives

7. Findings: Staff Survey Knowledge:  1/3 of MWs and HVs identified correct RDA of vitamin D  Approx 75% of MW’s and HV’s aware of vitamin D’s role in the absorption of calcium, but only 18% for phosphorous  60% HVs and 46% MWs able to list 3 or more vitamin D rich food sources – oily fish most common  22% HVs and 12% MWs incorrectly identified green vegetables as source  >60% of MWs and HVs able to identify 3 or more risk factors/symptoms of vitamin D deficiency

8. Findings: Staff Survey Most commonly identified risk factors/symptoms of vitamin D deficiency

9. Findings: Staff Survey Vitamin D training and practice:  47% of HVs and 22% of MWs reported discussing vitamin D with ‘all’ or ‘most’ clients.  A lack of knowledge was the most reported reason for not discussing vitamin D with clients.  42% of HVs and 29% of MWs reported being ‘very confident’ or ‘confident’ in discussing vitamin D  24% of HVs and 11% of MWs reported having received training in vitamin D  Approx 80% of HVs and MWs thought it would be ‘useful’ or ‘very useful’ to have further training in vitamin D.

10. Findings: Staff Survey Reasons for not discussing vitamin D amongst midwives and health visitors who reported not discussing vitamin D with ‘all’ clients

11. Findings: Staff Survey Healthy Start  76% of HVs and 37% of MWs reported discussing Healthy Start with ‘all’ or ‘most’ clients  33% of midwives reported not discussing Healthy Start with any clients.  Most frequently reported reason for not discussing HS: HVs: clients not eligible to receive Healthy Start (67%) MWs: not seen as part of their role (37%)  57% of HVs and 21% of midwives reported having a list of Healthy Start distributors to refer clients to.  81% of HVs and 39% of midwives reported feeling confident directing clients to a Healthy Start distribution point.

12. Findings: Staff Survey Reasons for not discussing Healthy Start amongst midwives and health visitors who reported not discussing Healthy Start with ‘all’ clients.

13. Summary of Findings  Policies, practice and personnel are lacking amongst majority of Trusts  There is a lack of knowledge amongst both MWs and HVs about the importance and facts surrounding vitamin D.  Confidence in discussing vitamin D is low  Few MWs and HVs reported having been trained in vitamin D supplementation  However, where policies were in place, MWs and HVs appeared more knowledgeable and confident, and practice was markedly different to those Trusts yet to tackle the issue.  Limitations: Small sample of MWs took part in survey Lack of response to online survey lead to paper copy having to be distributed Some Trusts may have implemented policies since this work was carried out.

14. Recommendations  All Trusts should start the process of developing a vitamin D policy relating to pre/postnatal women  All MWs and HVs need to be educated through appropriate training session regarding the importance and practices for supplementation for pre/postnatal women  All Trusts should ensure they have info and up-to-date distribution lists for Healthy Start vitamins  Those Trusts with a vitamin D policy in place/training packages should share their documentation/resources with other Trusts.