Maternal and child health pathfinder project
Life course stage / Pre-pregnancyIndicator / Time to pregnancy
Background / Time to pregnancy can be used as an indicator of reproductive effects following an exposure.
Evidence for interventions
Interventions in place
Surveillance (Wales) / Not routinely measured, information can only be obtained by survey.
Surveillance (Health Board) / Not routinely measured, information can only be obtained by survey.
Surveillance (Maternity Unit) / Not routinely measured, information can only be obtained by survey.
Maternal and child health pathfinder project
Life course stage / 1st trimesterIndicator / Teenage pregnancy
Background / It is important to note that for many teenagers, pregnancy is a positive life choice; however, for many it is unplanned and can be associated with negative health outcomes for both mother and baby (Welsh Assembly Government 2008b).
Some of the associated risks to maternal and child health from teenage pregnancy are shown in the list below (Department of Health 2010, Welsh Assembly Government 2008).
Teenage pregnancy and the associated risks to maternal outcomes
- 60% higher Infant Mortality Rate compared to older mothers
- Increased risk of low birth weight babies
- Increased risk of post natal depression and other mental health issues
- Less likely to complete their education
- Increased risk of unemployment or being in low paid employment
- Poor housing conditions.
- Increased hospital admissions in childhood
- Generally poorer health
- Poor housing conditions
- Lower educational attainment
- Lower rates of economic activity in adult life
- Twice as likely to be teenage parents themselves.
Evidence for interventions / Reducing the rate of teenage pregnancy – HDA Evidence Briefing Summary: Teenage pregnancy and parenthood 2003
Good (strong evidence containedin category 1 or 2 reviews) evidence wasfound for the effectiveness of thefollowing interventions aimed at
preventing unintended teenagepregnancies:
• School-based sex education,particularly linked to contraceptive
services (measured againstknowledge, attitudes, delaying sexual
activity and/or reducing pregnancyrates)
• Community based (eg family or youthcentres) education, development and
contraceptive services
• Youth development programmes:although the evidence base for thiswas small, reviews indicate thatprogrammes focusing on personaldevelopment (programmes thatsupport and teach confidence, selfesteem,negotiation skills), educationand vocational development mayincrease contraceptive use and reducepregnancy rates
• Family outreach: some good evidencewas found for the effectiveness ofincluding teenagers’ parents ininformation and preventionprogrammes.
Some good (category 1 or 2) review levelevidence was also found for thefollowing characteristics of effectiveservices and interventions:
• Focusing on improving contraceptiveuse and at least one other behaviourlikely to prevent pregnancy and/or STItransmission
• Long-term services and interventions,tailored to meet local needs of youngwomen and young men, with clearand unambiguous information andmessages
• Focusing on local high risk groups
• Including interpersonal skillsdevelopment – such as negotiatingand refusal skills – in programmes,and allowing young people topractise these skills
• Taking key opportunities – eg if anadolescent uses a clinic service andreceives a negative pregnancy test –for education and information
• Basing interventions and programmeson theory-driven approaches, withclear behavioural goals andoutcomes, and using participatory,inclusive teaching methods
• Checking that interventions andservices are accessible to youngpeople – in terms of location,opening hours and so on
• Selecting and training staff who arecommitted to programme and servicegoals and to the needs of youngpeople, who will respect theconfidentiality of young people where
Possible
• Making sure that information andeducation is in place before youngpeople become sexually active
• Working with teenage ‘opinionleaders’ and peer group influences
• Making sure that interventions areage appropriate
• Encouraging a local culture in whichdiscussion of sex, sexuality andcontraception is permitted
• Joining up services and interventionsaimed at preventing pregnancy withother services for young people, andworking in partnership with localCommunities.
Improving outcomes for teenage parents:
• Good antenatal care can improvehealth outcomes for mother and
child, and are cost effective (category1 evidence)
• Home visiting, parental andpsychological support can improvehealth and welfare outcomes formother and child (category 1), andmay prevent or delay repeatpregnancies (category 3 evidence).
However, home visiting is not a singleor uniform intervention, it is amechanism for the delivery of avariety of interventions directed atdifferent outcomes. Further work will
need to be undertaken about what ismeant by home visiting in a UK
context
• Improving housing for young parentsand their children will increase healthoutcomes (category 3 evidence)
• Support for young parents tocontinue education will improveeducational and employmentoutcomes for parents, mother/childinteraction, and social outcomes for
children. Early educationalinterventions for disadvantagedchildren can improve long-termoutcomes (category 3 evidence)
• Clinic-based healthcare programmesfor teenage mothers and theirchildren can improve their healthoutcomes (category 3 evidence).
NICE: Prevention of STI’s & under 18 conceptions (2007)
Commissioners should:
Ensure that sexual health services, includingcontraceptive and abortion services, are in place tomeet local needs. All services should includearrangements for the notification, testing, treatmentand follow-up of partners of people who have an STI
(partner notification).
• Define the role and responsibility of each servicein relation to partner notification (includingreferral pathways).
• Ensure staff are trained.
• Ensure there is an audit and monitoring frameworkin place.
Midwives and HV’s should:
• Regularly visit vulnerable women aged under 18 whoare pregnant or who are already mothers.
• Discuss with them and their partner (where appropriate)how to prevent or get tested for STIs and how toprevent unwanted pregnancies. The discussionshould cover:
– all methods of reversible contraception, includingLARC (in line with NICE clinical guideline 30), andhow to get and use emergency contraception
– health promotion advice, in line with NICE guidanceon postnatal care (NICE clinical guideline 37)
– opportunities for returning to education, trainingand employment in the future.
• Provide supporting information in an appropriateformat.
• Where appropriate, refer the young woman to therelevant agencies, including services concerned withreintegration into education and work.
Interventions in place
Surveillance (Wales) / ONS: Number of conceptions (live births, stillbirths, terminations of pregnancy) in under 18s, number of women under 18 in population, rate of conceptions in under 18s, under 16s
Surveillance (Health Board) / ONS: Number of conceptions (live births, stillbirths, terminations of pregnancy) in under 18s, number of women under 18 in population, rate of conceptions in under 18s, under 16s
Surveillance (Maternity Unit) / Number and proportion of women booking each month under 18 and (? under 16)
References:
Department of Health 2010. Teenage pregnancy strategy: Beyond 2010. Department of Health: London. Available at [accessed 08.07.10]
Welsh Assembly Government 2008. Children and young people’s well-being monitor for Wales. Welsh Assembly Government: Cardiff. Available at [accessed 27.07.10]
Maternal and child health pathfinder project
Life course stage / 1st trimesterIndicator / Alcohol
Background / There is evidence that alcohol can adversely affect the outcome of a pregnancy in a number of ways (Royal College of Obstetrics & Gynaecology 2006):
- Miscarriage
- Aneuploidy (chromosomal abnormality)
- Structural congenital anomaly
- Disordered fetal growth
- Perinatal death
- Developmental delay
- Susceptibility to disease for infant in later life.
Evidence for interventions / Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. Cochrane Database of Systematic Reviews 2009
The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women
Brief alcohol intervention to prevent drinking during pregnancy: an overview of research findings. Current Opinion in Obstetrics & Gynecology. 21(6):496-500, December 2009
Brief intervention has emerged as a promising approach to provide early intervention, before or soon after the onset of alcohol-related problems. There is convincing evidence for the efficacy and effectiveness of brief intervention in various healthcare settings. The findings from four randomized brief intervention trials that have been conducted with pregnant women are consistent with the broader literature on brief intervention. The interventions were effective in reducing alcohol consumption, but control group participants also reduced their consumption to the degree that statistically significant differences between the groups were difficult to detect
Interventions in place
Surveillance (Wales) / Profile of alcohol and health in Wales 2009
Infant feeding survey (every 5 years)
Hand held maternity record
Surveillance (Health Board) / Hand held maternity record
Surveillance (Maternity Unit) / Hand held maternity record
References:
Gartner A, Cosh H, Gibbon R, Lester N. 2009. A profile of alcohol and health in Wales. Cardiff: Wales Centre for Health. Available at
[accessed 15.07.10]
Royal College of Obstetrics and Gynaecology (RCOG) 2006. Alcohol consumption and the outcomes of pregnancy. RCOG statement no. 5. RCOG: London 2006. Available at [accessed 29.07.10]
Maternal and child health pathfinder project
Life course stage / 1st trimesterIndicator / Maternal obesity
Background / Obesity in pregnancy has been recognised as a significant risk factor for both the mother and the child. The Confidential Enquiry into Maternal and Child Health (CEMACH) state that “The magnitude of risk means that obesity represents one of the greatest and growing overall threats to the childbearing population of the UK” (Centre for Maternal and Child Enquiries 2007). The 2007 CEMACH report ‘Saving mothers lives’ found that thromboembolism was the commonest cause of direct maternal death and cardiac disease the commonest cause of indirect maternal death. Overweight and obesity are known risk factors for developing these (Centre for Maternal and Child Enquiries 2007).
Maternal risks related to obesity in pregnancy include:
- Maternal death or severe morbidity
- Cardiac disease
- Miscarriage
- Pre-eclampsia
- Gestational diabetes
- Thromboembolism
- Increased risk of Caesarean Section
- Infection post Caesarean Section
- Anaesthetic challenges
- Infection from other causes/sites
- Post partum haemorrhage
- Stillbirth
- Neonatal death
- Congenital abnormalities
- Prematurity - overweight and obese women have higher risks of preterm birth before 32 weeks and induced preterm birth before 37 weeks. The relative risk of premature birth was found to increase as maternal weight increased (McDonald et al 2010)
- Macrosomia
- Lower breastfeeding rates
- Increased risk of obesity and metabolic disorders in childhood
Increased rates of obesity in pregnancy are reflected in increased social and financial costs: (Galtier-Dereure et al 2000)
- On average obese women spend 4.43 more days in hospital;
- Antenatal care costs are increased five fold due to the increased levels of complications obese women experience during pregnancy and labour;
- Babies born to obese mothers are at increased risk (3.5 fold increase) of requiring admission to Neonatal Intensive Care Unit (NICU).
Evidence for interventions / NICE - Weight management before, during and after pregnancy (2010)
CMACE – Maternal Obesity in the UK (2010)
Recommendations:
- Preconception counselling and support, both opportunistic and planned, should be provided for women of childbearing age with a BMI ≥30.
- Women with a BMI ≥30 wishing to become pregnant should be advised to take 5mg folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy.
- Women with obesity should receive routine antenatal care supplemented by specialist services and facilities that are specific to their needs. Specialist midwives, senior anaesthetic expertise and a review by a senior team in the antenatal clinic may be required.
- All pregnant women should have their weight and height measured using appropriate equipment, and they should have their body mass index (BMI) calculated accurately at the antenatal booking visit.
- All pregnant women with a booking BMI ≥30 should be provided with accurate and accessible information about the risks associated with obesity in pregnancy and how these risks may be minimised.
- Women with obesity have an increased risk of gestational diabetes mellitus, pre-eclampsia and fetal abnormalities, and they should have surveillance and screening according to existing guidance.
- Pregnant women with a booking BMI ≥40 should have an antenatal anaesthetic consultation with an obstetric anaesthetist. An anaesthetic consultation should allow potential difficulties with venous access, regional or general anaesthesia to be identified and anticipated.
- Health professionals must be aware that women are at risk of thromboembolism from the very beginning of pregnancy, and that this risk increases significantly for women with obesity. At booking, a full risk and needs assessment must be undertaken and documented clearly in the maternity notes. Women with a BMI ≥30 should be assessed throughout pregnancy for the risk of thromboembolism.
- Women with a BMI ≥35 should give birth in a consultant-led obstetric unit with appropriate neonatal services, so that immediate intervention is available in the event of intrapartum and postpartum complications and emergencies.
- Links with existing public health services for effective weight management should be made at local levels, and pathways for referral into these services incorporated into local maternity guidelines for preconception, antenatal and postnatal care.
- Further research is needed in a number of areas.
Interventions in place / Betsi Cadwaladr University Health Board: Task & finish group established to develop obesity in pregnancy clinical pathway (pathway about to be ratified by CPG Board – includes all recommendations from latest CMACE report, Lead midwife identified, Pregnancy pathway linked to wider HB work on WAG obesity pathway.
Surveillance (Wales) / Welsh Study of Mothers and Babies
RadIS obstetric reporting module
Hand held maternity record
Surveillance (Health Board) / RadIS obstetric reporting module
Hand held maternity record
Surveillance (Maternity Unit) / RadIS obstetric reporting module
Hand held maternity record
References:
Centre for Maternal and Child Enquiries (CMACE) 2007. Confidential enquiry into maternal and child health: Saving mothers lives reviewing maternal deaths to make motherhood safer 2003-2005. The seventh report of confidential enquires into maternal deaths in the United Kingdom. CMACE: London. Available at [accessed 27.07.10]
Centre for Maternal and Child Enquires / Royal College of Obstetrics and Gynaecology (CMACE/RCOG) 2010. CMACE/RCOG joint guideline: Management of women with Obesity in pregnancy. CMACE: London. Available at [accessed 29.07.10]
Galtier-Dereure F. Boegner C. Bring J, 2000. Obesity and pregnancy: complication and cost. American Journal of Clinical Nutrition Vol 71, No 5, 12425-1248.
Maternal and child health pathfinder project
Life course stage / 1st trimesterIndicator / Infection
Background / Hepatitis B, hepatitis C, HIV, group B streptococcal infection and TORCH infections can lead to adverse pregnancy outcomes or neonatal morbidity and mortality.
Hepatitis B:10-20% of women seropositive for HBsAg transmit the virus to their neonates in the absence of immunoprophylaxis. In women who are seropositive for both HBsAg and HBeAg vertical transmission is approximately 90% (American College of Obstetricians and Gynecologists 2007). In patients with acute hepatitis B vertical transmission occurs in up to 10% of neonates when infection occurs in the first trimester and in 80 -90% of neonates when acute infection occurs in the third trimester (American College of Obstetricians and Gynecologists 2007). Chronic infection occurs in about 90% of infected infants (Centers for Disease Control and Prevention 2006). HBV infection does not appear to be cause birth defects, but there appears to be a higher incidence of low birth weight among infants born to mothers with acute infection during pregnancy (Shepard 1998).
Hepatitis C: Approximately 7-8% of hepatitis C virus-positive women transmit hepatitis C virus to their offspring with a higher rate of transmission seen in women coinfected with HIV (ACOG 1998). In one small study acute maternal hepatitis (type B or nontype B) had no effect on the incidence of congenital malformations, stillbirths, abortions, or intrauterine malnutrition. However, acute hepatitis did increase the incidence of prematurity (Hieber et al 1977). Pregnancy does not appear to be adversely affected by chronic HCV (Floreani et al 1996, Jabeen et al 2000).
HIV: Perinatal transmission of HIV can occur in utero, during labour and delivery, or postnatally through breastfeeding. Most transmission occurs during the intrapartum period. Transmission will vary from less than 2% in the developed world (with its access to antiretroviral therapy, caesarean section, and formula milk) to more than 30% in the developing world (where access to therapy is limited and breastfeeding is prolonged). Observational studies have shown that HIV infection is associated with varying rates of adverse pregnancy outcomes, such as increased spontaneous abortion, stillbirth, perinatal and infant mortality, intrauterine growth retardation, low birth weight, and chorioamnionitis. (In Gray and McIntyre 2007).
Group B streptococcal infection (GBS): women colonised with GBS during pregnancy are at increased risk of premature delivery and perinatal transmission of the organism. Pregnancy-associated GBS disease is most often manifest during labour or within the first few days of an infant's life; it can affect the woman or her baby or both. Ascending spread leads to amniotic infection, which can result in maternal sepsis and, very rarely, meningitis. GBS is also a leading cause of chorioamnionitis and is one of several bacteria now thought to enhance the risk of preterm premature rupture of membranes. Newborn babies can acquire GBS by aspiration of infected amniotic fluid or during passage through the birth canal. Since the 1970s, in many industrialised countries GBS has been the principal cause of sepsis and meningitis during the first week of life (ie, early-onset disease). GBS also causes late-onset infections (at more than 7 days of age but rarely after the third month). Three-quarters of neonatal GBS disease occurs in full-term infants, although attack rates per 1000 live births in preterm infants are much higher than in those born at 37 weeks' gestation or beyond. GBS amniotic infection can result in intrauterine death, although the proportion of all spontaneous abortions and stillbirths attributable to GBS is difficult to determine. (In Schuchat 1999).
TORCH infections: This includes Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus, and Herpes infections, are some of the most common infections associated with congenital anomalies (perinatal infections account for 2% to 3% of all congenital anomalies). Most of the TORCH infections cause mild maternal morbidity, but have serious fetal consequences, and treatment of maternal infection frequently has no impact on fetal outcome (Stegmann and Carey 2004).
Evidence for interventions
Interventions in place
Surveillance (Wales) / Public Health Wales Datastore: HepB, hepC, HIV, group B strep, TORCH
Surveillance (Health Board) / Public Health Wales Datastore: HepB, hepC, HIV, group B strep, TORCH
Surveillance (Maternity Unit) / Public Health Wales Datastore: HepB, hepC, HIV, group B strep, TORCH
References: