Early access to antenatal care
What happens during the early years, starting
in the womb, has lifelong effects on a range of health and
wellbeing outcomes including obesity, heart disease, mental health,
educational attainment and economic status (Marmot, 2010).
A healthy pregnancy and the first three years
of life are vital to a child’s development, life chances and
achievement. Healthy mothers tend to have healthy babies and
a mother who receives high quality maternity care throughout
pregnancy is well placed to provide the best possible start for her
baby. Therefore the care and support provided for mothers and
babies during pregnancy, childbirth and the postnatal period has a
significant effect on children’s healthy development and their
resilience to problems encountered later in life (DH, 2004).
NICE guidance on antenatal care (2008)
recommends that women should have access to maternity services for
a full health and social care assessment of needs, risks and
choices ideally by 10 weeks of pregnancy. This ensures women
are given up to date advice and are able to participate in
antenatal screening programmes and an appropriate care plan can be
developed. Late booking and poor attendance for antenatal
care are associated with poor outcomes.
The Healthy Child Programme (DH, 2009) was
developed to set out a universal preventive service to support a
healthy pregnancy and the foundations for future health and
wellbeing. The assessment in early pregnancy is the starting
point for the Healthy Child Programme.
Bedford Hospital data for 2014-15 shows that
Bedford Hospital sees at least 90% of women before 12 completed
weeks of pregnancy and a further 8% between 13-18 weeks. There is a
Late Booking Pathway in place to investigate underlying factors for
What do we know?
Since 2013-14, data for the 12 week maternal risk
assessment is collected by NHS England directly from providers.
Bedford Hospital NHS Trust provides maternity care for the majority
of women living in Bedford Borough (approximately 90%) with the
remaining women delivering at an alternative hospital.
Therefore Bedford Hospital data can be used as a proxy measure for
the Bedford Borough population. Graph 1 below shows the
number of women accessing a midwife/health professional in Bedford
Borough before 12 weeks and 6 days of pregnancy. The local
target is 90% and Bedford Hospital remains above target (following
a slight dip in the first quarter of 2014-15).
Source: Statistical Release. Maternal 12 week
risk assessment Quarter 1 2014/15. Analytical Services, NHS
In each quarter the data shows that between
600-700 women are having a timely assessment. The number of
women seen after this time in Quarters 1-3 in 2014-15 was 42, 71
and 62 respectively.
Further data from Bedford Hospital shows that
most of these women are seen between 13-18 weeks. The delay can be
for a number of reasons including holidays, uncertainty over dates
and delays in information getting from GP to community
midwife. Additionally some women who book later have
transferred from another area and have received their early
antenatal care from another hospital. Their data showed that
only a very small number of women were identified as presenting
later than 20 weeks. Whilst these women would not have
received early lifestyle advice, they would have all the routine
blood tests, scans and screening tests (apart from the nuchal
Current activity and services
The first antenatal appointment offered before
12 completed weeks of pregnancy is a full assessment of health and
social care needs, risks and choices. It is the starting
point of the Healthy Child Programme which was introduced in
Bedfordshire in 2009. As part of the universal schedule it is
offered to all families and identifies the need for further
Universal Plus and/or Universal Plus support that may be required
by families with additional needs and risks.
In Bedford, women can access the midwife
directly, in preference to a GP, as the first healthcare contact
upon learning of a pregnancy. Direct referral to the
community midwife by GP practices ensures delays are avoided.
All women living in Bedford Borough are then offered a Booking
Appointment through the Bedford Hospital Trust Midwifery Service,
either at Bedford Hospital or a local venue such as a GP Practice
or a Children’s Centre. Early access to maternity services
ensures women are given up to date diet and lifestyle advice, can
participate in antenatal screening programmes and have their
pregnancies accurately dated by ultrasound scan. Health
professionals develop an appropriate care plan that takes into
account medical and social history and information and support is
offered including maternity benefits (e.g. Health in Pregnancy
Grant and Healthy Start scheme); lifestyle issues such as smoking,
nutrition and diet advice including vitamin D supplementation,
sexual awareness; risks and benefits of screening tests; planning
place of birth and antenatal classes.
Bedford Hospital has a Late Booking Pathway in
place to explore any underlying issues or concerns that may have
contributed to the late booking. Following an audit into late
booking this was strengthened and implemented in January 2015.
National and local strategies
Service users sit on the Maternity Services
Liaison Committee for Bedfordshire and provide direct service user
input and represent the views of the wider public concerning issues
relating to maternity services delivered at Bedford Hospital.
· Early access to
maternity care contributes to delivering the NHS Outcomes Framework
indicator (2012/13) to reduce infant mortality and a number of
outcomes in the Public Health Outcomes Framework (2013-16)
including increased breastfeeding rates, reduced incidence of low
birth weight of term babies and reduced maternal smoking.
- Healthy Lives, Healthy People: Our strategy
for public health in England (2010)
- The Marmot Review: Fair Society, Healthy
- The Healthy Child Programme
- Maternity Matters: Choice, access
and continuity of care in a safe service (2007)
- Department of Health,
National Service Framework for Children, Young People and Maternity
Services – Maternity Services (2004)
- NICE Clinical Guidance 62, Antenatal care – Routine care for
the healthy pregnant woman, (June 2008)
- Bedford Borough Health and Wellbeing Strategy (2014)
- Bedford Borough Public Health Strategy 2013/14
- Bedford Borough Partnership Framework for Bedford Borough’s
Children, Young People and Families 2014-2017.
- Bedford Borough Early Help Strategy 2014
- Bedford Borough Early Years Strategy 2014 (Draft)
What is this telling us?
What are the key inequalities?
In Bedford Borough, Bedford Hospital Trust
sees the majority of women before 13 weeks of pregnancy. An audit
in 2014-15 identified that a very small number are seen after 20
weeks and they would all receive blood tests, a scan and screens
(except the nuchal scan).
Evidence suggests that disadvantaged women
with multiple social problems and minority groups are significantly
less likely to use maternity services early in pregnancy or
maintain contact. This results in worse outcomes for both the
mother’s and baby’s health and wellbeing than for the population as
a whole (DH, 2004).
A Health Equity Audit of access to maternity
care in Bedford Borough, undertaken by the Public Health Team,
looked at rates in 2009/10 and identified higher rates of women
failing to book by 12 weeks 6 days in the most deprived wards in
Bedford. The data also showed some correlation at ward level
between ethnicity and the percentage of mothers not booked before
12 weeks 6 days in Queens Park, Kingsbrook and Goldington
A survey carried out by the National Perinatal
Epidemiology Unit found that four out of five women (80%) realised
they were pregnant within the first 6 weeks, with smaller
proportions taking longer to become aware of their pregnancy.
16% of all pregnant women, including many of those aged under 18,
delay seeking maternity care until they are five or more months
pregnant, thus missing the crucial early days of maternity
A report commissioned by NICE (NCCWCH, 2010)
highlighted the issues faced by pregnant women with social complex
factors. The guideline was commissioned in response to findings
from reports which found that women from non-white ethnic groups
and women in the deprived population quintile had stillbirth and
neonatal death rates that were twice those of white women and those
resident in the least deprived areas.
In addition socially excluded women are at
higher risk of death during or after pregnancy than other women and
are far less likely to seek antenatal care in early
pregnancy. The Saving Mothers Lives Report (2007) found that
compared to women who had booked prior to 20 weeks, women who
booked late or missed more than four routine appointments were more
likely to be: Black African or Caribbean; experiencing domestic
abuse; substance misusers; known to social services or child
protection services; or unemployed.
The guidance identified four populations who
represented socially excluded women:
- Women who are substance misusers
(including drugs and/or alcohol)
- Recent migrants, refugees,
asylum seekers, and women with little or no English
- Young women aged under 20
- Women experiencing domestic
Whilst only a small number of women do not
receive antenatal care in early pregnancy in Bedford Borough,
national evidence suggests that the women presenting later are
those most likely to have worse outcomes for both them and their
- GP practices should guide women directly to
the community midwife as soon as possible.
- As a result of their audit into late booking
mothers, Bedford Hospital strengthened their Late Booking
Pathway. The pathway assists maternity staff to explore
issues that may have contributed to the late booking to ensure that
additional support needs are identified and women can be referred.
This process will enable maternity services to monitor late booking
and the reasons behind it.
This chapter links to the following
chapters in the JSNA:
Department of Health (2009) Healthy Child
Programme – Pregnancy and the first five years of life
Department of Health (2010) Healthy Lives,
Healthy People: Our strategy for public health in England
Department of Health (2012) Improving outcomes
and supporting transparency Part 1A: A public health outcomes
framework for England, 2013-2016
Department of Health (2007) Maternity Matters:
Choice, access and continuity of care in a safe service
Department of Health (2004) National Service
Framework for Children, Young People and Maternity Services
Department of Health (2012/13) The NHS
Marmot M. et al. (2010) Fair Society, Healthy
Lives, The Marmot Review
National Collaborating Centre for Women’s and
Child’s Health (2010) Pregnancy and complex social factors: A model
for service provision for pregnant women with complex social
National Perinatal Epidemiology Unit (2006)
Recorded Delivery: A national survey of women’s experience of
NICE (2008) Clinical Guideline 62 Antenatal
care: routine care for the healthy pregnant woman
The Confidential Enquiry into Maternal and
Child Health (CEMACH) (2007) Saving Mothers Lives: reviewing
maternal deaths to make motherhood safer (2003 – 2005).
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