Growing up in Scotland: a study following the lives of Scotland's children

Chapter 3: Pregnancy and Birth

3.1 Introduction

Parents' expectations and experiences of pregnancy and birth form an important backdrop for understanding the context into which a child is born, including whether the pregnancy was planned, welcomed, and supported by health and other services, and whether the pregnancy and delivery were associated with good or troubled health. It is also important for health services planners and other policy makers to have good evidence of how expectations and experiences of pregnancy and birth vary across the population. A Framework for Maternity Services in Scotland published in 2001 (Scottish Executive) sets out a philosophy of care, recognising that 'Childbirth and early infancy have an unparalleled impact on the lives of parents'. The Framework also states that maternity services should support the 'best possible start to family life' and offer a holistic package of care.

This chapter provides an overview of the period from conception to birth and focuses, in particular, on issues such as whether or not the pregnancy was planned, attendance at antenatal classes and use of other support, type of delivery and experience of the birth itself. As these questions were asked of parents of both babies and toddlers, no distinction is made between the two cohorts in the analysis that follows. It should be noted, however, that these data are therefore representative of a population constructed from two discrete groups; parents of children aged 0-1 and parents of children aged 2-3. Although it is highly unlikely that a sample based on a 'continuous' age profile would show markedly different results, the 'artificial' character of the sample should be borne in mind.

3.2 Whether the pregnancy was planned

Typically, pregnancies tend to be thought of as being either planned or unplanned. During cognitive testing of the questionnaire, however, it became clear that a slightly more nuanced approach was required in asking about this issue. As a result, respondents were given four response options, shown below along with the question wording as it was set out in the interview:

Some pregnancies are planned and others are a surprise. Which of these best describes your pregnancy?

• It was planned by me and my partner/child's father
• It was planned by me, but not really by my partner/child's father
• It wasn't planned but I/we didn't do anything to prevent it happening
• It wasn't planned at all

Overall, the survey suggests that the majority of cohort pregnancies (59%) were planned and that, of these, the vast majority were planned jointly by both parents. This figure is in line with estimates from other studies - e.g. the MCS (Scottish sub-sample) which indicated that 57% of pregnancies were planned. It would be wrong, however, to characterise the remainder as entirely accidental or unplanned. While just under a quarter of respondents (24%) said that their pregnancy was 'not planned at all', one in six (17%) said that while it was not planned they 'didn't do anything to prevent it happening/didn't mind'. First-time mothers were slightly more likely than those with other children to say that the pregnancy had not been planned at all (27% compared with 22%).

Figure 3-A Whether pregnancy was planned

There are very striking variations in the patterns of responses by age (Figure 3-B). For example, among respondents aged under 20 at the time of the child's birth, 62% indicated that the pregnancy was not planned at all, and a further 24% indicated that they had done nothing to prevent it happening; among those aged 30 to 39, on the other hand, the comparable figures were 14% and 14% and over seven in ten pregnancies were actively planned. Among those aged over 40 at the time of the birth, the pattern changes again, with the proportions of 'not planned at all' and 'did nothing to prevent it' responses rising again (to 21% and 23%).

This gives an interesting picture of changes in the extent to which pregnancies are actively planned across the lifecourse. The distinction between those whose pregnancies were 'not planned at all' and those who 'did nothing to prevent it/didn't mind' is an important one, especially perhaps in relation to the youngest age group and initiatives aimed at reducing teenage pregnancies. The relative importance of the 'didn't mind' group among mothers aged 40 and over is also worth noting, as it suggests that the increase in numbers of births to older women may not be entirely due to conscious decision-making nor to entirely 'surprise pregnancies'.

Figure 3-B Whether pregnancy was planned by age of mother at birth of cohort child

Not surprisingly, lone parenthood was also a key predictor of whether or not the pregnancy was planned (Figure 3-C). Over half (58%) of those who were lone parents at the time of interview indicated that the pregnancy was not planned at all, compared with just 15% of those in couple households. A similar pattern was evident across income groups: the vast majority of pregnancies in the highest income quartile (79%) were planned, compared with 34% of those in the lowest income quartile.

Figure 3-C Whether pregnancy was planned by family type and household income quartile

3.3 How parents felt about the pregnancy

We have already seen that 'unplanned' cannot be equated with 'unwanted', in that a quarter of respondents indicated that while the pregnancy was not planned they 'did nothing to prevent it/didn't mind'. This conclusion is reinforced by responses to subsequent questions about how respondents felt (and how they thought their partners had felt) when they found out about the pregnancy. The vast majority of all mothers interviewed said that they were either very happy (70%) or fairly happy (15%) about the pregnancy and only a small proportion were either fairly or very unhappy (4% and 2% respectively). Perceptions of partners' reactions were very similar - for example, 71% said that their partner was very happy about the prospect of having the baby and only 3% that they were very unhappy.

Not surprisingly, those whose pregnancy was 'not planned at all' were much more likely to indicate that they had been unhappy at the prospect of having the baby when they had first found out about the pregnancy - 12% saying they were fairly unhappy about it and 9% that they were very unhappy (Figure 3-D). The responses of those whose pregnancy was 'not planned' but who had 'done nothing to prevent it' were much closer to those of mothers whose pregnancy was planned. Over half of this group indicated that they were 'very happy' about the pregnancy, which suggests that conscious decision-making by no means accounts for all 'wanted' pregnancies.

Figure 3-D How mothers felt about the pregnancy by whether pregnancy was planned

Other key dimensions of variation in parental reactions to the pregnancy included age of the mother, income, social class and whether or not it was a lone parent or couple household. It needs to be borne in mind, however, that these were all also strongly correlated with the extent to which the pregnancy was planned.

3.4 Maternal health during pregnancy

The survey included two main measures of maternal health during pregnancy. First, respondents were asked whether they had any illnesses or other problems during the pregnancy that required medical attention or treatment. Secondly, they were asked how well they had kept during the pregnancy as a whole.

Overall, 36% of mothers had experienced illness or other problems requiring attention or treatment during their pregnancy with the cohort child. There were no marked variations in responses to this question by socio-economic variables such as income or social class and variation by age of mother at time of birth was also slight, at least across the three youngest age groupings. Interestingly, and perhaps contrary to expectation given ongoing concern about the health risks of delayed pregnancy, mothers who gave birth aged 40 or over were the least likely to report any illnesses or problems (31% doing so, compared with 36%-38% of the remaining three age groups).

A very wide range of specific medical problems were mentioned by respondents, the most common of which related to:

• Raised blood pressure, eclampsia/pre-eclampsia (15% of responses, 19% of all those experiencing problems)
• Bleeding or threatened miscarriage (8% and 11%)
• Persistent vomiting (8% and 11%)
• Anaemia (7% and 9%)
• Urinary infection (4% and 5%)

Although there was little difference in the rate of reported illnesses or other medical problems across different social groups, greater variation was evident in relation to respondents' overall assessments of how well they kept during the course of the pregnancy. Around half of all respondents (51%) indicated that they kept 'very well' during the pregnancy while a further third (35%) said that they kept 'fairly well'; 10% said they kept 'not very well' and 4% 'not at all well'. Again, there was an age effect, with older mothers significantly more likely to say that they had kept 'very well' (see Table 3.1). There was also a slight but consistent pattern of better self-reported health by those from more affluent households (Figure 3-E) and among mothers in couple households by comparison with single parents.

Table 3.1 Mothers' perceptions of how well they kept during the pregnancy by family type and age of mother at birth of cohort child

	All sample	Family type %		Age of mother at birth of cohort child (%)
		Lone parent	Couple family	Under 20 years	20 - 29years	30 - 39years	40 or older
Very well	51.4	46.1	52.9	48.2	48.5	54.0	60.0
Fairly well	35.2	36.1	34.9	34.7	36.9	34.0	31.4
Not very well	9.9	12.8	9.1	14.3	10.6	8.8	5.8
Not at all well	3.5	4.9	3.1	2.8	4.0	3.2	2.8
Bases
Weighted	7936	1733	6204	615	3347	3733	238
Unweighted	7935	1607	6328	530	3197	3945	261

Figure 3-E Mothers' perceptions of how well they kept during the pregnancy by household income

3.5 Attendance at antenatal classes

3.5.1 Attendance rates

Antenatal classes are clearly a cornerstone of current service provision for expectant parents. But the survey suggests that take-up varies greatly. Overall, around a third of all mothers-to-be (35%) attended all or most classes, and a further 11% went to at least some. ¹⁰ Around half, then, did not attend any. Whether or not it was a first child was a key consideration here; among primaparous mothers, around six in ten (57%) attended most or all classes, compared with only 14% of those who already had children. Even among first-time mothers, however, around three in ten did not attend any classes.

Figure 3-F Maternal attendance at antenatal classes by parity

Looking only at the experience of first-time mothers, as might be expected, some clear differences are apparent by family structure, income and age. For example, lone mothers are considerably more likely than mothers from couple families not to have attended any classes (54% compared with 20%). In addition, mothers from highest income households are far more likely to have attended at least some classes, indeed 91% had, than are mothers from low income households, of whom a little under half reported attendance.

Figure 3-G Maternal attendance at antenatal classes by family type and household income quartile (first-time mothers only)

In terms of age, it is clear that antenatal classes are failing to reach very significant numbers of younger mothers, and especially those in the youngest age group. Around two-thirds of those under 20 did not attend any classes. Approximately three-quarters of those aged 30 to 39 and two-thirds of those aged over 40, by contrast, went to most or all.

Figure 3-H Maternal attendance at antenatal classes by age of mother at birth of cohort child (first-time mothers only)

It is also worth noting that women from minority ethnic groups were more likely to have not attended any classes (41% compared with 21% of women from white ethnic groups); and that those with no educational qualifications were six times as likely as those with degrees to have attended no classes (66% compared with 11%).

We return to the question of maternal non-attendance at antenatal classes (and the reasons for it) below. First, however, we look at paternal attendance at classes, which - as might be expected - shows similar patterns of variation. Overall, around a third (31%) of all fathers and a half (53%) of fathers whose partner was primaparous attended at least one class or group. Income was a key predictor here: three-quarters of fathers from households in the highest income quartile attended at least one class or group, compared with a quarter (25%) of those in the lowest quartile. Age, level of educational attainment and social class were again significant predictors here.

3.5.2 Reasons for non-attendance

Why do expectant mothers, especially those expecting their first child, not attend antenatal classes? Is it a question of service availability or access, or are other factors at work? Among all those who did not attend antenatal classes, not surprisingly, the most common reason (mentioned by about half of all mothers interviewed) was that they had already had a previous pregnancy and had attended classes then. The next most common reason was that there was nothing more they needed or wanted to know. As the table below shows, however, the reasons given by mothers aged under 20, the group actually least likely to attend classes, are very different. By far the most common reason (mentioned by over a quarter of mothers in this age group) was that they simply do not like classes or groups, while a further 14% indicated that they did not know where there were any classes. It appears, then, that the form of antenatal provision is a key issue in relation to this important target group, as is simple awareness-raising. Issues of service availability and access figure less prominently here.

Table 3.2 Reasons for not attending any antenatal classes by age of mother at birth of cohort child

Reason	All (%)	Age of mother at birth of cohort child (%)
		Under 20	20 - 29years	30 - 39years	40 and over
Attended for previous pregnancy	47.7	4.0	38.1	64.4	67.5
Nothing more needed/wanted to know	29.3	16.4	29.4	31.5	35.1
Other reason	14.7	21.1	16.4	11.9	14.5
Do not like classes/groups	11	27.6	12.0	6.9	5.4
Didn't know where there were any classes	4.3	13.7	4.5	2.3	4.6
Travel problems	2.9	5.0	3.7	1.7	1.8
Could not get childcare while at class	3.9	1.7	4.4	3.9	1.8
No classes available	2.3	1.7	2.4	2.4	2.8
Cost problems	-	0.6	-	-	0.6
Bases
Weighted	4248	404	1789	1914	141
Unweighted	4217	347	1695	2021	153

3.5.3 Perceptions of usefulness

Mothers who had attended antenatal classes were generally positive when asked how useful they had found them. Around a third said they had found the classes to be 'very useful' (35%) and a further half (51%) 'fairly useful'; just 2% said that they had found the classes 'not at all useful'. And interestingly, there was little variation across subgroups - in other words, despite the fact that older, more affluent and better educated mothers are much more likely to attend classes in the first place, among those who did attend, they were no more likely than younger, less affluent and educated mothers to say that they had found the classes useful.

3.6 Other sources of help and information during the pregnancy

Apart from antenatal classes, parents were asked about any other sources of help, information or advice they had used during the pregnancy. Such help was most often sought via personal contact, either with health professionals, such as GPs or health visitors, or family and friends. Written information - whether produced by the NHS (as in the case of the Ready Steady Baby book) or other forms of published material - was also widely drawn on by expectant mothers. It is notable that a quarter also made use of the Internet as a resource in relation to the pregnancy.

Figure 3-I Main sources of help, information or advice during pregnancy

Use of the Internet was strongly related to maternal age at the child's birth. While it might be expected that younger people are more computer-literate and so would be more comfortable using such a resource, in fact, Internet use was higher among those in the older age groups - reflecting, perhaps, greater access among more affluent, professional households. Use of health professionals as a resource during the pregnancy was more evenly spread across age groups though, here too, the figures were lower for mothers aged under 20 than for those aged between 20 and 39.

Figure 3-J Use of the Internet and health professionals as sources of help, information and advice during pregnancy by age of mother at birth of cohort child

3.7 Gestation and birth weight

Overall, 41% of cohort babies were born before their due date and 45% after; 14% were born on time. Of those born early, the vast majority (83%) were less than five weeks early, 13% were born between five and eight weeks early, and the remainder (5%) were nine weeks or more early.

The overall rate of low birth weight (defined as less than 2.5 kilos) was 6.9%. This is slightly higher than suggested by NHSScotland records, but is very close to the estimate produced by the MCS in Scotland. Low birth weight babies were more common in lone parent and low income households.

Figure 3-K Low birth weight babies by family type and household income quartiles

3.8 Type of delivery

Figure 3-L below shows the type of delivery experienced by mothers of cohort children. These figures, which are in line with estimates from within the NHS and elsewhere, suggest that around six in ten experienced a normal vaginal delivery and that around a quarter had a Caesarean Section (12% before the labour began and 13% after).

Figure 3-L Type of delivery

Not surprisingly, type of delivery varies greatly by age of mother at birth, with the proportion of normal births falling and Caesareans rising with age. Among mothers aged 40 or over at time of birth, 38% had a Caesarean (21% before and 17% after labour began), compared with just 13% of those aged under 20 (5% before and 8% after labour began). This does appear to be primarily a medical rather than a social issue, insofar as the same patterns by age are largely reproduced within particular socio-demographic groupings. In other words, age remains a very powerful predictor of delivery type even if income and social class is controlled for.

Figure 3-M Type of delivery by age of mother at birth of cohort child

3.9 Key points

• The majority of pregnancies (59%) were actively planned - the vast majority of these by both parents. Around a quarter of mothers said that the pregnancy was 'not planned at all' but a further 17% indicated that 'it wasn't planned but I/we didn't do anything to prevent it happening'.
• Age was a key factor here: only 13% of mothers aged under 20 at time of birth indicated that the pregnancy had been planned and 62% said that it had not been planned at all; for mothers aged 30 to 39 the corresponding figures were 72% and 14%. Other key predictors of a greater likelihood of a planned pregnancy were being in a couple and being in the highest income quartile.
• Seven in ten respondents said they were 'very happy' at the point that they had found out about the pregnancy and a similar proportion of those in relationships said that their partner had felt the same way. Those whose pregnancy had been not planned at all were more likely to say they felt fairly or very unhappy about it (12% and 9%, respectively); but the reactions of those whose pregnancy had not been planned but who had done nothing to prevent it were closer to those of mothers whose pregnancy was planned.
• Overall, 36% of mothers experienced illness or other problems during the pregnancy that required medical attention or treatment - most commonly relating to raised blood pressure, bleeding or threatened miscarriage or persistent vomiting.
• Although there was little difference in the rate of reported illness or other medical problems across sub-groups, there was greater variation in relation to respondents' own assessments of how well they had kept during the pregnancy. Mothers in couples, living in households with higher incomes and who were older at the time of birth were all more likely to report feeling 'very well' during their pregnancy.
• About half of all mothers and seven out of ten first-time mothers said they had attended at least some antenatal classes, but there was marked variation by socio-economic group and by maternal age at birth. Around two-thirds of those aged under 20 did not attend any classes; three-quarters of those aged 30 to 39, by contrast, went to most or all.
• Overall, the most common reason given by mothers for non-attendance was that they had attended for a previous pregnancy (48%) - but mothers aged under 20 (who were actually least likely to attend) were much more likely than other groups to say that they simply did not like classes/groups (28%) or that they did not know where there were any classes (14%).
• Most of those who did attend antenatal classes indicated that they had found them either very or fairly useful, with little variation in responses across key sub-groups.
• Around four in ten cohort babies were born early (with a slightly greater proportion among mothers aged 40 or over). The overall rate of low birth weight (less than 2.5 kilos) was 7%, but the figure was significantly higher among lone parents (10%) and families in the lowest household income quartile (9%).
• Around six out of ten cohort mothers experienced a normal delivery, while around a quarter had a Caesarean section. Age was a key predictor here, with the number of normal deliveries falling and the number of Caesareans rising with maternal age at birth of the cohort child.

3.10 Conclusion

These data show that for most mothers, pregnancy and birth were planned, happy and healthy. Nonetheless, there are significant variations in that experience across the population and in relation to social divisions of income, age, partnership context and educational level. Most pregnancies were actively planned by both parents, a finding similar to that of the Millennium Cohort Study for the UK, where 58% of mothers reported planned pregnancies (Dex and Joshi 2004, p.76). However, for a large minority, pregnancy was an unplanned, though largely welcome, event, and this was disproportionately so for young mothers and for low income parents. Not surprisingly perhaps, mothers whose pregnancies were planned were virtually all happy or very happy about them, compared with those who reported their pregnancies were not planned at all. Nonetheless, it would be inappropriate to assume that unplanned pregnancies are all unwanted. There may also be reporting issues with younger women perhaps feeling that they have to say this was unplanned rather than they did not mind. However, the implications of unplanned or 'didn't do anything to prevent' pregnancies for the provision of pre-conceptual and early pregnancy care need to be taken into account when planning and delivering services in a local context.

Just over a third of mothers had experienced pregnancy-related ill health requiring medical attention or treatment, a similar rate as that reported for the UK by the Millennium Cohort Survey (ibid, p.77). While there were no significant variations across the population, mothers' positive perceptions of their health during pregnancy were more likely for older, financially better off and better educated mothers.

In terms of service use and satisfaction of antenatal classes a positive picture is evident for most, but important variations by different social divisions also emerge. In particular, the variation in service use by mother's age is striking; two-thirds of young mothers under 20 never attended, compared with about three-quarters of thirtysomething mothers who went to most or all antenatal classes. Income was another key factor affecting patterns of service use; the vast majority of mothers from the highest income households compared with under half of mothers from the lowest income households reported any attendance at classes. However, while take up of antenatal classes is uneven and mainly for first births, they were positively assessed by all groups of service users. The great majority of mothers, irrespective of age, income or education, who attended antenatal classes found them either very useful or fairly useful, and very few said they were not at all useful. Of those who did not attend, the most common explanations were that they had previously attended, there was nothing more they needed or wanted to know or they didn't like the mode of service delivery in classes or groups. This latter point suggests that classes, or an alternative, need to be flexible to meet the needs of these particular mothers to be. Apart from antenatal classes, the great majority of mothers reported seeking help, advice or information from health professionals, and about a quarter of mothers, particularly older mothers, had used the Internet as a source of information and help.

Combining these data, we can see a largely positive, though complex, picture of pregnancy and birth overall in which there are social divisions in those particular life experiences. These social divisions put those babies who are born into less advantageous contexts, and their mothers, at a relative disadvantage at birth.