Pathways of maternity care - patient leaflet: equality impact assessment

Key Findings

Revised Clinical Guidance and Schedule and Birthplace Decisions patient leaflet

Protected Characteristic: Age

Potential impact:

• Public Health Scotland data for Births in Scotland (year ending 31 March 2023) showed that the upward trend in maternal age has continued, with women aged 35 years and older accounting for around a quarter of all maternities in Scotland in the time period of the report.^[1]
• Some pregnancy complications are more common in older mothers^[2]. Clinicians will be familiar with these, and the revised clinical guidance and schedule include maternal age in the list of factors clinicians should consider as part of the pathway.
• The Birthplace Decisions patient leaflet provides information which will help women make an informed choice about where to give birth. Some factors such as clinical risk may affect where it is possible to give birth, and maternal age of 45 is such a factor. The leaflet provides this information.
• While teenage pregnancy rates have reduced in the last decade, those living in the areas of highest deprivation still have teenage pregnancy rates five times higher than those in the least deprived (44.3 compared to 9.9 per 1,000 women). Young parents tend to have poorer perinatal health outcomes, higher than average feelings of isolation and low self-esteem, significant socio-economic disadvantage in terms of lower educational qualifications and lower employment levels and lower income.^[3]
• The risk of poverty is higher in families where the mother is under 25 years of age.^[4]
• The revised clinical guidance and schedule provide information on the additional provisions and support young parents are offered in Scotland, including the Family Nurse Partnership, specific antenatal education tailored to suit their needs, and information on contraception.
• Through the policy, care provided will be tailored to each individual, with continued ongoing assessment of needs taking place throughout pregnancy, birth, and the postnatal period to inform the range of birth choices available. This will be enabled by delivery of continuity of carer.
• Continuity of carer (Recommendation 1 of the Best Start) is intended to enable the development of a closer relationship between a woman and her midwife across her pregnancy journey, which may be of particular importance for those whose age may be a factor in their clinical outcomes or socioeconomic circumstances.
• We do not expect that any elements of the policy will adversely impact women because of age.

Protected Characteristic: Disability

Potential impact:

• The ethos of the Best Start is that care is individualised around each woman and any clinical, social, physical, and psychological needs she may have.
• In the 2018 Maternity Care Experience survey, 17% of respondents self-identified as having one or more long-term health condition. The most commonly reported conditions were a mental health condition (reported by 7% of respondents) and chronic pain lasting at least three months (reported by 4% of respondents).^[5]
• The revised pathway will facilitate a closer relationship between a woman and her midwife throughout her pregnancy journey, which may be of particular importance for disabled women, and women with long-term health conditions which may not be classed as a disability, but still require consideration.
• Part of the Best Start is the ambition to deliver care closer to home wherever possible, including the use of technology where appropriate, which may be beneficial for disabled women.
• It is not expected that any element of the policy should adversely impact the workforce because of disability. Any adjustments that are required currently to enable a member of the workforce to carry out their job would also be expected to be made for any change to how that job is carried out in the future.

Protected Characteristic: Pregnancy/Maternity

Potential impact:

• There were 44,557 maternities (a pregnancy ending in a live or stillbirth) in Scotland in 2022/23. There is a downward trend in maternity rates in Scotland, from a peak of 54.4 per 1,000 women aged 15-44 years in 2008/09 to a rate of 43.2 per 1,000 in 2022/23.^[6]
• The policy schedule will affect all pregnant women and women who have recently given birth and should have a positive impact. The policy has been developed by an expert group, reflects the latest NICE guidelines, and emphasises the importance of person-centred care. Providing National Guidelines, to be used alongside local guidelines, encourages equity of service across the Health Boards.

Poverty and Pregnancy/Maternity

• The Scottish Government has identified six priority family types at highest risk of child poverty: lone parent families, minority ethnic families, families with a disabled adult or child, families with a younger mother (under 25), families with a child under one, and larger families (three or more children).
• Poverty and deprivation have an impact on the health of pregnant women and babies. Women from more deprived areas are more likely to be overweight or obese, have diabetes, to give birth prematurely and to babies small for their gestation compared to those from less deprived areas. ^[7]
• The person-centred focus of the policy is designed to address the specific needs of the family. Midwives will coordinate care around the woman, and liaise with other professionals as required, including health visitors and family nurses. Postnatal care will be tailored to any social requirements, and the number of postnatal visits can be adapted to suit the particular needs of mother and baby. We expect this may have a positive impact on child poverty, through increasing access and engagement with other services.

Protected Characteristic: Sex

Potential impact:

• As the policy concerns the provision of maternity care, there are inherent differences in how people will be affected by the revised clinical guidance and schedule. Women will be affected directly, as the primary recipients of maternity care.
• One part of the Best Start vision for maternity care is that fathers, partners, co-parents, and other family members are actively encouraged and supported to become an integral part of all aspects of maternal and newborn care. Therefore, we would expect the impact of the policy to be positive.
• No element of the policy should adversely impact the workforce because of sex.

Protected Characteristic: Gender Reassignment

Potential impact:

• The term ‘women’ has been used throughout the two Pathways for Maternity Care documents, as this is the way that the majority of those who are pregnant and having a baby will identify. For the purpose of the documents, this term includes girls. It also includes people whose gender identity does not correspond with their birth sex or who may have a non-binary identity.
• No element of the policy should adversely impact the workforce because of gender reassignment.

Protected Characteristic: Sexual Orientation

Potential impact:

• References to partners is intended to be inclusive of all sexual orientations and genders.
• No element of the policy should adversely impact the workforce because of sexual orientation.

Protected Characteristic: Race

Potential impact:

• Recent evidence from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Maternal mortality 2019-2021 report, published in October 2023, shows that risk of maternal death in 2019-21 was almost four times (3.84x) higher among women from Black ethnic minority backgrounds compared with White women. The report also found that women from Asian backgrounds were at higher risk of maternal death than White women (1.82x).^[8]
• MBRRACE-UK’s most recent Perinatal Mortality Surveillance report found that stillbirth rates continue to be higher for babies of Black ethnicity (7.52 per 1,000 total births) and babies of Asian ethnicity (5.15 per 1,000 total births) compared with babies of White ethnicity (3.30 per 1,000 total births). There was a very small increase in stillbirth rates since 2020 for babies of White and Asian ethnicity, but a larger rise for babies of Black ethnicity representing a widening of inequalities. ^[9]
• For neonatal mortality, the rate for babies of Black ethnicity increased to 2.94 per 1,000 live births. There was a fall in the neonatal mortality rate for babies of Asian ethnicity (2.22 per 1,000 births). The neonatal mortality rate for babies of White ethnicity increased but remained lower than rates for Black and Asian ethnicities at 1.68 per 1,000 live births.^[10]
• The ethos of the Best Start is that care is individualised around each woman. The revised clinical guidance and schedule are based on the Getting it Right for Every Child (GIRFEC) principle, which takes account of the wellbeing and specific needs of women throughout pregnancy and birth. This will be enabled through continuity of carer. This may have a positive impact on women from ethnic minority groups, and we do not expect that it will have a negative impact.
• No element of the policy should adversely impact the workforce because of race.

Protected Characteristic: Religion/Belief

Potential impact:

• Different religions or belief systems may have culturally specific beliefs around pregnancy and birth and have a right to continue to express their identity when receiving healthcare. The workforce is trained to accommodate religions and beliefs.
• A key element of the policy is the “whole-person” approach to care provided to the woman. This should facilitate a closer relationship between a woman and her midwife across her pregnancy journey. Through this relationship, midwives will be able to deliver appropriate care, which factors in a woman’s religion and belief.
• No recommendations within the Best Start should adversely impact women because of their religion or belief.
• No recommendations within the Best Start should adversely impact the workforce because of religion or belief.