Reducing Antenatal Health Inequalities: Outcome Focused Evidence into Action Guidance

RATIONALE FOR THIS GUIDANCE

'The medical and obstetric consequences of social risks, requires them to be managed by clinical services as robustly as they manage, for example, diabetes or epilepsy'
Dr Harry Burns, Chief Medical Officer, Scottish Government

This guidance details the specific actions needed to strengthen antenatal healthcare at NHS Board and national level. It requires action across each NHS Board's corporate functions, including specialist public health, planning and performance management. It is intended to support improvements in antenatal care for women, including care provided by Primary Care Services, Substance Misuse, Mental Health and Sexual and Reproductive Health Services.

The guidance has been developed by an Antenatal Inequalities Working Group - a sub group of the Maternity Services Action Group ( MSAG) ¹ in response to recommendation 4 of the Equally Well Implementation Plan ² that NHS Boards need to 'improve the capacity of ante natal services to reach higher risk groups³and identify and manage risks during pregnancy'. Its specific actions are based on a review of what the evidence says needs to happen to:

• Improve access to antenatal healthcare services (see page 10)
• Improve the assessment of health and social need (see pages 11-12)
• Ensure equity in the quality of care (see pages 13-14)

Poor and unequal access to antenatal healthcare contributes to inequalities in maternal and infant mortality and morbidity ⁴. We know that those women and babies who are at the greatest risk of poor health outcomes are the least likely to access and/or benefit from the antenatal healthcare that they need.

There is a compelling body of evidence that early intervention and preventative spending before babies are born is vital for improved outcomes for mothers, babies and families in Scotland. Indeed, the future financial constraints, rather than being a barrier to action, provide an imperative to take the action identified in this guidance. The evidence is strong that investing in early intervention, prevention and support as early as possible leads to significant savings across public services.

'A wide range of economic studies suggest that returns to early investment in children during the pre-birth period and first few months of life, up to the age of eight years old are high, but reduce the later the investment is initiated. Investment in early and effective interventions translates into substantial savings to the public sector'. ⁵

Reaching and managing higher risk groups in the antenatal period will help strengthen NHS capacity to both promote healthier pregnancies and effectively manage the co morbidities which often lead to premature births and poorer maternal and infant health outcomes- in turn this should reduce demand on neonatal and paediatric services in the short term and a range of public services in the medium to long term.

Improving access to, and the quality of antenatal healthcare, will strengthen NHS capacity to respond to the needs of women in high risk groups. It will strengthen its contribution to improving maternal and infant nutrition including breast feeding; promotion of smoking cessation, reduced alcohol use and the uptake of welfare support and income maximisation services.

Many of these improved outcomes are measureable and deliverable in the short term- they can be measured during pregnancy and in the first few weeks of a baby's life. We know that improving outcomes in the short term will also have a positive impact on a wide range of outcomes across the life course of mothers and babies and contribute to the implementation of the Early Years Framework.

There is substantial work already underway within NHS Boards to strengthen the contribution that antenatal health care makes to reducing health inequalities. In addition we know that maternity staff are committed and passionate about providing high quality antenatal health care. The guidance should therefore be used in conjunction with and/or with reference to:

• The Refreshed Framework for Maternity Care Services in Scotland - www.maternityservices.scot.nhs.uk
• The Maternal and Infant Nutrition Framework - www.maternityservices.scot.nhs.uk
• NHSQIS Vulnerable Families Pathways - http://www.nhshealthquality.org
• Getting it Right for Every Child CEL and implementation guidance http://www.scotland.qov.uk/Publications
• Gender Based Violence CEL - www.sehd.scot.nhs.uk/mels/CEL2008_41.pdf
• Hall 4 revised guidance - www.scotland.gov.uk
• Future Health Promoting Health Service requirements in relation to contraception services, in particular the promotion of longer acting reversible contraception.