Reducing Antenatal Health Inequalities: Outcome Focused Evidence into Action Guidance

THE NEXT SECTION GIVES AN OVERVIEW OF WHAT WE KNOW AND KEY MESSAGES FROM THE EVIDENCE IN RELATION TO THE 3 MAIN THEMES.

THEME 1 - ACCESS TO ANTENATAL CARE SERVICES

WHAT DO WE MEAN BY ACCESS?

Early access to antenatal care is important however access is not just about physical access to antenatal booking at a particular point in time - it is about the quality and impact of ongoing access to, and engagement with, antenatal healthcare.

WHAT DO WE KNOW

• Women under 20 and women living in areas of deprivation tend to 'book' for antenatal care later than other groups of women
• Some 'high risk' women do not book later but their engagement with and experience of antenatal care is sub optimal

BARRIERS TO ACCESS

• Womens' perceptions and fears of how they will be treated
• Womens' fear that their baby will be 'taken away' if they disclose for example- substance misuse or domestic abuse
• Treatment by and attitudes of staff
• Poor continuity of individual care and lack of Integrated care by local service providers
• Lack of staff knowledge and sensitivity about the impact of social inequalities on women's lives
• Poor communication between staff and women

KEY MESSAGES FOR IMPROVED ACCESS

• Communication and promotion of antenatal healthcare to high risk groups of women is a multi agency responsibility
• Integrated planning and provision of antenatal services between NHS specialist services and Local Authority services, for example-addiction services, mental health services, homelessness services, asylum and refugee services
• Known barriers to access are addressed and where possible services are co-located

THEME 2 - ASSESSMENT OF HEALTH AND SOCIAL NEED

WHAT DO WE MEAN BY 'HIGH RISK'?

For the purposes of this guidance, high risk is intended to refer to women who have complex health and social care needs. In other words those women whose social circumstances have a clinical impact - either physically, psychologically or both, which in turn may have an obstetric impact. As a result of this interlocking risk, any or all of the following outcomes may occur:

• The woman or baby is more likely than usual to become ill or die
• Complications before or after delivery are more likely than usual.
• Longer term child and maternal health and other social outcomes (educational, economic etc) are poorer when compared to other groups

IDENTIFYING AND MANAGING RISK

NHS antenatal health care has a unique role to play- as the only universal public service for women and infants in the pre birth phase. Health inequalities follow closely the social gradient ⁹, affecting all groups to a greater or lesser degree ¹⁰.

This means that action to reduce health inequalities in the antenatal period needs to be based on assessment of needs and assets for every woman across social groups including those at the 'high need' end who may already be 'known' to public services.

Antenatal care needs to be tailored and progressively intensive depending on individual need.

GIRFECPractice Model - Key Questions

What is getting in the way of this woman or baby's wellbeing?

Do I have all the information I need to help this woman or baby?

What can I do now to help this woman or baby?

What can my service do to help this woman or baby?

What help, if any, may be needed from others?

The Getting it Right for Every Child ( GIRFEC) approach enables assessment across the spectrum of need, whether there are early indications of additional needs within universal antenatal care or in higher risk situations involving the need for more complex interagency plans. It enables staff providing antenatal healthcare to ask the same key questions of themselves about a woman and her baby.

WHAT DO WE KNOW?

Staff who provide antenatal healthcare need to have the skills to assess individual women's risks and assets/strengths in partnership with the woman. This means taking into account the woman's communication needs and levels of health literacy. Effective assessment should be a mutual process carried out between the practitioner and the individual woman. Women are highly motivated to do what's best for their babies. However working in strengths or assets based way requires a shift from traditional practice - staff will need learning and development inputs and ongoing supervision in order to make this shift.

Developing and supporting the workforce will enable antenatal care services to harness the opportunity to support women make behavioral changes particularly in relation to smoking, use of alcohol and drugs and improved nutrition. Effective assessment will also improve the capacity to identify where other services or supports are needed. Management of risk and/or support for behaviour change is more likely to be effective if it there is also support for complex and challenging social circumstances. Identifying and responding to social risk factors is as important as addressing physical factors such as diabetes or pre-eclampsia.

KEY MESSAGES

• Effective assessment of health and social care needs is highly dependant on a partnership between the woman and a named practitioner and the continuity of that relationship.
• Assessment should look for assets/resources for health as well as identification of need and risk
• Continuity of carer(S) and the development of trusted relationships should be provided for all women but is critical to the effective and safe care of women who may have complex health and social care needs
• The GIRFEC approach helps assessment across a wide spectrum of need
• Assessment of health and social need should be a dynamic process throughout the woman's journey through antenatal care and beyond
• Supporting behavioural change should use person centred asset based approaches and happen alongside any collaborative support needed in relation to a woman and her families social circumstances
• Effective collaboration across services and professions with clear pathways of care is essential
• Workforce development, support and supervision is needed to shift practice

THEME 3 - EQUITY IN THE QUALITY OF CARE

WHAT DO WE MEAN BY EQUITY IN THE QUALITY OF CARE?

The NHSScotland Healthcare Quality Strategy ¹¹, recognises that healthcare quality is 'built from the ground up and is dependant on the effects of millions of individual care encounters'. Care encounters that are consistently person centred, clinically effective and safe for every person, every time. The strategy has been built around what people in Scotland have said they want from healthcare services. They said they wanted:

Caring and compassionate staff and services

Clear communications and explanation about conditions and treatment

Effective collaboration between clinicians, patients and others

A clean and safe environment

Continuity of care

Clinical excellence

Delivering this quality of care is at the heart of clinical values and the motivation for all healthcare staff, including staff providing antenatal care. Three high level Quality Ambitions have been developed to incorporate these aspects and the internationally recognised six dimensions of healthcare quality-person centred, safe and effective, efficient, equitable and timely into the Quality Strategy.

WHAT DO WE KNOW?

The quality of care experience reported by women using maternity care services is strongly socially patterned, declining in satisfaction with social status ¹², ¹³.

Women with complex social problems report that they experience discrimination and judgemental behaviour and that this impacts on their ongoing engagement with services ¹⁴. Women from disadvantaged groups report that they are not given the information they need or communicated with in a way that meets their needs.

Ongoing engagement with antenatal healthcare is critical for the effective management of risk and to improvements in maternal and infant health outcomes.

KEY MESSAGES

• Staff need to have knowledge and understanding of how social inequalities impact on women's health and health behaviours
• Staff need to understand and be aware of the impact their behaviours and attitudes have on women's engagement with services and women's concordance with advice and treatment
• Continuity of care and carer(s) is particularly important for women at risk of poorer outcomes
• Staff need appropriate training and ongoing supervisory support to safely and effectively manage the care of women and babies in high risk groups