A Refreshed Framework for Maternity Care in Scotland: The Maternity Services Action Group

4. POLICY AND EVIDENCE INTO PRACTICE

This section looks at key challenges for maternity care and gives an overview of what translating policy and evidence into practice means.

4.1 WHAT DO WE KNOW? ¹⁹

• Women under 20 and women from areas of deprivation tend to 'book' for antenatal care later than other women.
• Booking late for antenatal care is a significant factor in maternal and infant mortality and morbidity.
• There is marked variation by socioeconomic group and by maternal age at birth, in the proportion of pregnant women attending antenatal classes: two thirds of those aged up to 20 years (the majority of whom live in deprived areas) did not attend any classes while three quarters of those aged 30-39 years went to most or all.
• Younger mothers and those from less affluent areas are more likely to find it difficult to know who to ask for help regarding concerns and are also less likely to ask for that help.
• The highest birth rates occur in the most deprived communities.
• A higher proportion of babies born to mothers living in the most deprived fifth of the population have a low birth weight than those born to mothers living in the most affluent areas (9% compared to 5% in 2004-05).
• Older and younger mothers are more likely to have a low birth weight baby. A higher number of babies are born to younger mothers living in more deprived areas than to older mothers living in more affluent areas.
• Maternal obesity is a causal factor in poor maternal and infant outcomes including premature birth, intrauterine growth restriction and caesarean sections.
• Women and their babies from particular population groups: teenagers, women from black and minority ethnic communities, women with learning disabilities, women with mental health problems, experience poorer health outcomes when compared to other population groups. Women are of course not defined by age, ethnicity or poverty; rather these factors intersect, leading to comparatively poorer health outcomes and other outcomes.
• Lifestyle behaviours such as alcohol use, smoking, drug misuse, risky sexual behaviour, poor nutritional intake and physical activity have complex interlocking relationships with social inequalities and cultural norms and practices. The provision of health improvement advice and information is not effective in promoting behavioural change on its own.

4.2 SHIFTING PRACTICE

The Equally Well Ministerial Task Force (2008) ²⁰ and other reviews have found that social inequalities have a profound influence on the future health of children now being born in Scotland. The Task Force reconvened in 2010 to review progress with implementing the three social policy frameworks, in the light of current and continuing financial constraints. This review has been explicit about the need to continue to invest in effective early years intervention activity and has confirmed that the three social policy frameworks remain the best approach to deliver long term improvements in health outcomes. The Task Force has stressed the need for a shift from traditional approaches to improving health.

FROM TRADITIONAL TO ASSETS OR STRENGTHS BASED APPROACHES

For NHS services this means a shift from using traditional, deficit models of health - that start with what's wrong'; smoking, drug misuse, alcohol use, poor nutrition etc- rather than what is working in a person's life and what people care about.

Health asset or strengths based approaches recognise the strengths within an individuals' possession. Health assets or strengths embrace both internal and external strengths. Internal strengths include positive relationships with others, the motivation to control or change individual circumstances, and the presence of protective personal characteristics, such as for example, a resilient personality and/or a sense of optimism. External characteristics include social support networks, expectations of others, and physical and environmental elements. The antecedents of health assets are genes, values, beliefs, and life experiences. Using health asset based approaches can mobilise an individual to engage in risk assessment, decision making, and change.

Behaviour change in relation to risks such as alcohol, drug and tobacco use, poor nutrition and obesity remain critical ingredients in improving maternal and infant health outcomes. However, we know that women are highly motivated to do what's best for their babies and will be more likely to adapt and change their health behaviours if their emotional wellbeing and social circumstances are acknowledged and addressed, together with their hopes and aspirations for themselves and their babies.

Evidence from the Family Nurse Partnership programme demonstrates that by building on the strengths of the pregnant woman and working in tandem with her agenda , i.e. 'agenda matching', can lead to improved self efficacy and a wide range of improved social and health outcomes for both her and her baby ²¹.

A health assets model of working requires the fostering of mutually beneficial relationships between women and maternity care staff based on inequalities sensitive practice and continuity of care and as such is consistent with ambitions of the healthcare Quality Strategy. The potential for maternity care staff to work with women in this way is enormous; indeed it is the way that many staff already work. We need to ensure that all staff are encouraged and supported to have the capacity and capability to work in this way, recognising that the wellbeing of staff themselves is fundamental to this approach.