Key facts on maternal health

Maternal health refers to the health of the woman during pregnancy, childbirth and the postpartum period. It includes issues such as birth outcomes; recovery from childbirth; newborn care; nutrition and breastfeeding; and family planning. Risk factors include obesity, alcohol, drug misuse, homelessness, mental ill health, teenage pregnancy, domestic violence and sexually transmitted infection. Women on low income, women with a low level of education and previously ill women are more at risk of developing complications during childbirth and after delivery.

In Merton, in 2010-11:

  • There has been a 40% net increase in births from 2,535 in 2002 to 3,537 births in 2011; this is forecast to peak at 3,618 births in 2014.  
  • Half of these babies are delivered at St George’s Healthcare NHS Trust.
  • Birth rates are significantly higher than in England as a whole.
  • The proportion of babies born to older mothers is also significantly higher, with more than one quarter of babies born to mothers over 35 years.
  • Nearly 60% of babies are born to mothers born outside the UK.
  • Over three quarters of pregnant women had an antenatal assessment within the first 12 weeks of pregnancy, which is similar to the London average.  
  • The proportion of deliveries by caesarean section was significantly higher than the national average; this includes both elective and emergency caesarean deliveries.
  • Infant mortality rates are statistically similar to the national average.
  • The proportion of babies born with low birth weight is significantly lower than for England as a whole.

These findings from the London Maternity Pathway profile 2011-12 1and ChiMat 2 provide an overview of key issues and are based on nationally available data. It is important to note that some data is only available at primary care trust (PCT) level (Sutton and Merton) and that it may not reflect more recent local data.

Mother’s age

Analysis of women giving birth in Sutton and Merton during 2010-11 shows that the highest proportion of deliveries were to women aged 30-34 years old, accounting for 34.8% of all deliveries. 25% of deliveries were to women aged 35 and over. 2.6% of deliveries were to mothers under 20 years, compared with 3.1% for London and 5.5% for England.

Mothers aged 19 and under and mothers over 35 years old, and their babies, are at greater risk. Teenage mothers are at increased risk due to late presentation and the mother’s lifestyle and diet. Older mothers present a series of different challenges. They have a greater chance of developing medical disorders such as diabetes, high blood pressure or other chronic diseases. The likelihood of still births and multiple births also increases with the mother’s age. For more information on teenage pregnancy, see Lifestyle risk factors

Mother’s ethnicity

There are a number of reasons why the ethnicity of mothers in a local area may influence the needs which the services provided must meet. For example:

  • Certain conditions are known to be more common in particular ethnic groups, such as diabetes.
  • Mothers or their families who have recently moved to the UK may have difficulty reading or speaking English.
  • Different cultural norms may exist.

In Merton, just under 60% of babies were born to mothers who were born outside of the UK, which was similar to London, but significantly higher than England.

 

Babies born by country of mother’s birth 2012.

 

In 2013, 35.2% of all women aged 15-44 in Merton were from black and minority ethnic (BME) groups.3This is projected to rise to just under 40% by 2021.

 

Percentage of females aged 15-44 years by ethnic group –2013.

 

Percentage of females aged 15-44 years by ethnic group –2021

 

Maternity care

Antenatal care

The early stages of pregnancy are a key time in a baby’s development and a mother’s health. It is important for a woman to meet her midwife early and plan the care that she and her baby will need. All women are encouraged to contact Maternity Services as soon as they are pregnant and especially before 13 weeks of pregnancy

In Sutton and Merton in 2010-11, 77.9% of women recorded had an antenatal assessment before the first 13 weeks of pregnancy, compared with 75.5% for London and 84% for England. This means that about 1,000 women in Sutton and Merton did not receive antenatal care within 13 weeks of pregnancy. However, this data should be treated with caution as the level or recording has historically been low. Analysis by ethnic group shows that recording was lower for black and mixed race groups.4

Smoking in pregnancy

Smoking is the UK’s single greatest cause of preventable illness and early death. Smoking during pregnancy can cause complications during labour and an increased risk of miscarriage, premature birth, stillbirth, low birth weight and sudden unexpected death in infancy. Children may also suffer from on-going health risks such as symptoms of asthma and problems of ear, nose and throat if growing up in a home where there are smokers.5

In Sutton and Merton in 2011-12, the levels of smoking recorded at the time of delivery was 6.6%, similar to London at 6% and significantly lower than England at 13.2%. This equates to just over 200 mothers recorded as smoking during pregnancy in Sutton and Merton.  

Labour and postnatal care

In 2009-10, 55.4% of mothers had normal deliveries in Sutton and Merton, which is lower than both London (58.5%) and England (61.4%). The proportion of deliveries by caesarean section was significantly higher than the national average, at 27% for Sutton and Merton, compared with 24% for England. Of these, in Sutton and Merton 10.8% were elective caesareans and 16.2% emergency.

 

Key facts on Maternity Services

Maternity Services

Of the births in Merton mothers can choose to go to St George’s Hospital NHS Trust; Epsom and St Helier University Hospitals NHS Trust; or Kingston Hospital NHS Foundation Trust. About half of mothers deliver at St George’s Hospital. From April 2013, Merton CCG is responsible for commissioning Maternity Services.

Most of the care and support provided to women and their babies before, during and after pregnancy are provided by GPs, the three hospital Midwifery Services, obstetricians and paediatricians at the three hospital trusts and Sutton and Merton Community Services (The Royal Marsden NHS Foundation Trust).

The Care Quality Commission (CQC) undertook a review of women’s experiences of maternity care (CQC 2010), which showed that Epsom and St Helier Hospitals, Kingston Hospital and St George’s Hospital were performing ‘about the same’ in terms of patient experience as other similar hospitals that were surveyed. Experience of feeding baby in the first few days at St George’s Hospital was identified as worse than similar hospitals. For more information on breastfeeding, see section below.  

Survey of women’s experiences of maternity care, CQC 2010.

NHS Trust Care during pregnancy Labour and birth Staff during labour and birth Care in hospital after the birth Feeding baby after the first few days
Epsom & St Helier Hospitals 7.8/10 7.4/10 8.6/10 7.1/10 5.7/10
Kingston Hospital 8/10 7.7/10 8.7/10 8.1/10 6.3/10
St George’s Hospital 7.9/10 7.6/10 8.2/10 6.7/10 5.3/10

 

In 2009-10, in Sutton and Merton spend on maternity care was an average of £5,435 per birth, which was slightly lower than the London average, but the same as for England. When broken down by secondary and primary care settings, Sutton and Merton had significantly lower average spend in primary care, at £112 per birth, compared with £256 in London and £392 for England as a whole.

Programme budgeting data based on PCT level spend (Sutton and Merton 2010-11) indicates that Merton has higher spend and better outcomes on its Maternity Services relative to other CCGs.

A recent report on maternity and newborn services in South West London6identified the challenges in the provision of maternity services, in particular: the impact of rising birth rates; increase in maternal age; high rates of maternal obesity and diabetes; and migration, affecting both the demand for services and types of services needed.  

The South West London & Surrey Downs Maternity Network has been established and is attended by Merton CCG representatives alongside other local CCG and acute trust representatives from across South West London and Surrey Downs.

 

Evidence on what works and best practice

The NICE provides guidance based on best available evidence and gives a range of advice and recommendations e.g. on effective interventions. NICE has produced pathways and clinical guidance for antenatal care; caesarean section; and antenatal and postnatal mental health.

NICE has also produced a pathway for guidance for pregnant women with complex social factors (NICE 2010). These include: recent arrival as a migrant; asylum seeker or refugee status; difficulty speaking or understanding English; age under 20; domestic abuse; poverty; homelessness; substance misuse. This is particularly important in terms of addressing health inequalities. General recommendations include:

  • tailor services to meet the needs of the local population – ensure there is good recording of women with complex needs to guide service provision
  • involve women in their antenatal care – ensure women are asked about satisfaction and that their feedback is used to guide service provision
  • provide training on multi-agency needs assessment and information sharing
  • give information and offer referral at the first contact
  • reinforce contact at the first booking appointment
  • coordinate care and communicate sensitively
  • keep handheld records up to date

NICE Pathways

 

Key commissioning recommendations for maternity care

  • With increasing birth rates, commissioners need to assess the need for increased capacity in Maternity Services to meet the needs of Merton mothers, in the context of a regional strategy for maternity care.
  • With increasing numbers of mothers born outside the UK and from BAME backgrounds, commissioners need to ensure that Maternity Services are culturally sensitive.
  • In order to address health inequalities in outcomes, there is a need to ensure that Antenatal and Maternity Services address the needs of pregnant women with complex social factors in line with NICE guidelines.
  • It is recommended that commissioners review progress on recording of early antenatal assessment to increase the number of women who receive early access to Maternity Services before 13 weeks of pregnancy, and to increase access to women from BME communities.
  • It is recommended that commissioners review the rate of caesarean deliveries, both elective and emergency, and identify how this can be reduced.
  • There is a need to ensure that the South West London maternity dashboard is monitored to provide standardised data from providers and ensure that there is robust analysis of data for the Merton population to inform commissioning.
  • Going forward, commissioners need to ensure that the new national Maternity and Children’s Data Set, which started collecting data in May 2013 and over time will result in comprehensive data (HSCIS-MCDS), informs local commissioning.

 

References

1.^London Maternity Pathway Profile (2011-12) London Health Programmes.

2.^Child and Maternal Health Observatory, Public Health England.

3.^ GLA 2012 Round SHLAA EGPP custom age range creator. October 2013.

4.^ DH reported on ChiMat ([2011]). Integrated Performance Measures Monitoring: 22.1% of 4,531 women in 2010-11.

5.^ NICE Guidance PH26 (2010) Quitting Smoking in Pregnancy and Following childbirth, p22.

6.^ Maternity and Newborn Clinical Working Group (2012). Final Clinical Report (March 2012) Better Services, Better Value.