Health Inequalities and antenatal care · Health Inequalities and antenatal care Christine Duncan Change Manager, Maternity Services Maternal & Infant Health Scottish Government Health

Health Inequalities and antenatal care

Christine Duncan

Change Manager, Maternity Services

Maternal & Infant Health Scottish Government Health Directorates

[email protected] 0131 244 4634

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Overview

What are health inequalities? What do we know? What can we do?

The determinants of health

What are health inequalities? People’s lifestyles and the conditions in which they live and work strongly influence their health.

health inequalities - unjust or unfair differences in health outcomes within or between defined populations

What are antenatal health inequalities?

•  Largely socially determined variations in health outcomes for women and their babies determined pre conceptually and during pregnancy.

•  have clinical manifestations that require effective clinical responses

•  They result in poor comparative health outcomes for women and their babies –are especially significant where any or some of the following circumstances interlock: poverty, age (teenage/older), ethnicity, domestic abuse, disability, substance misuse problems, alcohol +tobacco use.

•  Women living in families where both partners were unemployed, many of whom had features of social exclusion, were up to 20 times more likely to die than women from more advantaged groups (CMACE 2002 http://www.cemach.org.uk/Publications-Press-Releases/Report-Publications/Maternal-Mortality.aspx )

•  Infants of women living in complex social circumstances have an increased risk of dying during the perinatal period (NICE, 2010).

•  Children born to women from more vulnerable groups experience a higher risk of morbidity and face problems with pre-term labour, intrauterine growth restriction, low birth weight and higher levels of neonatal complications. (CMACE 2007)

WHAT WE KNOW

WHAT WE KNOW

•  High risk factors during pregnancy -substance misuse, domestic abuse, smoking as well as diet and maternal nutrition impact on a child’s subsequent health and development outcomes (Early Years Framework Evidence Briefing, add webpage).

•  Almost two thirds of pregnant women under 20 did not attend any antenatal classes, these young women were more likely to indicate that they did not like groups or did not know where antenatal classes were. (Growing Up in Scotland http://www.growingupinscotland.org.uk/)

•  Women from BME communities are up to 7 times more likely to die in childbirth (CMACE 2007)

First birth by age of mother and deprivation quintile

First Birth by Age of Mother and Deprivation QuintileYear ending 31 March 2009

0

100

200

300

400

500

600

Lessthan16

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43andoverAge

Num

ber

1 - Most Deprived2345 - Least Deprived

Source: Information Services Division

Births and drug misuse

Births recording drug misuse 2007/8, rate per 1,000 births, by deprivation quintile

0

2

4

6

8

10

12

14

16

18

20

1 - Most Deprived 2 3 4 5 - Least Deprived

Source: Information Services Division

Premature birth and deprivation

Prematurity (<37 wks gestation) rate per 1,000 total births by deprivation - 2008

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

1 - Most Deprived 2 3 4 5 - Least Deprived

Source: Information Services Division

Why health inequalities matter…

•  They are a strong indicator of social injustice •  They result in poor health, social,

educational and economic outcomes across the whole of the life course

•  They are a significant drain on public spending resources across health, social care, education and criminal justice departments

•  They significantly hamper Scotland realising its ambition of becoming a more successful country, with opportunities for all of to flourish.

Poverty and …..

•  Health inequalities follow a social gradient- not just about the most deprived

•  Disability- 50% of women with learning disabilities have their children taken into care

•  Gender based violence- 14% of maternal deaths had reported domestic violence, over 40% of the women who died of suicide were ‘living with domestic abuse’.

•  Race and ethnicity- women from BME communities up to 7 times more likely to die in childbirth

http://www.cmace.org.uk/ http://www.education.gov.uk/

Risk and protective factors

•  Pre-conceptual health •  Planned or unplanned

pregnancy •  Social circumstances •  Age •  Culture and networks •  Individual

characteristics •  Health Behaviours •  Maternal mental

health/wellbeing

Interlocking risk and protective factors

social

Psychological/physiological

Obstetric/medical

What can antenatal healthcare do?

Health inequalities arising in the antenatal period need to be tackled through all areas of public policy and all public services they cannot be tackled by health policy and health care alone.

However –antenatal healthcare has a unique and vital

contribution to make through: •  Improving access to antenatal care and the quality of

the care provided And •  Effective, collaborative work with other public services

including the Voluntary Sector.

Access and quality of care-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.

•  Quality of care experience reported by women is strongly socially patterned, declining in satisfaction with social status/position

Barriers to ‘Access’ Physical Cognitive Transport Literacy- health and reading/

writing skills

Timings Communication/language /information

Location Culture/beliefs

Key Messages Improving access and quality of antenatal care

will make a difference

Assessment and response to risks and protective featues should be a mutual process between women and health professional

Assessment of need needs to be inequalities sensitive- takes account of

individual circumstances, culture, literacy levels Effective assessment of and response to health and social care need is

highly dependant on continuity of carer(s) and care Continuity of care and carer(s) is critical to the safe and effective care of

women who have complex health and social care needs Effective collaboration between public services at policy, planning and

practice levels is critical

Action •  Refreshment of the framework for maternity

services- focusing on dimensions of healthcare Quality Strategy- person centred, safe, effective, equitable, efficient and timely

•  Antenatal inequalities guidance for NHS Boards •  Maternal and infant nutrition framework •  Improvements in information and data collection

and analysis •  GIRFEC •  FNP •  +++++………

Young mothers’ contact with health professionals in the early

years

Louise Marryat

Aims of the presentation

•  Provide brief introduction to GUS

•  To illustrate differences in circumstances and characteristics of mothers of different ages

•  To explore variations in engagement with health professionals

•  To examine differences in attitudes towards health professionals by maternal age

What is the Growing Up in Scotland study?

GUS: The A to Z of the Early Years

Accidents and injuries

Attachment

Behaviour

Child health

Diet

Childcare

Education

Family

Lone  parents    

Mental health

Neighbourhood

Obesity���

Parental support

Parenting styles

Resilience

Social networks

Births by age of mother, 1976 - 2008

0%

5%

10%

15%

20%

25%

30%

35%

40%

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

p

Under 2020 - 2425 - 2930 - 3435+

Source: ISD

First Birth by Age of Mother and Deprivation Quintile (2009)

p

0

100

200

300

400

500

600

Less

than

16 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

43 an

d ove

r

Age

Num

ber

1 - Most Deprived2345 - Least Deprived

Source: SMR02ISD Scotland

GUS family characteristics at 10mths by maternal age

48 44 44 47

11 816

8

0102030405060

Lowestincomegroup

No parentemployed

Living inarea with

highdeprivation

Lone parentfamily

%

Under 25 30 to 34

How does age affect engagement?

Reactive vs. proactive engagement

Reactive engagement

1319

32

812

24

05

101520253035

Child hadaccident or

injury

Childhospitalised

Contact withhealth prof for

illness 3+ times

%

Under 25 35+

Variations in ante-natal class attendance by maternal age for first-time mothers

38

16

46

72

14 14

01020304050607080

Went to all ormost

Went to some Didn't go to anyclasses

%

Under 25 35+

Reasons for not attending ante-natal classes by age

29

8

20

2

29

13

27

12

46

05

101520253035404550

Don't l

ike gr

oups

Didn't k

now w

here

they w

ere

No rea

son

No clas

ses a

vaila

ble

Other re

ason

s

%

Under 25 35+

For sources of advice on child health, younger mothers were… More likely to speak to their own parents (56% vs. 31%) Less likely to speak to a Health Visitor (52% vs. 58%) Less likely to use the internet

(6% vs. 16%) Equally likely to use a GP as a

source of advice (around 75%)

Attitudes towards parenting and help-seeking

•  “Nobody can teach you how to be a good parent, you just have to learn for yourself”

•  “If you ask for help or advice about parenting from professionals like doctors or social workers, they start interfering or trying to take over”

•  “It's difficult to ask people for help or advice about parenting unless you know them really well.”

•  “It's hard to know who to ask for help or advice about being a parent”

•  “If other people knew you were getting professional advice or support with parenting, they would probably think you were a bad parent”

•  “It’s more important to go with what the child wants than stick to a firm routine”

Parenting issues •  “Nobody can teach you how to be a good parent, you just

have to learn for yourself”

•  “If you ask for help or advice about parenting from professionals like doctors or social workers, they start interfering or trying to take over”

•  “It's difficult to ask people for help or advice about parenting unless you know them really well.”

•  “It's hard to know who to ask for help or advice about being a parent”

•  “If other people knew you were getting professional advice or support with parenting, they would probably think you were a bad parent”

•  “It’s more important to go with what the child wants than stick to a firm routine”

“Nobody can teach you how to be a good parent you just have to learn for yourself”

81

10 9

65

16 19

55

19 25

48

15

37

0102030405060708090

Strongly agree/agree

Neither agree nordisagree

Stronglydisagree/disagree

%

Under 25 25 to 2930 thru 34 35 or older

Parenting issues •  “Nobody can teach you how to be a good parent, you just

have to learn for yourself”

•  “If you ask for help or advice about parenting from professionals like doctors or social workers, they start interfering or trying to take over”

•  “It's difficult to ask people for help or advice about parenting unless you know them really well.”

•  “It's hard to know who to ask for help or advice about being a parent”

•  “If other people knew you were getting professional advice or support with parenting, they would probably think you were a bad parent”

•  “It’s more important to go with what the child wants than stick to a firm routine”

Conclusions

Young mums more likely to be from disadvantaged backgrounds

Reactive engagement is strong

Proactive engagement is far weaker

Partly due to set-up and logistics

Also due to attitudes towards help-seeking

Maternal Mental Health and Early Child Outcomes

Claudia Martin and Louise Marryat

Introduction

Instances of poor maternal mental health

None At one sweepAt two sweeps At three sweepsAt every sweep

Mothers experiencing poor mental health Mothers with poor mental health were

more likely to be living in difficult circumstances

Repeated mental health problems were

additionally associated with poor social support

Poor child outcomes and maternal mental health status

01020304050607080

Relations withpeers

Emotionalwell-being

Behaviour Cognitiveability:naming

task

Cognitiveability:picture

task

Good/average mental health Brief poor Repeated poor

Conclusions Maternal mental health was associated with socio-economic disadvantage, impoverished interpersonal relationships and poor social support. There was evidence of deficits in relation to children’s emotional, social and behavioural development linked to their mothers’ emotional well-being. When controlling for other factors, maternal mental health did not have an impact on child cognitive development Should mother’s mental health be monitored beyond the first few months after birth?

Further information: Claudia Martin Scottish Centre for Social Research [email protected] Louise Marryat Scottish Centre for Social Research [email protected]