Transcript The Government Economic Strategy

Health Inequalities and antenatal
care
Christine Duncan
Change Manager, Maternity Services
Maternal & Infant Health
Scottish Government Health Directorates
[email protected] 0131 244 4634
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.
WHAT WE KNOW
• 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/ReportPublications/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
• 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 Quintile
Year ending 31 March 2009
600
1 - Most Deprived
2
3
4
5 - Least Deprived
500
Number
400
300
200
100
0
Less 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
than
and
16
over
Age
Source: Information Services Division
Births and drug misuse
Births recording drug misuse 2007/8, rate per 1,000 births, by deprivation
quintile
20
18
16
14
12
10
8
6
4
2
0
1 - Most Deprived
2
Source: Information Services
Division
3
4
5 - Least Deprived
Premature birth and deprivation
Prematurity (<37 wks gestation) rate per 1,000 total births by deprivation - 2008
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1 - Most Deprived
2
Source: Information Services
Division
3
4
5 - Least Deprived
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
Transport
Cognitive
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?
Mental health
Accidents and injuries
Obesity
Family
Behaviour
Diet
Parenting styles
GUS: The A to Z of the Early Years
Child health
Neighbourhood
Lone parents
Attachment
Parental support
Resilience
Childcare
Education
Social networks
Births by age of mother, 1976 2008
40%
35%
30%
Under 20
20 - 24
25 - 29
30 - 34
35+
25%
20%
15%
10%
5%
Source: ISD
20
06
20
08
p
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
19
80
19
78
19
76
0%
First Birth by Age of Mother and
Deprivation Quintile (2009)
1 - Most Deprived
2
p
600
3
4
500
5 - Least Deprived
Number
400
300
200
100
42
ov
er
d
41
40
39
38
37
36
35
34
33
32
an
th
43
ss
Le
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
an
16
0
Age
Source: SMR02
ISD Scotland
GUS family characteristics at 10mths
by maternal age
60
50
40
% 30
20
10
0
Under 25
48
30 to 34
44
11
Lowest
income
group
47
44
16
8
No parent
employed
8
Living in Lone parent
area with
family
high
deprivation
How does age affect
engagement?
Reactive vs. proactive engagement
Reactive engagement
35
30
25
20
%
15
10
5
0
Under 25
35+
32
24
19
13
12
8
Child had
accident or
injury
Child
hospitalised
Contact with
health prof for
illness 3+ times
Variations in ante-natal class attendance
by maternal age for first-time mothers
80
70
60
50
% 40
30
20
10
0
72
Under 25
35+
46
38
16
Went to all or
most
14
14
Went to some Didn't go to any
classes
Reasons for not attending ante-natal
classes by age
Under 25
50
45
40
35
30
% 25
20
15
10
5
0
D
35+
46
29
29
20
13
8
7
2
't
on
e
lik
p
ou
r
g
s
D
id
no
t' k
n
w
wh
e
er
e
th
y
w
12
e
er
N
o
re
2
on
s
a
N
o
cla
es
ss
a
bl
la
i
va
e
t
O
r
he
r
so
ea
ns
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
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”
90
80
70
60
% 50
40
30
20
10
0
Under 25
30 thru 34
81
25 to 29
35 or older
65
55
48
37
16 19 15
10
Strongly agree/ Neither agree nor
agree
disagree
19
25
9
Strongly
disagree/
disagree
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 two sweeps
At every sweep
At one sweep
At three sweeps
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
Good/average mental health
Brief poor
Repeated poor
80
70
60
50
40
30
20
10
0
Relations with
peers
Emotional
well-being
Behaviour
Cognitive
Cognitive
ability:naming ability:picture
task
task
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]