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Maternal and child health – a national
and international perspective
Dr Hora Soltani
Health & Social Care Research Centre
Sheffield Hallam University
• What factors influence Maternal & Child Health (MCH):
– Local & National
– Global
• Current concerns & priorities in MCH from a national and global
perspective
• Effective MCH promotion strategies – group activity
– The role of health professionals in support of MCH
– The role of communities
– National and International Initiatives
• Health promotion and preventive strategies/services to
improve the health of mothers, infants, children and
adolescents in order to maintain/enhance the health of
families and communities as a whole.
• It is multidisciplinary.
• Objectives:
– reduce maternal, neonatal and child mortality &
morbidity
– the promotion of the physical and psychosocial health
and well-being of mothers and children/families in:
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reproductive health
the maternity cycle (preconception, pregnancy & birth, PP)
nutrition
infection
UK specific
• Changing Childbirth (1993)
• National Service Framework (NSF) 2004: for Children, Young
People & Maternity Services
• Healthcare Commission
• Maternity Matters 2007
• NICE guidance
• Centre for Maternal and Child Enquiries (CEMACE) [formerly
CEMACH]
– Maternal and Perinatal Health:
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National Maternal & Perinatal Mortality Surveillance
Maternal Death Enquiry
Obesity in Pregnancy
Intrapartum Care
Diabetes in Pregnancy
Child death review [Jan-Dec 2006] (28 Children days-18yrs) (n=150)
Head injury
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Between 2000-05 the HCC investigated complaints about poor maternity care at
Northwick Park Hospital in North London, New Cross Hospital in Wolverhampton
and Ashford and St Peter’s NHS Trust in Surrey (HCC report 2006).
10 Maternal Deaths between 2002-2005; Causes: 4 cases of Ecclampsia, 4 cases
of Post Partum Haemorrhage, 2 post C/S - Cardiac Arrest & Liver Rupture
Attributed to:
Failure to recognise when progress in labour deviates from the expected, normal
course of events.
Delays in seeking medical advice.
Lack of clear management plans for women whose pregnancies are classified as
high-risk.
Low staff numbers, high numbers of agency staff/locums and the impact on the
safety of patients.
Equipment failure, or a lack of equipment or facilities (baths & showers).
Failure to record blood results in the clinical case notes.
Commissioned a survey of maternity services (2007)
Woman-centred care:
• She must feel and be in control of what happens to her.
• She must be able to make informed decisions about her care,
based on her own needs.
• She must have input into service planning and design (service
user involvement).
• Maternity services should be based in the community, sensitive
to the needs of the local population and easily accessed by that
population.
• Women should have a choice of primary carer (NHS midwife,
independent MW or Doctor) and place of birth (home, birth
centre, hospital).
• There should be continuity of care and of the carer – a named
midwife (team of midwives), a named obstetrician (if required).
• NICE – Antenatal Care (ANC) guideline: a reduced no. of
antenatal visits.
• Confidential Enquiries into maternal death (saving mothers’
lives) 2007 or CEMACE.
– Maternal death (14/100,000) is a rare event.
– More than half of women who died were overweight or obese.
– Health inequalities: women from poor backgrounds were 7 times
more likely to die than those from other demographic backgrounds.
– A reduction in death from maternal suicide/mental health.
• Infant feeding survey (2005): 76% initiation but a dramatic
reduction at 6 weeks and 6 months.
Late ANC booking
• 17% of the women who died booked for maternity care after
22 weeks or had missed over four antenatal visits VS 5% of
women who were self-employed or had a partner in
employment.
Unemployment/Single
Parents – Lack of
(family) support
• A third of all women who died were either single and
unemployed or in a relationship where both partners were
unemployed.
• Of the 360 existing children whose mothers died, 112 were
already in the care of social services.
Ethnicity
• Black African women, including asylum seekers and newly
arrived refugees, have a mortality rate nearly six times
higher than White women. To a lesser extent, Black
Caribbean and Middle Eastern women also had a
significantly higher mortality rate.
Deprivation
• In England, women who lived in the most deprived areas
were five times more likely to die than women living in the
least deprived areas.
Of the women who died from any cause:
Domestic Abuse
• 4% self-declared that they were subject to
domestic abuse.
Substance abuse
• 11% had problems with substance abuse,
60% of whom were registered addicts.
Vulnerable
groups/Social
deprivation
• 10% lived in families known to the child
protection services.
Deprivation
• 1/3 of all stillbirths and neonatal deaths were born to
mothers in the most deprived quintile (compared with
the expected 20%).
• Stillbirth and neonatal mortality rates for mothers
resident in the most deprived areas were 1.7 times >
than those in the least deprived area.
Ethnicity
• Compared with women of White ethnicity, ethnicspecific mortality rates showed significantly higher
stillbirth, perinatal and neonatal death rates for women
of Black ethnicity (2.4, 2.4 and 2.2. times higher,
respectively) and Asian ethnicity (2.0, 1.9 and 1.8 times
higher, respectively).
•CEMACH aims to further explore these differences by developing
further analysis of specific causes of deaths by ethnic group.
Babies born to • Mortality
women from
VG had a
• Morbidity
higher risk of:
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Premature labour
Intrauterine growth restriction
Low Birth Weight
Higher rates of neonatal complications
Lower breastfeeding rates
• A lack of cross-disciplinary or cross-agency working.
Inter-disciplinary work
Communication
Language
Barrier
• There was poor communication, particularly the risk of self-harm
and child safety, between the health and social services, and there
was an assumption by social services that their pregnant clients
were receiving maternity care.
• Language barriers and unfamiliarity with the NHS, concerns about
confidentiality, and a lack of provision of services to meet the
individual needs of these women.
UK Mortality Incidence:
• The mortality rate for maternal
deaths from Indirect causes of
death was 7.71 per 100,000
maternities.
Social
Disadvantag
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Delayed
Pregnancy
Obesity
• The mortality rate for maternal
deaths from Direct causes of
death was 6.24 per 100,000
maternities.
Suboptimal
Care
Midwifery-led versus other models of care – Cochrane
review (11 trials: 12,276 women) – Women who were
randomised to MLC were:
Less likely to experience:
- antenatal hospitalisation
- the use of regional analgesia
- Episiotomy and instrumental delivery
- intra-partum analgesia/anaesthesia
- fetal loss (<24wks)
More likely to experience:
- vaginal birth
- a feeling of control during
labour and childbirth
- breastfeeding initiation
- shorter baby hospitalisation
Overall, there was no increased likelihood for any adverse outcome for women
or their infants associated with having been randomised to MLC.
Pre-conception care: (Opportunistic and planned) for women of
childbearing age with pre-existing serious medical or mental health
conditions that may be aggravated by pregnancy.
Migrant women who have not previously had a full medical examination
in the UK should have a medical history taken and a clinical assessment
should be made of their overall health, including a cardio-vascular
examination at booking or as soon as possible thereafter by an
appropriately trained doctor.
Women with genital mutilation should be sensitively asked about this
during their pregnancy and management plans for delivery should be
agreed upon during the antenatal period.
•Accessible and welcoming ANC – full booking from 1 to 12 weeks
gestation.
•Midwifery care should be offered to all women without complications.
International Perspectives
• Maternal mortality ratios range widely, from an estimated 12
maternal deaths per 100,000 live births in North America to more
than 700 per 100,000 in some parts of sub-Saharan Africa.
• For the developing world as a whole, maternal mortality is estimated
at more than 400 deaths per 100,000 live births, while the ratio is
below 30 per 100,000 in the developed world.
• One woman dies every minute (515,000/year).
Global maternal mortality: http://www.infoforhealth.org/pr/m12/m12chap2_2.shtml
• 99% of maternal deaths occur in developing countries.
• Maternal mortality is the largest disparity between the developed
and developing worlds.
• Pregnancy or birth complications are the leading cause of maternal
disability and death (15-49 yrs old) in developing countries – 20
times more than Maternal Death (MD) for an average woman in
Developed Countries (CDs).
• The huge implications for the child, family and community (e.g. caregiving, psychosocial and economic cost).
• 8.000.000 neonatal deaths (up to 1m perinatal (PN)) and stillborn
babies/year, mainly due to:
– Infection
– Asphyxia
– Prematurity and its complications
– 40-80% associated with Low Birth Weight (LBW)
• Almost all in developing countries.
• The mother and child’s health are inter-linked.
• Challenges – Interventions?
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Investment
Political commitment (war-peace)
Establishing reliable audit systems
Skilled birth attendants/Traditional Birth Attendants
Empowering communities: support networks
Facilitate access to care, prevent delayed referrals
Nutritional interventions (Vit A supplementation has reduced MD by
40% by reducing infection)
• Emphasis on women’s health rather than just FP
• Care continuum
• Improve mothers’ health, targeting women of childbearing age as
early as possible.
• Support education and provide skilled attendance at birth.
• Improve health and nutrition, prevent infection.
• Keep babies warm after birth.
• Encourage (long-term) breastfeeding.
Women and Children first available from http://www.wcf-uk.og/issues
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http://www.safemotherhood.org/
*Lawn JE, Tinker A, Munjanja SP, Cousens S. Where is maternal and child health now?
Lancet, 2006; 368(9546): 474-1477
Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwifery-led versus other models of
care delivery for childbearing women. Cochrane Database of Systematic Reviews, 2008
Lewis G. The Confidential Enquiry into maternal and child health (CEMACH). Saving
Mothers’ Lives: reviewing maternal deaths to make motherhood safer 2003-2005. UK, 2007
D'Souza L, Garcia J. Confidential Enquiry into Maternal and Child Health (CEMACH).
Perinatal Mortality 2006: England, Wales and Northern Ireland. CEMACH: London, 2008
D'Souza L, Garcia J. Improving services for disadvantaged childbearing women. Child:
Care, Health & Development 2004; 30: 599-611
Maternity Matters.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_073312
Maternal Mortality. http://www.patient.co.uk/showdoc/40000301/
Centre for Maternal and Child Enquiries (CEMACE). Improving the health of mothers,
babies and children. http://www.cmace.org.uk/Programmes/Child/Child-Death-Review.aspx
• Why psychosocial aspects are important
• An analysis of contributing psychosocial factors at the different
stages:
– (Pre-)conception
– Deciding on parenthood
– Antenatal
– Intrapartum, birth & postpartum
• Professionals’ impact
• The psychosocial preparation for birth
• Conclusion
• Pregnancy and birth are social as well as biological events.
• Pregnancy is a complex psychosocial event.
Motivations for reproduction:
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Genetic immortality.
– Achieving
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true adulthood.
desire to emulate parental care.
To actively explore a new object/source of love.
Cultural transmission: individual and societal goals intertwine to
pass on knowledge, skills, etc., so cultures develop a means to
promote this.
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Not only as survival but (in some cultures) children constitute
wealth.
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• Long-term commitment with irreversible effects.
• Contraception adds to the dilemma of choice and
parenthood – it’s no longer possible to “leave it to fate.”
• Modern life
– competing professional ambitions
– social and economic responsibilities on women
impacting on women’s inner desire “to be like
mummy”
• Wanting to be pregnant: is it the same as wanting
children?
• Positive prenatal attachment: trust in the outcome;
falling in love, chatting or daydreaming about the baby as
well as imagining a particular infant: the child of her
dreams.
• Neutral: a conscious effort to have no “feeling” or an
expectation of fear of something going wrong (more
common in cases of a previous baby loss) – protecting the
self or family.
• Negative: it’s normal at times but some women are
preoccupied with largely negative feelings.
Sometimes when I’m exhausted my baby seems so horrible, like a
monster: vicious, greedy and bad. I end up like a monster myself,
furious with my husband and with the pregnancy, just wanting to smash
everything up, get rid of it all and force everyone out of my way. But I
also feel desperate, like a screaming baby inside. What does all that do
to the fetus? How will I bear its crying when it’s born, not to mention
looking after it too? How will I cope without ever wanting to exterminate
the baby the way I feel my mother would have liked to get rid of me?
There is evidence to suggest
• Fetus is sensitive and reactive
• Aware of maternal reactions and affected by:
– Temperature
– Pressure
– Sound and light
– The mother's respiratory and vascular systems
i.e. There is a great responsibility for Professionals in dealing with
women to protect them from unnecessary impingements during
investigations.
• Professionals appear to be the key holders.
• They should know that the “mother’s eagerness
to know” is a sign of health (responsibility) rather
than idle curiosity.
• Profound psychological and physical changes occur during
pregnancy.
• Respect the normality of alterations (e.g. anxiety, worry, mood
changes, impaired concentration, regressive shifts and increased
dependence).
• Be vigilant for increased psycho-socio-economic stressors: a study
in south London 1st ANC found:
– 35% negative GHQ (general health Q)
– 29% psychiatric “cases” – largely neurotic depression
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Key steps
Housing & financial difficulties
Unemployment
Poor social support
Poor marital relationship
• Timely identification
• Referral
• Individual or group interventions
Triggering hidden vulnerable areas in women who appear healthy –
obtainable through looking at the AN/booking history
• Test interpretation – the
communication of results.
• Ultrasound scanning – the “Truth
Test”: reliance on professionals.
• Controversial evidence should be
rescanned: this is normal, informative,
reassuring and popular but increases
anxiety. There should be a balanced
use of technology – rescanning
should be kept to a minimum with
detailed feedback.
• Amniocentesis: anxiety over
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Awaiting Results
Fetal injury
Miscarriage
What to do if the fetus is abnormal…
Mother
Scanning
screen
• Emotional preparation: talking to other women, reading about labour,
discussing her fears with her friends, mother, etc.
• (Some) unconsciously work through their anxieties in repetitive
dreams.
• Daydreaming about the ideal birth: the accompanying person, the
type of birth, monitoring, the birth place.
• Preparation for disappointing realities rather than focusing solely on
ideal situations.
1. Psychoprophylactic (distraction):
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Introduced to the West by Dr Ferdinand LaMaze (from the
Pavlovian method from Russia).
Distraction from contractions and conscious control in the 2nd
stage of labour (patterned breathing).
Other methods include:
• Singing songs
• Envisaging a relaxing pastoral scene
2. The body harmony range
– By Dr Grantly Dick-Read (1940) (the father of natural
childbirth?)
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The fear-tension-pain syndrome (a self-perpetuating
syndrome).
The ability to overcome fear, tension and pain by a better
understanding of the labour process and deep breathing and
relaxation.
– Jacobson’s progressive relaxation
– Sheila Kitzinger’s approach: Physical and psychical education
to “foster a woman’s delight in the rhythmic harmony of her body’s
functioning, and training to maintain her conscious & active
participation, the power of self-direction.”
– Active birth: a combination of the above with changes in position
(kneeling, squatting or sitting), the use of gravity.
• Maternal responsibility phases (assumptions):
– Taking in: preoccupied with her own needs (2-3 days)
– Taking hold: tries to be in control, eager to learn but
this coincides with the “blues” – appropriate support
– Letting go: accepting the baby’s separation (10 days)
• Blues (50%-75%): a transitory syndrome of weepiness –
it coincides with rapid physiological & hormonal changes,
incoming milk.
• Encourage the woman to make a bridge between her
pregnant self and the mother-to-be to establish a new
emotional identity; early bonding helps.
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Keeping in mind the importance of maternal psychosocial well-being, the following skills/qualities are
essential for health professionals:
Effective communication (verbal and non-verbal), eye
contact, gestures
Appropriate questioning/sensitivity
Listening skills
Counselling abilities
– Empathy
– Acceptance
– Genuineness
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Raphael-Leff J. Psychological processes of childbearing. London:
Chapman & Hall,1991
Raphael-Leff J. Pregnancy – The inside story. London: Karnac
Ltd., 2003
DH: National Service Framework for Children, Young People and
Maternity Services – Executive Summary, 2004 . [Online] Available
from:
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTo
pics/ChildrenServices/fs/en
More references in your module guidebook