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Level of need in the population

Adults :: Maternity and pregnancy :: Level of need in the population

Demographics and fertility rates

Population estimates for 2012 indicate there are 54,972 women of childbearing age (15–44 years) residing in Medway. This represents 20.5% of the total (male and female) population, a slightly higher proportion than the national estimate of 20.0% and South East estimate of 19.2%.

It is estimated that the number of women of this age group in Medway will increase in 2021 compared to 2011, by around 2,000 as shown in table 1.

2011 2016 2021
Number Number Difference (%) Number Difference (%)
Medway 54600 55000 0.7 56500 3.5
South East 1679900 1665400 -0.9 1675100 -0.3
England 10725400 10711900 -0.1 10821300 0.9
Table 1: Projections based on mid 2011 estimates of the population aged 15–44 years [1]

Some areas in Medway have a larger percentage of women in this age group than others. Figure 1 shows where the highest proportions of women aged 15–44 live in Medway.

Figure 1: Percentage of female population aged 15 to 44 years, by lower layer super output area, with ward boundaries.
Figure 1: Percentage of female population aged 15 to 44 years, by lower layer super output area, with ward boundaries

Figure 2 shows which wards in Medway have the highest number of women aged 15–44 residing of BME ethnicity.

Figure 2: Number of females aged 15-44 with ethnicity other than White British, Irish or Irish/gypsy traveller.
Figure 2: Number of females aged 15-44 with ethnicity other than White British, Irish or Irish/gypsy traveller

In 2012, there were 3,693 live births to mothers usually resident in Medway. Table 2 shows the year on year increase since 2006. The increase between 2006 and 2012 is 436 (13.4%).

  2006 2007 2008 2009 2010 2011 2012
Medway 3,257 3,345 3,419 3,515 3,538 3,564 3,693
Table 2: Live births to Medway residents, 2006 to 2012 [2]

The distribution of live births in 2012 by age of mother suggests that women in Medway are choosing to have babies younger than in the South East and England (figure 3).

Figure 3: The percentage of 2012 live births per age band.
Figure 3: The percentage of 2012 live births per age band [2]

This is supported by analysing the general fertility rate by age group. Figure 4 shows that women aged under 30 resident in Medway have consistently had a higher general fertility rate than for the South East and England. For women aged 30 and over, however, this pattern reverses.

Figure 4: General fertility rate (live births per 1,000 females aged 15-44) trend, by age band, 2003 to 2012.
Figure 4: General fertility rate (live births per 1,000 females aged 15-44) trend, by age band, 2003 to 2012 [2]

The overall general fertility rate for Medway residents in 2012 was 67.2 per 1,000 females aged 15-44, higher than for England (64.9 per 1,000). In line with national trends, this has increased over recent years (figure 5). In 2012, Medway's rate was significantly higher than for the South East.

Figure 5: General fertility rate (live births per 1,000 females aged 15-44) trend, 2003 to 2012.
Figure 5: General fertility rate (live births per 1,000 females aged 15-44) trend, 2003 to 2012 [2]

The total period fertility rate (the average number of children a woman is expected to have during her reproductive life if she experiences the current age specific fertility rates) in Medway has been consistently higher than the England rate over recent years with the exception of 2008 when it was the same as the national rate of 1.97.

  2006 2007 2008 2009 2010 2011
Medway 1.9 2.0 2.0 2.1 2.1 2.0
England 1.9 1.9 2.0 2.0 2.0 1.9
Table 3: Total period fertility rate, Medway and England 2006 to 2011 [3] [2]

Abortions

Some pregnancies are unplanned to the extent that they result in terminations. Figure 6 shows that the rate of terminations is significantly higher in Medway than in England. In 2012, there were 1,094 terminations in Medway resident women. The highest age group was 20-24 years old with 349 terminations. This suggests there is a need for more effective sexual health and contraceptive services in Medway.

Figure 6: The rate of abortions per 1,000 Medway resident women,2012.
Figure 6: The rate of abortions per 1,000 Medway resident women,2012 [4]

Booking

Women are encouraged to contact midwifery services as soon after they are aware they are pregnant as possible. Medway NHS Foundation Trust (MFT) offers “early bird group sessions” where women in the early stages of pregnancy have the opportunity to receive information and advice from community midwives prior to their booking appointment which is ideally at 8–10 weeks gestation (measured from the first day of a woman's last menstrual period). Data from MFT of the week of booking in is shown in table 4. Owing to the number of unknown/blank entries, definite conclusions cannot be drawn, but it seems most women are booking in prior to 12 weeks gestation and the number of unknown entries is reducing year on year.

  2009 2010 2011 2012 2013
<6 weeks 181 594 554 342 216
6-8 weeks 374 974 925 924 840
8-10 weeks 574 1,271 1,396 1,490 1,468
10-12 weeks 281 556 592 860 766
12-16 weeks 115 232 253 375 358
16-20 weeks 44 72 78 94 90
20-24 weeks 21 57 58 60 54
24-30 weeks 22 40 48 42 44
30+ weeks 28 38 64 70 81
Can’t remember/don’t know/blank 3,156 1,056 975 951 944
Table 4: Gestation of women booking at MFT, 2009 to 2013 [5]
Where do women booking at Medway hospital live?

The majority of women registered with Medway GP practices are booked for maternity care with MFT. This hospital also provides maternity care for a large proportion of women in Swale. Table 5 shows the local authority of residence of women giving birth at MFT. The number of women from Maidstone district has almost doubled in 2012 compared to 2009. This could be partly due to the consultant-led maternity provision moving to Pembury hospital in Tunbridge Wells, although the number has reduced again in 2013. Figure 7 shows the same data, but hotspots by lower super output area (LSOA) the areas with the highest numbers of women booking into MFT.

  2009 2010 2011 2012 2013
Medway 3,274 3,284 3,387 3,488 3,279
Swale 1,263 1,351 1,284 1,361 1,339
Maidstone 78 94 104 141 102
Tonbridge and Malling 76 65 77 95 85
Gravesham 34 22 34 36 38
Canterbury 5 6 11 19 6
Dartford 6 5 7 15 12
Bexley 5 7 5 8 4
Other 28 31 26 34 26
Total 4,769 4,865 4,935 5,197 4,891
Table 5: Local authority of residence of women booking at MFT
Figure 7: Lower super output area of residence of women booking at MFT, 2009 to 2012.
Figure 7: Lower super output area of residence of women booking at MFT, 2009 to 2012

Table 6 shows that, of the women living in Medway and booking in at MFT, nearly 10% live in the Gillingham North ward. A high proportion of women also live in Chatham Central, Gillingham South and Luton and Wayfield. These 4 wards represent a third of women living in Medway and booking in at MFT.

  Number Proportion
Gillingham North 1,535 9.3
Chatham Central 1,488 9.1
Gillingham South 1,316 8.0
Luton and Wayfield 1,199 7.3
Strood South 1,077 6.6
Princes Park 770 4.7
Strood Rural 758 4.6
Rainham South 739 4.5
Rochester East 734 4.5
Strood North 739 4.5
Twydall 721 4.4
Peninsula 614 3.7
Rochester South and Horsted 586 3.6
Rochester West 584 3.6
Lordswood and Capstone 554 3.4
Walderslade 538 3.3
Rainham Central 516 3.1
Rainham North 508 3.1
River 503 3.1
Watling 435 2.6
Hempstead and Wigmore 315 1.9
Cuxton and Halling 207 1.3
Table 6: The ward of residence of Medway women booking at MFT, 2009 to 2013 [5]

Table 7 contains data for all women booking into MFT (not just those living in Medway) and so the deprivation quintiles used are for England. There is a reduction across the quintiles in 2013 compared to 2012 due to the lower number of births, with the exception of quintile 5 (least deprived).

  2009 2010 2011 2012 2013
1 928 1,027 1,017 1,122 1,082
2 1,639 1,583 1,648 1,729 1,603
3 795 791 812 809 729
4 612 703 635 775 691
5 568 518 558 502 527
Table 7: Deprivation quintile (England) of women booking at MFT, 1 = most deprived [5]

The number of women booking in at MFT with ethnicity 'Any other white background' has risen by 70% between 2009 and 2012 (table 8).

  2009 2010 2011 2012 2013
White British 4047 4087 4172 4,304 4,040
White Irish <5 <5 <5 9 6
Any other White background 209 275 279 355 343
Indian 106 114 114 123 99
Pakistani 26 28 26 22 28
Bangladeshi 38 26 22 29 27
Any other Asian background 32 51 46 48 65
White and Asian <5 14 6 11 13
White and black African 6 <5 7 7 6
White and black Caribbean 7 11 9 15 9
Any other mixed background 20 15 17 19 15
Black African 110 142 128 140 130
Black Caribbean 24 25 24 16 25
Any other Black background 15 11 8 13 9
Chinese 18 18 21 23 17
Any other ethnic group 98 51 59 62 63
Not collected/Not stated/blank 34 17 10 13 15
Table 8: Ethnicity of women booking in at MFT [5]

Parity and Gravidity

Parity is the number of children previously born at a gestation of 24 weeks or more, regardless of whether they were live or stillborn, and gravidity is the number of times a woman has been pregnant. As mentioned in the last section, parity can be a factor in infant mortality. The number 'unknown' has fallen significantly in 2013.

  2009 2010 2011 2012 2013
0 2,048 2,152 2,201 2,240 2,120
1 1,526 1,595 1,564 1,809 1,734
2 709 664 756 745 710
3 271 282 268 304 234
4 86 98 87 99 110
5 36 40 38 25 34
6 18 16 15 14 18
7 and over 12 16 15 19 18
Unknown 173 120 88 57 16
Table 9: The number of births with the following parity [5]
  2009 2010 2011 2012 2013
1 1,727 1,729 1,750 1,772 1,651
2 1,447 1,531 1,471 1,542 1,458
3 796 838 822 958 882
4 362 399 449 479 474
5 187 177 230 241 235
6 90 91 104 121 133
7 41 49 51 64 69
8 21 21 25 36 33
9 21 17 22 21 14
10 12 6 7 11 9
11 and over 175 125 102 67 35
Unknown 0 0 0 0 1
Table 10: The number of births with the following gravidity [5]

Languages

Table 11 shows the main languages spoken by women aged 16-49 resident in Medway and the five wards with the highest numbers of women of child bearing age. Women in these wards account for just over 31% of all women aged 16-49 in Medway, but they account for 60% of speakers of languages other than English. 78% with a main language of 'other South Asian language' live in these five wards along with 66% of Gujarati and 'other European language (non EU)' speakers. Please note this is a table of the main language spoken and English may be a second language for anyone not having it as their primary language.

  Medway Chatham Central Gillingham North Gillingham South Luton and Wayfield River
English 58,399 3,581 4,569 3,702 3,110 2,276
French 134 18 15 15 8 7
Portuguese 101 20 11 7 8 6
Spanish 91 15 6 3 5 10
Polish 589 124 58 77 78 34
Other European language (EU) 1,145 255 112 145 149 91
Other European language (non EU) 383 79 31 39 46 34
Arabic 70 5 10 6 3 15
West/Central Asian language 88 14 6 15 7 10
Panjabi 302 59 13 32 15 3
Urdu 115 12 13 32 11 4
Bengali (with Sylheti and Chatgaya) 207 57 11 31 13 8
Gujarati 76 16 7 12 6 9
Tamil 71 6 8 7 6 13
Any other South Asian language 234 30 21 60 4 68
Chinese 209 25 23 15 7 44
Any other East Asian language 283 34 31 75 17 13
African language 236 32 31 24 19 26
Other language 28 4 6 3 2 2
Total 62,761 4,386 4,982 4,300 3,514 2,673
Table 11: The main language spoken by resident women aged 16-49 [6]

Delivery

Place of delivery

The Birth Place opened in October 2011 and it can be seen in table 12 the impact this has had on the number of deliveries in the Delivery Suite. The number of deliveries in theatre has gone up however, in line with the increase in emergency caesarean sections shown in table 13. The number of planned homebirths decreased by nearly 40% between 2011 and 2012

  2009 2010 2011 2012 2013
Delivery Suite 3036 3122 3067 2430 2374
Theatre 1437 1472 1448 1696 1576
The Birth Place <5 <5 152 882 770
Planned homebirth 187 157 145 89 87
Unknown 121 140 131 87 57
Unplanned homebirth 56 52 46 72 73
Other ward/triage/hospital grounds 29 27 29 31 44
In ambulance on route to hospital <5 <5 <5 12 <5
A&E <5 <5 6 10 5
Other 6 5 6 <5 6
Table 12: Number of births at each location between 2009 and 2013 [5]
Type of delivery

There has been a 19% increase in emergency c-sections between 2009 and 2012 (+149). The number of normal vaginal deliveries has also increased (7.5%, +234). 'Breech' means a breech vaginal delivery. The majority of breech presentations are likely to be delivered by caesarean. Despite the lower number of births in 2013, the number requiring forceps continues to rise.

  2009 2010 2011 2012 2013
Delivery Suite 3036 3122 3067 2430 2374
Theatre 1437 1472 1448 1696 1576
The Birth Place <5 <5 152 882 770
Planned homebirth 187 157 145 89 87
Unknown 121 140 131 87 57
Unplanned homebirth 56 52 46 72 73
Other ward/triage/hospital grounds 29 27 29 31 44
In ambulance on route to hospital <5 <5 <5 12 <5
A&E <5 <5 6 10 5
Other 6 5 6 <5 6
Table 13: Method of delivery [5]

Figure 8 is data taken from nationally published tables and shows that the proportion of elective caesarean sections has decreased slightly over the last four years; Medway is not significantly different to England. However, the proportion of emergency caesarean sections is increasing in Medway, whilst England is approximately stable meaning that Medway is significantly higher.

Figure 8: The proportion of deliveries that are elective or emergency caesarean sections.
Figure 8: The proportion of deliveries that are elective or emergency caesarean sections [7]
Pain relief

Table 14 shows the number of deliveries using the main types of pain relief. It is common for women to use more than one type of relief during labour and delivery. Regional anaesthesia is also known as a spinal block and is used for caesareans.

  Pethidine Epidural Entonox None Other Regional.Anaesthesia
2012 912 790 3,022 1,145 101 67
2013 798 782 2,867 733 85 47
Table 14: The number of births involving each type of pain relief in 2012 and 2013 [5]
Smoking at time of delivery (SATOD)

Smoking in pregnancy has significant health consequences. Babies of women who smoke are more likely to be born prematurely, have twice the risk of being low birthweight and are up to three times more likely to die from Sudden Unexpected Death in Infancy (SUDI). Figure 9 shows the percentage of women smoking at time of delivery in Medway is significantly higher than in England.

Figure 9: The percentage of women smoking at time of delivery.
Figure 9: The percentage of women smoking at time of delivery [8]

Accurate recording of smoking status at time of delivery has now been implemented as a CQUIN (Commissioning for Quality and Innovation) indicator meaning that, as of April 2013, more women have their smoking status accurately recorded at time of delivery.

  Number of mothers Number smoking at delivery Percentage
Apr 2013 298 57 19.1
May 2013 264 42 15.9
Jun 2013 281 50 17.8
Jul 2013 339 48 14.2
Aug 2013 310 54 17.4
Sep 2013 335 56 16.7
Oct 2013 348 61 17.5
Nov 2013 311 56 18.0
Dec 2013 284 56 19.7
Table 15: Number of mothers smoking at time of delivery [5]

Mortality rates

Still births and deaths in infancy are rare events so three year rolling averages are used for the presentation of this data. Figure 10 shows that the still birth rate for 2010-12 was 4.8 per 1,000 total births.

Figure 10: Stillbirth rate in Medway and England, 3 year pooled data, 2001 to 2012.
Figure 10: Stillbirth rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

The neonatal mortality rate in Medway for 2010-12 was 2.1 per 1,000 live births, the lowest rate since 2001-03, but not significantly lower than England. The trend is shown in figure 11.

Figure 11: Neonatal mortality rate in Medway and England, 3 year pooled data, 2001 to 2012.
Figure 11: Neonatal mortality rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

Table 16 shows the causes of neonatal deaths in England and Wales in 2011. The most common causes are conditions related to prematurity. This is supported when considering mortality rates by birthweight. In 2011, babies with birthweight <1,500 grams had a neonatal mortality rate of 145.4 per 1,000 live births in England and Wales. For babies with birthweight <2,500 grams, the neonatal mortality rate was 28.9 per 1,000 births compared to 0.7 per 1,000 live births with birthweight at least 2,500 grams.

  Number Proportion (%)
Immaturity related conditions 1,207 57.6
Congenital anomalies 553 26.4
Asphyxia, anoxia or trauma (intrapartum) 185 8.8
Antepartum infections 40 1.9
Other conditions 33 1.6
Infections 31 1.5
Sudden infant deaths 22 1.1
Other specific conditions 17 0.8
External conditions 7 0.3
Total 2,095
Table 16: Causes of neonatal deaths in England and Wales, 2011 [9]

Infant mortality rates have decreased nationally and in Medway over the past decade. Figure 12 shows that Medway's rate is lower than England, but not significantly so. The infant mortality rate in Medway for 2010-12 was 3.3 per 1,000 live births.

Figure 12: Infant mortality rate in Medway and England, 3 year pooled data, 2001 to 2012.
Figure 12: Infant mortality rate in Medway and England, 3 year pooled data, 2001 to 2012 [2]

Birth weight

Preterm babies often have low birth weights which is associated with inhibited growth and cognitive development, and chronic diseases later in life. Low birth weight also increases the risk of stillbirth. Figure 13 shows that the most common weight category is 3-3.5kg and most babies weighed between 3 and 4kg. Babies with a high birth weight are at higher risk of injuries during the birth and problems with blood sugar control. High birthweight is classified as more than 4.5kg (9lb 15oz).

Figure 13: Weight distribution of live births, 2009 to 2012.
Figure 13: Weight distribution of live births, 2009 to 2012 [2]

APGAR

The APGAR score was devised to quickly assess the health of a newborn baby by scoring 0 to 2 for: appearance/complexion, pulse rate, reflex irritability, activity and respiratory effort. Table 17 shows the APGAR scores of babies 5 minutes after birth. Babies with a 0 recorded have been excluded from table 17 due to uncertainty in recording practices.

  Number
1 10
2 8
3 10
4 19
5 55
6 107
7 221
8 568
9 8,759
10 13,941
Table 17: The number of babies with the following APGAR scores at 5 minutes, 2009 to 2013 [5]

Breastfeeding

Increasing breastfeeding initiation rates is an important target for the NHS in Medway. Breastfeeding is a key indicator of child health and wellbeing, which contributes to reducing infant mortality, health inequalities and obesity. There is evidence that babies who are breast fed experience lower levels of gastro-intestinal and respiratory infection. Observational studies have shown that breastfeeding in associated with lower levels of child obesity.

The UK Infant Feeding Survey 2010 [10] showed that 81% of women in the UK breastfed their babies after birth. By 6 weeks, this was down to 55% of mothers, 7 percentage points higher than in the 2005 survey. However, 85% of women stopping breastfeeding between 1 and 2 weeks said they would have preferred to breastfeed for longer. This suggests that much more could be done to support and help them to exclusively breastfeed up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond as per World Health Organisation guidance.

Breastfeeding rates in Medway are well below the national average and have remained at that rate for several years. The percentage of mothers initiating breastfeeding in Medway was 71% in Q2 of 2013/14. Medway has consistently been below the national and regional level each quarter. By the age of 6–8 weeks, 39.8% of babies were still receiving breast milk in Medway. [11] This represents a significant fall in breastfeeding rates during the first two months after birth.

Figure 14: Percentage of women initiating breastfeeding, 2009/10 -- 2013/14.
Figure 14: Percentage of women initiating breastfeeding, 2009/10 – 2013/14 [11]

Figure 15 shows the percentage of babies either totally or partially breastfed at 6–8 weeks of age. Totally breastfed is defined as infants who are exclusively receiving breast milk - that is, they are not receiving formula milk, any other liquids or food. Partially breastfed is defined as infants who are receiving breast milk and who are also receiving formula milk or any other liquids or food. [12]

Figure 15: Percentage of women breastfeeding at 6--8 weeks, 2009/10 -- 2013/14 .
Figure 15: Percentage of women breastfeeding at 6–8 weeks, 2009/10 – 2013/14 [11]

Breastfeeding can contribute significantly towards reducing health inequalities amongst those in the UK least likely to breastfeed. These groups were identified in the Infant Feeding Survey 2010 as white, under 20 years old, having left school at sixteen or younger, never worked, and living in the most deprived quintile.

In Medway, breastfeeding rates are highest among older mothers and those from the least deprived areas. White women are less likely to initiate breastfeeding than BME groups. Continuation of exclusive breastfeeding is lowest among younger mothers and White women. At the time of the Maternity Matters Needs Assessment (2007), only 25% of babies born to White women locally were receiving any breast milk at 6 to 8 weeks compared with 62% of babies born to women from Black/ Black British background. [13]

Funding from the Department of Health in 2009 has enabled a programme of interventions to be put in place to increase breastfeeding in Medway. These interventions include:


• Development of a cross-organisation Infant Feeding Strategy (see appendices) and a group which meets quarterly to implement it.
• Implementation of the UNICEF UK Baby Friendly Initiative (BFI) as routine practice in maternity and community services.
• Maternity services achieved the Certificate of Commitment for BFI in August 2011 and the Level 1 award in 2012.
• Community services achieved the UNICEF UK BFI Level 2 Award in September 2011 and are working towards the Level 3 award with the assessment in summer 2014.
• Introduction of a peer support network (Medway Breastfeeding Network) to support local mothers.
• Implement workforce training and development in all maternity and early years settings to increase knowledge of infant feeding. The Infant Feeding Strategy Group is working on a training matrix to assess the level of breastfeeding knowledge and skill amongst the workforce. Training in introducing solids is now being delivered to Children's Centre staff.


References

[1]   Office for National Statistics. Sub-national population projections, 2008- based projections
[2]   Office for National Statistics. Vital statistics tables
[3]   The NHS Information Centre for Health and Social Care. The Indicator Portal
[4]   Department of Health. Abortion Statistics, England and Wales 2013;
[5]   Medway Foundation NHS Trust.
[6]   Office for National Statistics. Table LC2104EW: Main language by sex and age 2012;
[7]   Health ans Social Care Information Centre. NHS Maternity Statistics - England 2012-13 2013;
[8]   Health and Social Care Information Centre. Statistics on Women's Smoking Status at Time of Delivery - England 2013;
[9]   Office for National Statistics. Infant and Perinatal Mortality in England and Wales 2011, Table 8
[10]   McAndrew F, Thompson J, Fellows L, et al. Infant Feeding Survey 2010 2012; The Information Centre for Health and Social Care. http://www.hscic.gov.uk/catalogue/PUB08694 .
[11]   Department of Health. Statistical Release: Breastfeeding initiation and prevalence at 6-8 weeks 2013; Department of Health. https://www.gov.uk/government/statistical-data-sets/breastfeeding-statistics-q4-2012-to-2013 .
[12]   Department of Health. Public Health Outcomes Framework 2012;
[13]   Bird A. Maternity Matters Needs Assessment 2009; NHS Medway. http://www.kmpho.nhs.uk/geographical-areas/primary-care-trusts/medway-pct/?assetdet956103=91215 .