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Current services in relation to need

Adults :: Maternity and pregnancy :: Current services in relation to need

Ideally women should plan their pregnancies — this enables them to conceive a baby when they are physically as fit as possible — having given up smoking if they are smokers and gained a normal healthy weight. Planning a pregnancy also enables women to take a low dose of folic acid which has been proven to reduce neural tube defects such as spina bifida during the time when they are trying to conceive, vitamin D (deficiency impairs the absorption of dietary calcium and phosphorus, which can give rise to bone problems such as rickets in children, and bone pain and tenderness as a result of osteomalacia in adults) [1] and to discuss any changes in medication with their doctor if they have a chronic disease such as hypertension, epilepsy or diabetes so that they are not taking any drugs which might prove harmful to the baby and receive optimal care.

Medway hospital has a range of maternity services: Consultant Led Unit — Primarily for women with complications identified in their previous medical history, previous birth experiences or their current pregnancy or labour. All aspects of intrapartum care can be provided within Medway NHS Trust without the need to transfer women to a neighbouring Trust or specialist unit. Midwifery Led Unit (MLU) — The Birth Place is staffed and led by midwives and is designed for women experiencing low risk pregnancies. It is a co-located unit at Medway Hospital and has been open since October 2011. The unit contains five birth rooms two of which also contain birth pools as well as a 4-bedded postnatal bay. If an unforeseen complication occurs or there is a change in risk status, there is direct and instant access to the consultant led unit along the corridor. Home Births — All four community teams offer a home birth service. A planned home birth is a safe option for women with low risk pregnancies. A midwife will help in preparation for the birth and two midwives will attend the birth to assist with labour and delivery. In the case of any concerns during labour or birth, the woman will be transferred to the local consultant-led unit by ambulance accompanied by the attending midwife.

There are three wards that provide postnatal care.

Specialist maternity services

In every society there are some groups who are more vulnerable than others, brought about by societal factors and the environments in which people live. There are some common challenges across all vulnerable groups including the risk of stigma and discrimination, restricted access to educational opportunities and exclusion from income generation. Within these groups there are varying levels of vulnerability. This section illustrates the needs of some (it is not exhaustive) of the vulnerable groups in Medway and Swale. The intention here is to show how vulnerability is an important issue to consider in the design and implementation of services and programmes.

Smoking

The smoking status of the woman and her partner is assessed at booking and updated throughout her pregnancy. The effects of smoking on the fetus and new born baby are discussed. 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). Carbon monoxide (CO) levels have been assessed at booking since April 2011 and smoking cessation clinic services are offered to couples in collaboration with Medway Public Health.

Breastfeeding

The benefits of breastfeeding for both mother and baby are widely recognised, however the choice of feeding for mothers in Medway and Swale doesn't reflect this (for current breastfeeding levels, see Level of Need). Peer support workers attend the post natal wards voluntarily to offer help and advice to all women. Those women with particular breastfeeding issues that cannot be addressed by the ward staff are referred to the breastfeeding midwifery specialist who assesses their needs, makes a plan of care in collaboration with the mother and supports both her and the staff to achieve success. Breastfeeding promotion needs to be continued throughout the first six months following delivery. A specialist clinic for 1:1 advice and assessment of breastfeeding is run on a weekly basis by the breastfeeding midwifery specialist and the Medway Public Health breastfeeding lead. There are 26 breastfeeding support groups throughout Medway, available for all mothers to attend, run by the same peer support workers who attend the wards to provide continuity for the women. The Trust has achieved the UNICEF accreditation in breast feeding standards

Infectious Diseases and Haemoglobinopathy

There are on average 10 HIV cases per year, 35 Hepatitis B cases per year, 10 Hepatitis C cases per year and 6 syphilis cases per year. Clients require Genito-Urinary Medicine (GUM) input, specialist referral for the Hepatitis B and C to gastroenterology and lead consultant input.

There are 90 haemoglobinopathy (genetic defect that results in abnormal structure of one of the globin chains of the hemoglobin molecule, a common example being sickle-cell disease) carriers per year requiring partner testing. On average 10% will be carriers and require counselling from the Antenatal Screening Co-ordinator for Infectious Diseases and Haemoglobinopathies who has received additional training, to decide whether they wish invasive prenatal diagnosis followed by referral to fetal medicine. Around 50% choose prenatal diagnosis.

Substance Misuse

The Windmill Clinic is a joint midwifery and drug service clinic that is held on Tuesday afternoons alongside the Antenatal Clinic of the lead Obstetric Consultant for substance misuse. Any pregnant women with significant substance misuse issues including alcohol misuse can access care from a specialist midwife in substance misuse and a keyworker from KCA or Medway Alcohol Services.

The aim of the clinic is not to replace normal midwifery care – it is an extra service to provide specialist input under one roof. Clients with recognised high risk pregnancies (as recognised by NICE [2]) have access to Consultant obstetric care, specialist midwifery care, drug service care and access to obstetric ultrasound, phlebotomy and neonatal input in one place. As part of the clinic a weekly multidisciplinary meeting is held where the drug and alcohol keyworkers, specialist midwives in substance misuse, safeguarding and mental health, the liaison midwife from the transitional care ward as well as the neonatal liaison sister can meet to discuss clients.

  Heroin Alcohol Cannabis Amphetamine
2010 18 <5 <5 <5
2011 5 <5 <5 <5
2012 9 <5 <5 <5
2013 11 <5 <5 <5
Table 1: The number of women seen with substance misuse issues
Antenatal and Postnatal Mental Health

Women experiencing mental health problems during pregnancy or after birth are referred to the mental health specialist midwife who will offer them a one hour appointment to discuss their mental health needs, talk to them about how best to manage their psychological difficulties, advise them on the support available locally, and make referrals to specialist services if needed. Referrals come from other midwives, as well as GPs, obstetricians, social workers and health visitors.

There is a clear robust pathway to ensure women are referred to the obstetric lead and Mother and Infant Mental Health Service (MIMHS). There is a weekly multidisciplinary team meeting to review all cases. Participants include the specialist midwife, the specialist obstetrician, the perinatal psychologist, the specialist nurse and a midwife from the antenatal department. Since the development of this position, women and their families have experienced much more coordinated support to help them to improve their mental health.

  Advice by letter Received a consultation
2009 700 527
2010 850 1,000
2011 780 1,428
2012 900 600
2013 800 626
Table 2: The number of women receiving advice from the specialist midwife
Teenage Pregnancy

The Swale community team has a lead midwife who looks after young parents. The teenagers would benefit from multiple services being offered in one location on the same day. Liaison with representatives from Health Visiting, support for finances, education and other Medway Public Health services would be essential. There is a Family Nurse Partnership scheme available if the young women agree to engage with them. The Family Nurse Partnership is a maternal and early years public health programme. It provides on-going, intensive support to young, first–time mothers and their babies (and fathers/other family members, if mothers want them to take part). Structured home visits are delivered by highly trained nurses and start in early pregnancy, continuing until the child's second birthday. [3] A seamless service of care is provided by ensuring that the community midwives work closely with the clinical lead for safeguarding and mental health issues and Medway Public Health services.

Diabetes

Women with diabetes or those who develop diabetes in pregnancy are seen in a specialist clinic supported by lead midwives for diabetes. They are monitored closely throughout their pregnancy, owing to the associated risks, in the fetal medicine department and at a specialist antenatal clinic. The multi-disciplinary clinic includes the obstetric lead, the specialist midwife and a dietician all working collaboratively to ensure the best care for the women.

The specialist midwife for diabetes will accompany the woman to theatre, if an elective caesarean section has been decided upon, to provide continuity of care. During the postnatal period the clinical leads review the plans of care and support the ward staff to give the appropriate care. Training of all staff is a priority to ensure continuity of practise and the safe wellbeing of both the woman and her new baby.

The number of women booking in with diabetes was 120 in 2011, 130 in 2012 and 165 in 2013. Of those booking in 2013, 122 had gestational diabetes, 25 had Type 1 diabetes and 18 had Type 2 diabetes.

Obesity

Maternal obesity is a significant challenge for maternity services. According to the national audit of obesity during pregnancy by the Centre for Maternal and Child Enquiries (CMACE), the UK prevalence of women with a known BMI >35 at any point in pregnancy, who give birth at 24+ weeks' gestation, is 4.99%. This equates to approximately 38,478 maternities each year. The prevalence of women with a pregnancy BMI >40 (Class III obesity) in the UK is 2.01%, while super-morbid obesity BMI >50 is 0.19% of all women giving birth.

It is a challenge not only because of the increasing prevalence of the problem as almost one in five of pregnant women in the UK are obese, but also because of the impact that obesity has on women's reproductive health and the health of their babies. There are higher rates of miscarriage, fetal abnormality, blood pressure problems, diabetes, thrombosis, difficulty in delivery leading to higher caesarean rates and infection following delivery. Obesity also predisposes women to diabetes during pregnancy.

Care provision has been enhanced for women with issues of obesity with the introduction of a clinical midwifery specialist since June 2012. The lead midwife for obesity runs a clinic with an obstetrician and a support group for the women in her care with assistance from Medway Public Health (IC Mum). CNST requires the provision of support services for all women with a BMI of 30kg/m2. A healthy living clinic is run for women with a BMI of 35-44kg/m2 with no medical conditions. A preconception clinic would be valuable.

In 2013, 1,413 women booked in with a BMI 27–35 and 487 with a BMI over 35. In 2013, 252 new referrals attended who were then followed up in subsequent clinics. Five support group sessions were held with 20 couples at each.

Learning Disabilities

Working with colleagues at Medway Public Health has ensured that the Antenatal access pathway has appropriate and adequate steps in it for women with learning disabilities so that they are able to access maternity services. At booking the community midwives assess the women's needs and refer to other health professionals and care support as necessary. The women are assessed at each antenatal appointment to ensure that all risks are being addressed and that needs are met. Support from the specialist midwife for safeguarding and collaboration with social services will ensure that the mother and baby will be fully supported on discharge from the hospital and will have a safe transition into community care.

Safeguarding Children

The Trust has a specialist midwife who works collaboratively within a multidisciplinary team within health and social care, to assess risk factors and the needs of complex families. Through collaboration with the named community midwife, the specialist midwife will ensure that the care pathway is monitored throughout the antenatal period. All safeguarding referrals are alerted to the hospital staff to ensure continuity of information especially if circumstances change. The specialist midwife meets regularly with the women on the wards, during child protection conferences and pre discharge planning meetings in the community.

Training is high on the agenda for the maternity directorate, Trust-wide and for the Local Safeguarding Children's Board (LSCB).All maternity staff are required to update on safeguarding issues on a three yearly basis. The training for this update is bespoke to the needs of maternity staff and is mainly delivered by the specialist midwife. This is an area within the maternity directorate that will be improved so that more in-house training sessions can be offered on a regular basis, with a stronger focus on other vulnerable groups, for example, those with learning difficulties and teenage pregnancy.

The role has a responsibility to co-ordinate all cases. For child protection concerns, this is effective through ongoing supervision of each case and there is an essential bi-monthly meeting with the community midwives. For all other cases, for example concerns and vulnerability, there is a monthly meeting with each community team to monitor progress of the cases. The specialist midwife attends the child death overview panel meetings and contributes to investigations as necessary in order to support staff to learn from incidents, embed change and review policy.

There is now a new role of a Band 6 midwife support which will relieve the lead from a lot of the clinical aspects and allow time to develop the role.

Antenatal and newborn screening

There are 6 antenatal and newborn screening national programmes in England which are offered to women as part of routine antenatal care and to newborns.

The UK National Screening Committee (NSC) defines screening as “a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition”

Whilst screening has the potential to save lives or improve quality of life through early diagnosis of serious conditions, it is not a foolproof process. Screening can reduce the risk of developing a condition or its complications but it cannot offer a guarantee of protection. In any screening programme, there is a minimum of false positive results (wrongly reported as having the condition) and false negative results (wrongly reported as not having the condition). The UK NSC is increasingly presenting screening as risk reduction to emphasise this point.

The NHS screening agenda is driven by a range of NHS and Department of Health policies and standards. These can be viewed at www.screening.nhs.uk

The current UK National Screening Committee (UK NSC) programmes for antenatal and newborn screening are:

Antenatal:
• Sickle Cell and Thalassaemia
• Fetal Anomaly (Down's syndrome and fetal anomaly ultrasound)
• Infectious Diseases (Hepatitis B, HIV, Syphilis, Rubella)

Newborn screening:
• Newborn Blood Spot (Phenylketonuria, Medium Chain Acyl CoA Dehydrogenase Deficiency (MCADD), Cystic Fibrosis, Congenital Hypothyroidism, Sickle Cell)
• Newborn and Infant Physical Examination
• Newborn Hearing

Figure 1 shows the optimum time for the various screening tests

Figure 1: Antenatal and newborn screening timeline.
Figure 1: Antenatal and newborn screening timeline
Sickle Cell & Thalassaemia Screening Programme

Sickle Cell disorders are a group of heritable genetic conditions in which there is an abnormality of the haemoglobin. Haemoglobin carries oxygen to the various organs of the body and is contained in the red blood cells. In the sickle cell disorders, some of the red blood cells assume a sickle shape following the release of oxygen. This abnormal shape causes the cells to clump together making their passage through smaller blood vessels difficult, which may lead to blockage of these small blood vessels, death of tissues and an associated inflammatory reaction. Sickle Cell Disease is now the most common serious genetic condition in England, affecting more than 1 in 2,000 live births.

Thalassaemia major is a life threatening, genetically inherited, progressive anaemia common in the Mediterranean, Asian, South East Asian and Middle Eastern countries.

The screening for Sickle Cell and thalassaemia is offered to women between 10 to 12 weeks of pregnancy. The antenatal screening policy has been defined into two categories, high and low prevalence, based on a fetal prevalence of sickle cell disorders. High prevalence is defined as a fetal prevalence of more than 1.5 babies with sickle cell disorders per 10,000 births.

Kent and Medway were low prevalence areas until April 2011 when maternity units at Darent Valley Hospital (part of Dartford and Gravesham NHS Trust) were classified as high prevalence. In these sites all pregnant women are offered screening for sickle cell, thalassaemia and other haemoglobin variants rather than just those identified as high risk using a screening questionnaire asking about family history.

Fetal Anomaly Screening Programme

This programme offers screening for Down's syndrome and a minimum of two ultrasound scans during pregnancy to screen for physical (structural) abnormalities

Down's Syndrome is a genetic disorder, therefore present at birth and lifelong. It affects approximately one in every 1,000 babies. This figure is similar in all ethnic populations and is an overall population risk, though it increases markedly with maternal age. Down's Syndrome is caused by the presence of an extra copy of chromosome 21 in a baby's cells. It affects the physical appearance and the ability to learn. The severity of Down's syndrome symptoms can vary from person to person. There is currently no cure for the condition. However, there are treatments that can help someone with the syndrome to lead an active and independent life and the average life expectancy of someone with Down's syndrome is now 60–65 years of age. There are about 600 babies with Down's Syndrome born each year in the UK. The condition tends to affect male and female babies equally. It is estimated that there are approximately 60,000 people with Down's Syndrome currently living in the UK.

The recommended screening strategy for Down's Syndrome is for the combined test (blood test and nuchal translucency scan) undertaken between 10 and 14 weeks. Looking at two proteins in the blood test and measuring the thickness of the fluid in the back of the baby's neck calculates the risk of the women having a child with Down's Syndrome at her present age. If this is missed, a quadruple blood test can be done between 14 and 20 weeks which looks at four proteins.

As part of the NHS Fetal Anomaly screening programme, all women in England should be offered a minimum of two ultrasound scans during their pregnancy to screen for physical (structural) abnormalities in their unborn babies.

The first is an early scan, undertaken after eight weeks gestation and used mainly for dating the pregnancy and confirming viability. The second ultrasound scan is undertaken between 18+0 to 20+6 weeks of pregnancy and screens for major structural anomalies. In 2012/13, 3,647 women booking in Medway had a second ultrasound scan, of which 84 revealed a confirmed fetal anomaly (24 revealed serious cardiac abnormality).

Infectious Diseases Screening Programme

The Infectious Diseases in Pregnancy Screening (IDPS) Programme is responsible for ensuring that women with hepatitis B, HIV, syphilis and susceptibility to rubella infection are identified early in pregnancy, ideally between eight to twelve weeks. The tests can usually be taken from one blood test.

The four infections screened for are:


• Hepatitis B is a serious viral disease, which affects the liver. It is blood borne and may cause acute illness. Mothers can pass on their infection to their baby. An infected baby may develop liver problems later in life. To reduce the risk of infection, the newborn baby will be vaccinated within the first 24 hours of life and then given three further doses within the first 12 months.


• HIV, human immunodeficiency virus (HIV) results in progressive destruction of the immune system. As a result of this, an infected individual becomes susceptible to a number of different infections and is also liable to become wasted and also to develop neurological problems. It can be passed on to the baby and risk of this can be reduced by, for example, drug treatment and elective caesarian section.


• Rubella is no longer a common disease of childhood in the UK. This is a result of the Mumps, Measles and Rubella (MMR) vaccination programme . Rubella infection usually presents as a mild disease, often without symptoms. However if the infection occurs during pregnancy it can cross the placenta and pass to the fetus with serious consequences.


• Syphilis is a bacterial infection that is typically passed on through sexual contact. However, it can be passed on by intravenous drug use (injecting drugs directly into the vein), blood transfusions and from an infected mother to her unborn child.

  No. of tests completed No. positive results
Hepatitis B 5,505 21
HIV 5,500 6
Syphilis 5,502 8
Rubella Negative 5,502 319
Table 3: The number of women tested and found to have an infectious disease in Medway Foundation Trust in 2012/13 [4]

Of the women booking at Medway hospital in 2012/13, 140 women were administered MMR vaccination prior to leaving the hospital. The GP practice of each of these women was informed so that a second dose could be arranged subsequently.

Newborn Bloodspot Screening Programme

Parents of every newborn baby are offered a Newborn Screening Test. A heel prick blood sample, routinely taken between day five and eight is currently screened for Sickle Cell disorder as described earlier and five other conditions:

MCADD – 1 in 10,000 babies born in the UK has Medium Chain Acyl CoA Dehyrogenase Deficiency (MCADD).
Babies with this inherited condition have problems breaking down fats to make energy for the body. This can lead to serious illness, or even death. Screening means that most babies who have MCADD can be recognised early, allowing special attention to be given to their diet, including making sure they eat regularly. This care can prevent serious illness and allow babies with MCADD to develop normally.

Phenylketonuria – 1 in 10,000 babies born in the UK has phenylketonuria (PKU). Babies with this inherited condition are unable to process a substance in their food called phenylalanine. If untreated, they will develop serious, irreversible, mental disability. Screening means that babies with the condition can be treated early through a special diet, which will prevent severe disability and allow them to lead a normal life. If babies are not screened, but are later found to have PKU, it may be too late for the special diet to make a real difference.

Congenital Hypothyroidism – 1 in 4,000 babies born in the UK has congenital hypothyroidism (CHT).
Babies with CHT do not have enough of the hormone thyroxine. Without this hormone, they do not grow properly and can develop serious, permanent, physical and mental disability. Screening means that babies with CHT can be treated early with thyroxine tablets, which will prevent serious disability and allow them to develop normally. If babies are not screened and are later found to have CHT, it may be too late to prevent them becoming seriously disabled.

Cystic Fibrosis – 1 in 2,500 babies born in the UK has cystic fibrosis (CF) The condition is characterised by early onset of severe intestinal malabsorption, failure to thrive and recurrent chest infections and pneumonia, which, if untreated, leads to death from malnutrition and respiratory failure in infancy or early childhood.

Newborn Hearing Screening Programme

The early identification of hearing loss is known to be important for a child's development. One to two babies in every 1,000 are born with a hearing loss in one or both ears. Most of these babies are born into families with no history of hearing loss. The aim of the NHS Newborn Hearing Screening Programme (NHSP) is to identify all children born with moderate to profound permanent bilateral deafness within four to five weeks of birth and to ensure the provision of safe, high quality age-appropriate assessments and world-class support for deaf children and their families.

  2012 2013
Number of babies screened 5,202 4,984
Bilateral referrals 29 41
Unilateral referrals 174 168
Table 4: Babies born in Medway and Swale screened by West Kent NHSP
The Newborn and Infant Physical Examination Programme (NIPE)

Newborn and Infant Physical Examination Programme (NIPE) offers parents the opportunity of a head to toe physical examination for their baby to check for problems or abnormalities. The examination is carried out within 72 hours of birth and then again at six to eight weeks of age, as some conditions can develop later and includes a general all over physical check, as well as specific examination of the baby's:


• eyes
• heart
• hips
• and testes, in boys.

Quality Assurance

National Quality Assurance teams have been developed and commissioning frameworks for antenatal and newborn screening programmes are now in place.

Locally, Kent and Medway's Antenatal and Newborn Screening committee meet quarterly to review performance and promote compliance with national guidelines. Sub-groups have also been tasked to review individual programmes to ensure standards are met.

Antenatal and Newborn Midwifery Screening coordinators, Child Health Record Departments and the Newborn Screening Laboratory now report key performance indicators on a quarterly basis; this will improve understanding of the programmes and provide relevant and accurate data to manage performance and track trends.


References

[1]   Department of Health. Vitamin D - advice on supplements for at risk groups - letter from UK Chief Medical Officers 2012; Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213703/dh_132508.pdf .
[2]   National Institute for Health and Clinical Excellence. Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors September, 2010; National Institute for Health and Clinical Excellence. http://www.nice.org.uk/nicemedia/live/13167/50822/50822.pdf .
[3]   Family Nurse Partnership. 2014;
[4]   Kent and Medway Antenatal and Newborn Screening Coordinators.