Maternity and Infant Feeding

Executive Summary

Pregnancy is an important period of time, when a mother’s physical and mental health can have a lifelong impact upon her child. Evidence has shown that maternal stress, diet and alcohol or drug misuse can place a baby’s development at risk. ‘Social and biological influences on development start at conception, or earlier, in terms of genetic effects. (1) These accumulate through pregnancy to influence the health of the child at birth. From the time of birth, the individual is exposed to a wide range of experiences – social, economic, psychological and environmental.’ (2). Early identification of need and risk will ensure that appropriate monitoring, screening and support is put in place and higher risk parents who may need additional support are identified. Early access to antenatal care is essential and has a positive effect on low birth weight, infant mortality rates and infant feeding choices.

There were 13,542 live births in Surrey in 2015. The national average birth rate in 2015 was 62.5 per 1,000 population and in Surrey it was 63 per 1,000 population. Whilst there is an increase in the projected numbers of children under 1 in Surrey this is due to net migration rather than an increase in numbers of births (by a factor of 4 in 2022). Whilst we are seeing a decline or levelling off in terms of birth rate, the number of births is still increasing and the proportion of high risk and complex pregnancies continues to grow due to an increase in maternal age, raised body mass index and a number of long term conditions.

There are currently 5 maternity units, 3 community providers and large numbers of GPs providing maternity care across Surrey. Each service has evolved differently, partly in response to local need, but this has led to inconsistencies in the service offer. There are also challenges on these maternity services around workforce, demand and safety.

There are specific public health commissioned services around smoking, drugs and alcohol which have pathways for and prioritise pregnant women.

Introduced to the UK in 1995, the Unicef UK Baby Friendly Initiative is based on a global accreditation programme of Unicef and the World Health Organisation. It is designed to support breastfeeding and parent infant relationships by working with public services to improve standards of care. It is the first ever national intervention to have a positive effect on breastfeeding rates in the UK. Research has shown that even modest increases in breastfeeding can result in significant savings. The Baby Friendly standards deliver this change for public services (as evidenced by a studies showing the effectiveness of the Baby Friendly Initiative), whilst ensuring long lasting, sustainable improvements in the care of mothers and babies.

Recommendations for Commissioning:

  • There are a number of gaps in current information, there is a lack of consistent Surrey wide data on a number of public health potentially modifiable factors including, weight, mental health issues, drug and alcohol use in pregnancy.
  • There is a need for a more detailed maternity needs assessment in order to provide more detailed and localised data and to address work force and other issues.
  • Commissioners should continue to support the Unicef BFI programme due to the strong evidence base along with the other recommendations within the Surrey Breastfeeding Strategy.
  • Increasing rates of breastfeeding in neo-natal units should be a priority, especially for those units who do not have stand-alone BFI accreditation.
  • Commissioners should commission services which operate in partnership across the maternity pathway to support consistent delivery of public health messages.

Introduction

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There were 13,542 live births in Surrey in 2015. The national average birth rate in 2015 was 62.5 per 1,000 population and in Surrey it was 63 per 1,000 population. Whilst there is an increase in the projected numbers of children under 1 in Surrey this is due to net migration rather than an increase in numbers of births (by a factor of 4 in 2022). Whilst we are seeing a decline or levelling off in terms of birth rate, the number of births is still increasing and the proportion of high risk and complex pregnancies continues to grow due to an increase in maternal age, raised body mass index and a number of long term conditions.

Pregnancy is an important period of time, when a mother’s physical and mental health can have a lifelong impact upon her child. Evidence has shown that maternal stress, diet and alcohol or drug misuse can place a baby’s development at risk. ‘Social and biological influences on development start at conception, or earlier, in terms of genetic effects. (3) These accumulate through pregnancy to influence the health of the child at birth. From the time of birth, the individual is exposed to a wide range of experiences – social, economic, psychological and environmental.’ (2). Early identification of need and risk will ensure that appropriate monitoring, screening and support is put in place and higher risk parents who may need additional support are identified. Early access to antenatal care is essential and has a positive effect on low birth weight, infant mortality rates and infant feeding choices.

In their National Maternity Review, ‘Better Births’ the NHS sets out their ‘vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances.

And for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.’

A child’s long and short term health is influenced by their time in the womb and their early developmental years. Maternity is an important time for healthcare professionals to focus on the mother’s health and wellbeing, including their mental health as well as lifestyle factors such as diet, physical activity, smoking, drugs and alcohol and promote the benefits of breastfeeding. There is often a fear that if breastfeeding is actively promoted, bottle feeding mothers will be left out or made to feel guilty. Good antenatal information allows all women to make informed choices, skin-to-skin contact, keeping baby close and responsive feeding and building a relationship with their baby are important for all mothers. All women should be supported in their choice of feeding by their health professional. They should be offered an opportunity in the antenatal period to have a conversation about feeding, according to their needs.

Babies can get all the fluid, nutrients and energy they need from breast milk or first infant formula until they’re about six months old. From six months of age, a vitamin supplement containing vitamins A,C and D should be given to all babies (or when a formula fed baby is taking less than 500ml infant formula). Follow-on formula isn’t suitable for babies under six months and parents should be advised that there’s no need to introduce it after six months either. From 12 months old those babies on formula milk can be given cow’s milk with vitamin drops, research has shown no clear benefit to babies of follow-on formula.

Evidence shows that about six months is the best age for introducing solids. Before this,

the baby’s digestive system is still developing, and introducing solids too early can increase the risk of infections. Research has also shown that introducing solid food has virtually no impact on how long a baby sleeps. It is also easier to introduce solids at six months.

Who’s at risk and why?

The Marmot Report (2010) on health inequalities reports evidence that development begins before birth and that the health of the baby is significantly affected by the health and well being of the mother. One of the key policy recommendations from Marmot is ‘giving priority to pre- and post-natal interventions that reduce adverse outcomes of pregnancy and infancy.’

The National Institute for Clinical Excellence (NICE) antenatal standard now recommends early access for pregnant women to antenatal care at around 10 weeks gestation. This is vital as it has a direct positive effect on infant mortality and low birth weight. This allows the midwife to provide essential information about the pregnancy and give advice about folic acid, vitamin D and free Healthy Start Vitamins and lifestyle factors such as smoking, diet, drugs and alcohol in pregnancy early on. This also allows the midwife to assess risk and needs and give mothers available choices. There are differences in rates of timely access for antenatal care for certain groups of mothers, especially younger mothers.

The Chief Medical Officer report (2012) highlights the evidence around a baby’s social and emotional, language and cognitive development in infancy. Marmot in Fair Society, Healthy Lives suggested that in order to reduce future social and health inequalities we need to give every child the best start in life, and this reflects the view that the origins of much adult disease lie in the ‘developmental and biological disruptions occurring during the early years of life’ and more specifically what has recently been referred to as ‘the biological embedding of adversities during sensitive developmental periods’.

Nationally infant mortality is a significant factor in overall life expectancy, with 61% of all deaths in children (0-19 years) being infant deaths. Many of these stillbirths and deaths are preventable. Reducing infant deaths and stillbirths is a priority for the NHS and government, captured in the NHS and Public Health Outcomes Frameworks. (PHE, 2014). There are a number of risk factors for stillbirth and infant death. These include maternal age, maternal smoking, maternal obesity, socioeconomic position, multiple birth, and influenza.

Domestic Abuse

Pregnant women are at an increased risk of domestic abuse, with national prevalence rates of 5% to 21% during pregnancy and 13% to 21% postnatally. There is a significant threat to the health and wellbeing of the mother and baby that may lead to potential morbidity and mortality. A total of 80% of women in abusive relationships seek help at least once and, on average, seven to eight visits are made to health professionals before disclosure of abuse. Pregnant women are routinely screened for domestic abuse as part of the routine care in the UK, but we do not know what interventions work in reducing abuse in pregnancy. (4) Guidelines from NICE (2008) underlined the urgent need for evaluation of domestic abuse interventions.

Vaccines in pregnancy

Pregnant women are more likely to develop complications from flu, including pneumonia. It has also been shown that flu can increase the risk of miscarriage, low birth weight and in extreme cases stillbirth or death in the first week of life; therefore it is vitally important that pregnant women are offered a flu vaccination. In Surrey the uptake of the flu vaccine among pregnant women is 35.0%, which compares to 39.8% nationally. More information on vaccines in pregnancy and early years can be found in the Immunisation JSNA Chapter.

Infant feeding

In 20013/14, 81.7% of mothers giving birth in Surrey initiated breastfeeding their babies. The data for breastfeeding at 6-8 weeks (2012/13) based on information from 81.8% of babies, indicates that 57.3% were either totally or partially breastfed 6 to 8 weeks after birth, a drop of around 25%.

For generations in the UK, formula feeding and care based on strict routines has become the cultural norm (5). As a consequence, the physiological norm of breastfeeding, and subsequently emotional attachment and parenting skills, have been interrupted. In addition to this, media attention and social trends undermine women’s confidence in their ability to breastfeed (6). For some women living in this environment, breastfeeding can be very challenging. Women make decisions about their infant feeding choices for a variety of reasons, including their own cultural expectations and personal circumstances (7). If women then choose not to breastfeed, they need the best possible evidence-based information to help them to minimise the risks of formula feeding. (8)

Breastfeeding brings many advantages to both mothers and babies, including preterm infants. A total of 926 preterm infants were studied by (9). 51 of whom developed nectrotising enterocolitis (NEC). Exclusively formula-fed infants were 6 to 10 times more likely to develop NEC than those who received breastmilk. Although NEC is rare in babies over 30 weeks gestation, it was 20 times more common if the baby had received no breastmilk. There is also a correlation between higher rates of breastfeeding prevalence and lower rates of inpatient admissions among infants under one year old for 10 conditions: lower respiratory tract infections, infant feeding difficulties, wheezing, gastroenteritis, non-infective gastroenteritis, eczema, otitis media (ear infections), infant feed intolerance, lactose intolerance and asthma (10). This reduction in admissions has the potential to bring cost savings to the NHS. In the longer term, infants who are not breastfed tend to have higher blood pressure and are at greater risk of type 2 diabetes and obesity. (11). In addition to this the impact on outcomes for children who have been breastfed such as IQ and other measures of development is being consistently seen in high-quality studies. (12).

Breastfeeding provides a unique opportunity for attachment between mother and baby and can protect the child from maternal neglect. (13).

Benefits to the mother include:

  • Reduction in the incidence of pre-menopausal breast cancer (WCRF/AICR, 2009)
  • Reduction in the incidence of ovarian cancer (WCRF/AICR, 2009)
  • Reduction in the incidence of hip fractures, low bone density, osteoporosis and rheumatoid arthritis (14)
  • Increased likelihood of returning to pre-pregnancy weight (15)

Young mothers and mothers from lower socioeconomic groups, are least likely to breastfeed. (16). Evidence has demonstrated that a child from a low-income background who is breastfed is likely to have better health outcomes than a child from a more affluent background who is formula-fed. (17).

Necrotising Entercolitis

Necrotising enterocolitis (NEC) is now the most common gastrointestinal emergency occurring in neonates. Prematurity and low birth weight are the most important risk factors;

  • It mainly affects premature infants who, it is a disease with high morbidity and mortality.
  • With obstetric advances more infants of very low birth weight survive the neonatal period, increasing the population at risk of NEC.

NEC is rare in term babies as a whole; however, these account for 10% of cases. In term babies, the initiating events are different and it often associated with underlying disorders. (18), (19), (20).

Deprivation

Deprivation has been identified as a key risk factor for pre-term birth and infant mortality. (ONS, 2006) (PHE, 2014). A 2016 population study undertaken by the National Institute of Health Research (NIHR) on reducing variations toward infant mortality and morbidity showed that socio-economic inequalities have a direct impact on the outcome of pre-term birth. Rates of still birth are doubled in the most deprived areas. “Approximately 70% of all infant deaths are the result of pre-term birth or a major congenital abnormality, and those are heavily influenced by the mother’s exposure to deprivation.”

Low Birth Weight

Low birth weight is associated with poorer long term health and educational outcomes. Low birth weight is the % of live births born below 2500g.

Pre-term birth

A leading risk factor in SEND in children is pre-term birth, particularly before 37 weeks gestation. Research has shown that infants born before the full gestational period are at risk of short and long term consequences. (21).

Marlow et al. (22) found the ‘prevalence of neurodevelopmental impairment was significantly associated with length of gestation, with greater impairment as gestational age decreased: 45% at 22-23 weeks, 30% at 24 weeks, 25% at 25 weeks, and 20% at 26 weeks (P<0.001).’ They identified cerebral palsy, motor impairment, and developmental impairment as possible outcomes for extremely pre-term babies, with the risk increasing from 27 weeks to 22 weeks. There were 10 (out of 576 births) incidents of morbidity related to pre-birth. In a comparison to a similar study completed in 1995 the research shows that outcomes had improved for babies born before 27 weeks completed gestation, including survival rates and survival without disability.

Alcohol

Exposure to alcohol in utero can cause a number of disorders which can be ‘physical, cognitive, communicatory and psychiatric functioning.’ These disorders are often given the umbrella term of Foetal Alcohol Syndrome (FAS) or Foetal Alcohol Spectrum Disorder (FASD). Approximately 7000 babies in the UK are born with FASD (which includes FAS) and although there is no clear UK data, a European study showed that there were 40.8 cases per 100 in Croatia and 35.2 per 100 in Italy. (23)

FAS is marked by growth retardation, facial dysmorphia, abnormalities of the central nervous system (structural, neurological and functional) and rare birth defects (such as sensory and cardiac problems.). This can be prevented by the abstinence of drinking during pregnancy. (24) (25).

The Chief Medical Officers’ Guidance (2016) states:
‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to the baby to a minimum.

Drinking in pregnancy can lead to long-term harm to a baby, with the more you consume the greater the risk.

Most women either do not drink alcohol (19%) or stop drinking during pregnancy (40%).

The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy. Women who find out they are pregnant after already having drunk during early pregnancy, should avoid further drinking, but should be aware that it is unlikely in most cases that their baby has been affected.’

Drug use

Both recreational and habitual use of drugs during pregnancy is associated with adverse outcomes for children in the long term. A UK study looked at the use of methylenedioxymethamphetamine (MDMA) or ecstasy during pregnancy and assessed the exposed child at 12 months. They found that higher amounts of MDMA exposure predicted poorer mental and motor outcomes and assessor ratings of poorer motor quality in the children at 12 months than those with which they were compared. (26)

The impact of antipsychotic drugs taken by a mother on the foetus is relatively unknown. Women suffering from psychiatric disorders such as Bipolar Disorder, Schizophrenia, depression and anxiety – are treated with antipsychotic drugs which continue during pregnancy. Many studies have highlighted that there is a lack of evidence regarding antipsychotic use in pregnancy and breastfeeding. It is unknown whether these drugs can increase the risks of stillbirth, pre-term birth and other neonatal problems post-birth. (27).

Smoking

Smoking in pregnancy is a significant health problem for the mother and the baby and can lead to low birth weight, spontaneous abortion and increased complications. To give the child the best start to life, the best thing a mother can do is quit smoking. The smoking at time of delivery (SATOD) rate is low in Surrey at 6.5%. Some women find it difficult to say they smoke because the pressure not to smoke during pregnancy is so intense. This makes it difficult to ensure they are offered appropriate support. NICE Guidance PH26 Smoking: stopping in pregnancy and after childbirth recommends a carbon monoxide (CO) test as an immediate method for helping to assess whether someone smokes and to trigger a referral to the stop smoking service.

In Surrey, midwifery teams are being supported to implement mandatory CO screening at booking and opt-out stop smoking referrals for all pregnant women and their partners.

Maternal Nutrition and Diet

According to the Annual Report (2012) of the Chief Medical Officer, ‘Maternal under-nutrition in pregnancy is associated with the development of heart disease in the adult offspring. There may even be effects transmitted to future generations. This finding (another example of fetal programming) is a very active area of research at the moment.’

Research (28) demonstrates that prenatal folic status in the mother can have an effect on the neurodevelopment of the foetus. ‘Neural tube defects (NTDs), including spina bifida and anencephaly, are severe birth defects of the central nervous system that originate during embryonic development when the neural tube fails to close completely.’ NTDs can be affected by either genetic or environmental factors. Low maternal folic status has been identified within mothers of NTD children in numerous studies and although the mechanisms by which folic acid helps prevent NTDs, the relationship is apparent enough for inclusion of folic acid supplement intake in maternal nutritional guidelines. (29).

Previous studies also found that ‘higher folate concentrations during pregnancy predicted better childhood cognitive ability’ and some evidence to suggest other benefits, such as ‘protection from cardiovascular defects, Down syndrome, limb defects, cleft lip with or without cleft palate, urinary tract anomalies and congenital hydrocephalus.’ (30)

Maternal weight and diabetes

‘Maternal obesity and diabetes are well-recognized risk factors for NTDs’ and other possible foetal complications. Obesity in women before pregnancy and excessive weight gain during pregnancy presents significant risk factors to the unborn child. These women are at an increased risk of pre-eclampsia, stillbirth, perinatal death, macrosomia and gestational diabetes. (31).

A 2012 US study examining the relationship between pre-pregnancy BMI (Body Mass Index), weight change during pregnancy and the risk in children were able to draw a direct correlation between the two. Maternal obesity greatly increased the risk of ID in children, most strongly in ‘the children of women who were morbidly obese, were the risk of ID of any severity increased by over 50%, and the odds of sever ID were increased by more than 80%.’ However, this study did not find that being underweight or weight gain during pregnancy was significantly associated with increased of odds of ID. As this study drew its data from South Carolina Medicaid billing records (as well as other sources such as birth certificates), there is again an association between socio-economic deprivations as Medicaid provides medical assistance to those with incomes insufficient to pay for healthcare in the USA.

Women who are overweight or obese before pregnancy and those who gain an excessive amount during pregnancy are at an increased risk of gestational diabetes. Maternal diabetes can present in three different manifestations, pre-existing type 1, pre-existing type 2 diabetes or gestational diabetes, with gestational diabetes being the most common type amongst pregnant women.

Exposure to diabetes in utero is a risk factor for a number of adverse outcomes for the child, including cardiomyothapy, hypoglycaemia, congenital abnormalities and SIDS (Sudden Infant Death Syndrome). These risk factors can in turn cause neurological development issues and affect cognitive abilities in the future. (32) report that in addition to these; risk factors ‘shared familial environmental exposures such as socioeconomic position, educational attainment, levels of physical activity and nutrition may result in associations between pregnancy diabetes and impaired offspring cognitive ability.’

Maternal Age

Stillbirth rates are highest for women aged under 20 or over 40. The risk of giving birth to a child with a birth defect increases as the mother’s age increases. The risk of a baby having Down’s syndrome increases with the mother’s age when she gives birth. The greatest risk at around one in 30 is linked to women who are 45 or over when their baby is born. Studies show that the risk of miscarriage (loss of a pregnancy before 20 weeks gestation) is 12% to 15% for women in their 20s and rises to about 25% for women at age 40. The increased incidence of chromosomal abnormalities contributes to this increased risk of miscarriage in older women. High blood pressure and diabetes can develop for the first time during pregnancy, and women over the age of 30 are at increased risk. Stillbirth is more common in women over age 35. Older women are also more likely to have low-birth weight babies

Caesarean birth is also slightly more common for women having their first child after age 35.

Sepsis and neo-natal bacterial infections

The overall incidence of neonatal bacterial infections is between one and eight infants per 1000 live births, and between 160 and 300 per 1000 very low-birthweight infants. Group B streptococcal infection accounts for nearly 50% of serious early-onset neonatal bacterial infections. Surveillance conducted between 2000 and 2001 estimated that there were 0.72 cases of group B streptococcal infection per 1000 live births in the UK and Ireland and that, of these, 0.48 cases per 1000 live births were early onset, and 0.24 cases per 1000 live births were late-onset infection. (33). Although the estimated incidence of early-onset group B streptococcal infection is 0.5 per 1000 births in the UK overall, incidence varies geographically from 0.21 per 1000 live births in Scotland to 0.73 per 1000 live births in Northern Ireland.

Homebirths

According to NICE (2014) the evidence now shows midwife-led units to be safer than hospital for women having a straightforward (low risk) pregnancy. Its updated guidance also confirms that home birth is equally as safe as a midwife-led unit and traditional labour ward for the babies of low risk pregnant women who have already had at least 1 child previously. The updated NICE guidance says that women should be given this information to help them think about where they would most like to give birth, but that the final decision should be made by them and supported by healthcare professionals.

Ethnicity

Black and Minority Ethnic women and children have an increased risk of some poor outcomes:

  • Conception – Women in Gypsy Roman Traveller families tend to marry at a young age and start having children early, compared to the UK population as a whole. (34).
  • Stillbirth and infant death – babies of mothers born in India, Bangladesh and East Africa have an increased risk, and mothers born in the Caribbean, the rest of Africa and Pakistan have double the risk compared with babies of mothers born in the UK (ONS data). Infant mortality in the Gypsy Roman Traveller community is three times higher than in the rest of the population.
  • Low birthweight – babies of mothers born in the Caribbean, East Africa, India and Pakistan have an increased risk and mothers born in Bangladesh have double the risk compared with babies of mothers born in the UK (ONS data). This may be explained as these ethnicities are more likely to live in a deprived area and more likely to have parents in a less advantaged socio-economic position.
  • Preterm birth – babies of mothers of Afro-Caribbean and African origin are at increased risk compared to babies of mothers of other ethnic origins (35)
  • Congenital abnormalities – babies of mothers of born in India and Bangladesh are at increased risk and babies of mothers born in Pakistan are three times more likely than babies of mothers born in the UK to be born with a congenital abnormality (36)
  • Severe maternal morbidity – Black and Minority Ethnic women are 50% more likely than White women to suffer severe maternal morbidity, and the risk is more than double for women of African and Afro-Caribbean origin (37)
  • Maternal death – In the UK mothers of Black Caribbean and Black African origin are more than three times more likely to die in pregnancy or in the year after birth than White women. (Saving Mothers’ Lives)

Caesarean

According to calculations from the Hospital Episode Statistics (HES) data, the total caesarean section rate has increased from 21.8% in 2000 to 25.1% in 2013 (first quarter) in English NHS trusts, it was 12% in 1990 for the UK as a whole.

At the same time, the proportion of pregnant women classified as “high risk” is also increasing: from 34% in 2000 it increased to more than 55% in the first quarter of 2013. The age profile of women giving birth is also following an upward trend. The proportions of women older than 35 years old giving birth have been increasing while the proportion of those under 20 years old giving birth has declined over the period 2000-2013.

NICE guidance (2012) outlined the risks of planned caesarean section compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous caesarean section. Planned caesarean section may reduce the risk of the following in women:

  • Perineal and abdominal pain during birth and 3 days postpartum
  • Injury to vagina
  • Early postpartum haemorrhage
  • Obstetric shock.

Planned caesarean section may increase the risk of the following in babies:

  • Neonatal intensive care unit admission.

Planned caesarean section may increase the risk of the following in women:

  • Longer hospital stay
  • Hysterectomy caused by postpartum haemorrhage
  • Cardiac arrest.

Women who have had a caesarean section are less likely to initiate breastfeeding than those who have had a vaginal birth.

Female Genital Mutilation (FGM)

Female genital mutilation, also known as ‘female genital cutting’, ‘female genital mutilation/cutting’ or ‘cutting’, refers to ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons’. FGM is practised for a variety of complex reasons, usually in the belief that it is beneficial for the girl. It has no health benefits and harms girls and women in many ways. FGM is a human rights violation and a form of child abuse, breaching the United Nations Convention on the Rights of the Child, and is a severe form of violence against women and girls.
UNICEF estimates that worldwide over 125 million women and girls have undergone FGM. It is a traditional cultural practice in 29 African countries. It has been estimated that 137 000 women and girls in England and Wales, born in countries where FGM is traditionally practised, have undergone FGM, including 10 000 girls aged under 15 years. These provisional interim estimates were derived by combining published data on FGM prevalence in FGM-practising countries with census and birth registration data in England and Wales. There are no published studies on the prevalence of FGM in Scotland or Northern Ireland. There is anecdotal evidence that girls are taken from the UK to their country of origin to undergo FGM and that FGM also takes place in the UK.

In order to capture data about numbers of women with FGM receiving care from the National Health Service in England, the Department of Health implemented an FGM data set in 2014. In April 2015, an enhanced data set was introduced, requiring all acute trusts, general practices and mental health trusts to record FGM data and return patient-identifiable data to the Health and Social Care Information Centre (HSCIC). Information can be found on the HSCIC website: http://www.hscic.gov.uk/fgm.

At present, there are no well-planned studies that confirm whether or not FGM leads to infertility. Potential factors could include lack of sexual intercourse (apareunia, dyspareunia, impaired sexual function) and ascending infections caused by the FGM procedure. One case– control study showed an association between primary infertility and FGM.

There are no good quality European or UK studies investigating FGM and perinatal outcomes. However, evidence from epidemiological studies of non-European migrants in Europe has shown a higher incidence of stillbirth and neonatal death, so women in the UK from FGM-practising countries may be at higher risk.

Ante-natal and new born screening

All women and babies should have access to high quality antenatal and newborn screening programmes. NICE guidance (2016) outlines the screening programmes that should be offered to women. Midwives and healthcare professionals should offer and recommend testing to all pregnant women as part of their antenatal care.

Women of South Asian origin are likely to initiate care later and have fewer antenatal visits than White women; women from some Black and minority ethnic groups are more likely than White women to book for maternity care later than 22 weeks of pregnancy, to miss more than four antenatal visits or to receive no antenatal care at all; women who are asylum seekers or refugees are disproportionately represented within unbooked births (Rowe & Garcia; Saving Mothers’ Lives)

Mental health

According to NICE Antenatal and postnatal mental health clinical management and service

guidance. (2015) ‘Pregnancy and the period from childbirth to the end of the first postnatal year comprises one of the most important times of a woman’s life, but for women with a mental health problem it can be difficult and distressing. In pregnancy and the postnatal period, women are vulnerable to having or developing the same range of mental health problems as other women, and the nature and course of the large majority of these problems are similar in women at other times of their lives. However, the nature and treatment of mental health problems in pregnancy and the postnatal period differ in a number of important respects:

  • Women might not want to tell anyone about their feelings because of the stigma of mental health problems during a period that is broadly associated with happiness; they might also worry that social care will become involved, which they might fear could lead to loss of custody (38).
  • There is a risk of pregnant women with an existing mental health problem stopping medication, often abruptly and without the benefit of an informed discussion, which can precipitate or worsen an episode. (39).
  • In women with an existing mental health problem (for example, bipolar disorder), there is an increased risk of developing an episode during the early postnatal period. There are also some other differences in epidemiology, which are reviewed for the specific disorders below.
  • The impact of any mental health problem may often require more urgent intervention than would usually be the case because of its potential effect on the fetus/baby and on the woman’s physical health and care, and her ability to function and care for her family.
  • Postnatal-onset psychotic disorders may have a more rapid onset with more severe symptoms than psychoses occurring at other times (39) and demand an urgent response.
  • The effects of mental health problems at this time require that not only the needs of the woman but also those of the fetus/baby, siblings and other family members are considered (including the physical needs of the woman or fetus/baby) – for example, when considering waiting times for psychological interventions, acute treatment for severe mental illnesses or admission to an inpatient bed.
  • The shifting risk-benefit ratio in the use of psychotropic medication during pregnancy and the postnatal period (particularly when breastfeeding) requires review of the thresholds for treatment for both pharmacological and psychological interventions. This may result in a greater prioritisation of prompt and effective psychological interventions.

More data on peri-natal mental health can be found in the Maternal mental health JSNA Chapter.

The level of need in the population

In 2015 there were 13,542 births in Surrey, of these 3 in every 1,000 were still births, with rates higher than the national average (of 4.4/1000) in Surrey Heath (5.1/1000). During 2012-2014 there were 71 early neo-natal mortalities, a rate of 1.7 per 1000 live births, which compares favourably with a national average of 2.1. Although some boroughs and districts in Surrey have higher than average early neo-natal mortalities, with 3.1 in Waverley, 2.6 in Woking and 2.5 in Guildford. None of the differences to the national rate of early neonatal mortality are statistically significant.

Neonatal mortality varies among districts and boroughs but the data does not indicate any significant differences between the national and local rates. Infant mortality rates are also not significantly different to the national rate of 4.0/1000 in most districts and boroughs apart from Mole Valley and Surrey Downs CCG where it is lower.
6.8% of all births in 2015 (including stillbirths) were classed as low birthweight babies; this compares to 7.0% nationally. In comparison to this Surrey has more very low birthweight babies (1.7%) than the national average (1.0%). Of these very low birthweight babies the numbers are higher in Reigate and Banstead (2.1%) and Guildford (2.3%).

In the 2013 ‘State of Maternity Services’ report ’, the Royal College of Midwives reported an 85% increase, between 2001 and 2012, in women in England aged 40 and over giving birth. They also noted that maternal obesity in the first three months of pregnancy more than doubled from 7.6 per cent to 15.6 per cent between 1989 and 2007. The result is an extra 47,500 women nationally requiring more demanding care.
29.9% of women giving birth in the area in 2012/13 were aged 35 or above, this has risen to 31.3% in 2015 and which compares to 19.2% nationally in 2012/13; 0.4% of women were under 18 (in 2014/15), which compares to 1% nationally. So there are increasing numbers of older mothers within the Surrey population, although again this varies within different district and boroughs. There are also lower numbers of young mothers, although these figures also vary across Surrey, with higher numbers in some boroughs. These young parents also may need more support and a higher level of intervention. See the sexual Health JSNA chapter for further information on the rates of under 18 conceptions by borough and district and information on the support available for young parents in Surrey.

The smoking at time of delivery (SATOD) rate is low in Surrey at 6.5%. Some women find it difficult to say they smoke because the pressure not to smoke during pregnancy is so intense.

Surrey is ranked 150 of the 152 local authorities in England when considering relative deprivation, with 1 being the most deprived (this is based on the Index of Multiple Deprivation average score for 2015). Within the county there are pockets of deprivation and this will have an impact on outcomes for mothers and babies.

In 2012, 7,435 children aged under 5 years lived in low income families, which equates to a rate of 10.2 per 100 children. Regionally, the rate is 15.7, and nationally 20.9.

In Surrey there were 1 homeless households with dependent children or pregnant women per 1,000 total households. This compares to 1.8 nationally.

Exact figures for necrotising enterocolitis (NEC) are difficult to obtain due to reporting mechanisms, there are differing estimates of prevalence among low birthweight babies, based on evidence and using a prevalence of 12% among all births under 1500g where there were 224 births in Surrey under 1500g in 2015, that gives an estimate of 27 babies developing NEC annually. Approximately 85% of NEC cases occur in these births.

Whilst breastfeeding initiation rates are higher in Surrey at 84.68% in 2014/15 compared to the national average of 74.33% with the strong evidence base regarding the long and short term benefits to both the mother and baby of breastfeeding interventions to improve this rate further are important. Traditionally there has been a decrease in rates at 6-8 weeks.

The National Infant Feeding Survey (40) shows that breastfeeding rates decrease further with time, with only 25% of mothers breastfeeding and fewer than 1% exclusively breastfeeding at six months. National research further indicates that:

  • 91% of women who stopped breastfeeding at 1-2 weeks would like to have breastfed for longer, but stopped because of problems or lack of support. (41)
  • When women stop breastfeeding before six weeks; nine out of ten would have liked to have breastfed for longer. (40).
  • Fewer teenage mothers than older mothers breastfeed. (In Surrey only 40% of mothers aged under 20 initiate breastfeeding).
  • Asian and Black women living in the UK are less likely to breastfeed exclusively than white women, despite relatively high rates of initiation and breastfeeding at 6 to 8 weeks. (41)
  • Some Asian mothers avoid feeding colostrum to new born babies depriving them of protection against infection. (41)

In Surrey 86.7% of the population aged 0-17 are White (81.7% White British), 5.0% are mixed, 6.3% are Asian/Asian British and 1.1% Black/Black British. The recording of ethnicity of children who have died is currently not sufficiently complete to be conclusive however current data could suggest that the pattern of deaths does not match the ethnic distribution within the live population.

In the booking data from one local hospital for Surrey residents in 2015-2016 it showed women reported drinking alcohol in 1.4% of the 1756 births, this figure is likely to be under reported. Gestational diabetes was 5.35%, this is in line with the national average of around 5%, but is concerning since we would expect Surrey rates to be lower than the national average. Mothers with a BMI of over 30 accounted for approximately 17% of the births, national statistics for the prevalence of maternal obesity are not collected routinely in the UK.

A huge majority of fathers now attend the birth of their children. One analysis of national statistics (42) puts the overall percentage at 86%. This figure rose to 93% for fathers living with their child’s mother (more than four out of five couples are living together at the time of the birth). Among the couples not living together at that time, but still having a positive relationship with each other (one in ten couples), 64% of fathers were at the birth. Even where fathers were described as ‘not in a relationship’ with the mothers (one couple in 20), 10% of the fathers were present at the birth (43. Kiernan and Smith, 2003).

Services in relation to need.

There are currently 5 maternity units, 3 community providers and large numbers of GPs providing maternity care across Surrey. Each service has evolved differently, partly in response to local need, but this has led to inconsistencies in the service offer. There are also challenges on these maternity services around workforce, demand and safety.

There are specific public health commissioned services around smoking, drugs and alcohol which have pathways for and prioritise pregnant women.

All acute and community providers in Surrey are working towards or have achieved BFI accreditation, alongside this children centres are also either working towards or have achieved BFI accreditation. At present, different models for community breastfeeding support operate in Surrey. Healthcare professionals run drop in clinics in acute hospitals and some children’s centres. Community providers runs Breastfeeding drop- ins and peer support groups from a number of health centres and Children’s centres. In some places breastfeeding support is delivered following the Baby Café charity model which is delivered in partnership with health professionals, Children’s Centres, confederations and voluntary sector.

Baby Cafés operate in areas of low breastfeeding prevalence. Evaluations show that mothers appreciate the informal contact with health professionals and peer supporters, but further work is needed to attract more vulnerable young mothers.

For the past five years organisations across Surrey have been working hard to achieve the aims of the 2010-2015 Breastfeeding Strategy. There has been an increase in hospitals and community health providers across Surrey achieving BFI accreditation; there are robust data collection methods in place for ensuring access to breastfeeding rates and data across Surrey and whilst initiation rates have increased there is also an increased continuation of breast feeding at 6-8 weeks across Surrey by 7. The new strategy 2016-20121 aims to build on the good practice and work that has taken place by addressing some of the gaps in the previous strategy and working towards having a County where breastfeeding is seen as the social norm.

Unmet needs and service gaps

There is an absence of a specialist Perinatal Mental Health Service within Surrey.

There is no standalone birthing unit within Surrey.

Neo-natal unit staff need to be linked in more effectively with breast feeding provision within midwifery units and be more confident to begin discussions early on with women whose babies are either expected to visit neo-natal units or who receive care there.

There is insufficient recording across the County of some modifiable factors, which means that interpretation of data in areas where for instance there are higher numbers of low birth weight babies is flawed.

Training for GPs on supporting women to continue breastfeeding or being able to signpost effectively is limited.

What works

Introduced to the UK in 1995, the Unicef UK Baby Friendly Initiative is based on a global accreditation programme of Unicef and the World Health Organisation. It is designed to support breastfeeding and parent infant relationships by working with public services to improve standards of care. It is the first ever national intervention to have a positive effect on breastfeeding rates in the UK. Research has shown that even modest increases in breastfeeding can result in significant savings. The Baby Friendly standards deliver this change for public services (as evidenced by a studies showing the effectiveness of the Baby Friendly Initiative), whilst ensuring long lasting, sustainable improvements in the care of mothers and babies.

This programme is now recognised and recommended in numerous government and policy documents across all four UK nations. The majority of maternity units and health visiting services across the UK are now working towards Baby Friendly, with neonatal and children’s centre services now able to work towards a standalone accreditation. The Unicef UK Baby Friendly mark of accreditation is a nationally recognised mark of quality care for mothers and babies.

Baby Friendly is an accreditation programme that is implemented over several years, using a staged approach. All 5 acute hospitals, 3 community providers have some level of BFI, children’s centres are also working with community health providers to achieve accreditation.

Recommendations for Commissioning

  • There are a number of gaps in current information, there is a lack of consistent Surrey wide data on a number of public health potentially modifiable factors including, weight, mental health issues, drug and alcohol use in pregnancy.
  • There is a need for a more detailed maternity needs assessment in order to provide more detailed and localised data and to address work force and other issues.
  • Commissioners should continue to support the Unicef BFI programme due to the strong evidence base along with the other recommendations within the Surrey Breastfeeding Strategy.
  • Increasing rates of breastfeeding in neo-natal units should be a priority, especially for those units who do not have stand-alone BFI accreditation.
  • Commissioners should commission services which operate in partnership across the maternity pathway to support consistent delivery of public health messages.

Key contacts

  • Breastfeeding Strategy Group members
  • Maternity Lead Commissioners, Guildford and Waverley CCG
  • Public Health Lead children and young people, Surrey County Council

Chapter References

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Additional resources

  • Mann JR et al. (2012) Pre-pregnancy body mass index, weight change during pregnancy, and risk of intellectual disability in children. BJOG An International Journal of Obstetrics and Gynaecology. 120. p.310
  • NICE PH26 Smoking: stopping in pregnancy and after childbirth. Available at: https://www.nice.org.uk/guidance/ph26/chapter/1-recommendations
  • Office for National Statistics (ONS). Gestation-specific infant mortality by social and biological factors among babies born in England and Wales in 2006 (Internet). Newport: ONS; 2009 (cited 2014 Nov 13). Available from: www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-england-and-wales/2006/stb-gestation-specific-infant-mortality–2006.html
  • Public Health England. (2016) Tobacco Control Profiles. Available at: www.tobaccoprofiles.info/
  • Public Health England (2014). Key facts on infant mortality and stillbirths.
  • Rowe R & Garcia J. (2003) Social class, ethnicity and attendance for antenatal care: a systematic review. Journal of Public Health Medicine 25:113-119
  • http://bestpractice.bmj.com/best-practice/evidence/background/0323.html
  • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/535160/Commissioning_infant_feeding_services_a_summary.pdf
  • https://www.nice.org.uk/guidance/qs22
  • https://www.nice.org.uk/guidance/cg192/evidence/full-guideline-193396861
  • https://www.nice.org.uk/guidance/CG190
  • https://www.nice.org.uk/guidance/cg62/chapter/1-guidance
  • https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-53-fgm.pdf
  • XIX State of Maternity Services 2013 – RCM

Signed off by

Breastfeeding Strategy Board