All NHS boards have adopted maternity policy principles which advocate women and family centred services, with care tailored to individual need and provided by the most appropriately skilled professional. In adopting these principles, services have been developed to take account of the evidence for improving public health and ensure that maternity care provision reflects wider policy.
Public health and early years policies, including Better Health, Better Care, Equally Well and Getting It Right For Every Child (GIRFEC), outline a commitment to reduce health inequalities.
In relation to maternity care, they highlight the importance of seamless and early access to services, alongside early tailored intervention for women and families with additional social or medical need.
Information must be tailored and sensitive to the communication and language needs of the woman which may include learning difficulties, sensory impairment, literacy levels including health literacy, and English as a second language.
Inequalities in antenatal care
Disadvantage starts before birth and increases throughout life and so efforts to reduce health inequalities must begin before birth. Reducing inequalities in pregnancy requires the attention of everyone who works with pregnant women and their partners, across the spectrum of settings and disciplines.
Quick links:
- what are health inequalities?
- how can health inequalities be addressed during pregnancy?
- outcomes of health inequalities
What are health inequalities?
Health inequalities are avoidable differences in health status or determinants between population groups. They are usually the result of a complex matrix of lifestyle choices, personal history and circumstances, and access to services.
The Marmot Review (external link) suggests that these inequalities are reflected best as a gradient across society rather than as a gap between two population groups. The review calls for a universal service, tailored to provide a gradient of support for populations with differing needs.
How can health inequalities be addressed during pregnancy?
It is essential that those providing antenatal care address social and health inequalities. Professionals should aim to provide universal services that are available and accessible to all pregnant women and their partners, identifying individual needs to tailor responses.
This approach is not stigmatising, and allows for early intervention before any issues reach critical levels:
'Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism,' Marmot review.
An example of this need is in provisions for parents with low health literacy levels. Health literacy is the mixture of social skills and understanding that allows people to access and use health information effectively, and to make informed decisions about their health care.
To address low health literacy we need to:
- break down barriers to health and find ways to help people access the services and support they need
- help people gain greater control over their health and wellbeing
- allow them to make informed health choices
- enable them to advocate for their own health as well as their family and community
Addressing these issues can help to make an impact in pregnancy and support the development of skills that provide protective factors to health.
Outcomes of health inequalities
Health inequalities in the antenatal phase arise from complex social factors. They have the potential to increase the vulnerability of both the pregnant woman and her child, during and after pregnancy.
The National Institute for health and Clinical Excellence (NICE) guideline, Pregnant women with complex social factors (2010) (external link) highlights complex social factors that are associated with an increased risk of maternal death.
These include:
- contact with child protection services or social services
- substance misuse
- domestic abuse
- being single
- being unemployed
- having a partner who is unemployed or employment unclassifiable
- being a recent migrant to the UK
- speaking no English
The guidance recognises the need for multi-agency working and needs assessment. It also states that health professionals should be trained to assess any additional social and psychological needs that women may have.
Infants of women living in complex social circumstances have an increased risk of dying during the perinatal period (NICE Guidance as above). This supports the findings of Confidential Enquiry into Maternal and Child Health - Why Children Die (external link), which says, 'Children born to women from more vulnerable groups also experience a higher risk of death or morbidity and face problems with pre-term labour, intrauterine growth restriction, low birth weight, low levels of breastfeeding and higher levels of neonatal complications'.
Complex social circumstances can constitute a high risk during pregnancy. However, biological, genetic and social factors are often closely linked. Related factors include:
- the relationships between diabetes, obesity and poor nutrition
- teenagers, smoking and poverty
- gender-based violence, substance misuse and poor mental health
