Maternal and child health – a national and international perspective Dr Hora Soltani

1. Maternal and child health – a national and international perspective Dr Hora Soltani Health & Social Care Research Centre Sheffield Hallam University

2. Introduction • What factors influence Maternal & Child Health (MCH): • Local & National • Global • Current concerns& priorities in MCH from a national and global perspective • Effective MCH promotion strategies – group activity • The role of health professionals in support of MCH • The role of communities • National and International Initiatives

3. What is maternal and child health? • Health promotion and preventive strategies/services to improve the health of mothers, infants, children and adolescents in order to maintain/enhance the health of families and communities as a whole. • It is multidisciplinary. • Objectives: • reduce maternal, neonatal and child mortality & morbidity • the promotion of the physical and psychosocial health and well-being of mothers and children/families in: • reproductive health • the maternity cycle (preconception, pregnancy & birth, PP) • nutrition • infection

4. Local andnationalinfluences on maternalandchildhealth UK specific

5. Supporting documents • Changing Childbirth (1993) • National Service Framework (NSF) 2004: for Children, Young People & Maternity Services • Healthcare Commission • Maternity Matters 2007 • NICE guidance • Centre for Maternal and Child Enquiries (CEMACE) [formerly CEMACH] • Maternal and Perinatal Health: • National Maternal & Perinatal Mortality Surveillance • Maternal Death Enquiry • Obesity in Pregnancy • Intrapartum Care • Diabetes in Pregnancy • Child death review [Jan-Dec 2006] (28 Childrendays-18yrs) (n=150) • Head injury

6. Health care commission • Between 2000-05 the HCC investigated complaints about poor maternity care at Northwick Park Hospital in North London, New Cross Hospital in Wolverhampton and Ashford and St Peter’s NHS Trust in Surrey (HCC report 2006). • 10 Maternal Deaths between 2002-2005; Causes: 4 cases of Ecclampsia, 4 cases of Post Partum Haemorrhage, 2 post C/S - Cardiac Arrest & Liver Rupture • Attributed to: • Failure to recognise when progress in labour deviates from the expected, normal course of events. • Delays in seeking medical advice. • Lack of clear management plans for women whose pregnancies are classified as high-risk. • Low staff numbers, high numbers of agency staff/locums and the impact on the safety of patients. • Equipment failure, or a lack of equipment or facilities (baths & showers). • Failure to record blood results in the clinical case notes. • Commissioned a survey of maternity services (2007)

7. Maternity matters: principles of good maternity care Woman-centred care: • She must feel and be in control of what happens to her. • She must be able to make informed decisions about her care, based on her own needs. • She must have input into service planning and design (service user involvement). • Maternity services should be based in the community, sensitive to the needs of the local population and easily accessed by that population. • Women should have a choice of primary carer (NHS midwife, independent MW or Doctor) and place of birth (home, birth centre, hospital). • There should be continuity of care and of the carer – a named midwife (team of midwives), a named obstetrician (if required).

8. Other reports • NICE – Antenatal Care (ANC) guideline: a reduced no. of antenatal visits. • Confidential Enquiries into maternal death (saving mothers’ lives) 2007 or CEMACE. • Maternal death (14/100,000) is a rare event. • More than half of women who died were overweight or obese. • Health inequalities: women from poor backgrounds were 7 times more likely to die than those from other demographic backgrounds. • A reduction in death from maternal suicide/mental health. • Infant feeding survey (2005): 76% initiation but a dramatic reduction at 6 weeks and 6 months.

9. Confidential enquiry into maternal & child health (CEMACH) [Lewis2007]

10. CEMACH [Lewis2007]

11. Fetaland neonatal outcomes [CEMACH 2008]

12. Vulnerable groups (VG)

13. Identified issues in service provision [D'Souza & Garcia 2004]

14. Additional influential factors on maternal mortality • UK Mortality Incidence: • The mortality rate for maternal deaths from Indirect causes of death was 7.71 per 100,000 maternities. • The mortality rate for maternal deaths from Direct causes of death was 6.24 per 100,000 maternities.

15. Models of maternity care[Hatem et al 2008 Cochrane Systematic Review] Overall, there was no increased likelihood for any adverse outcome for women or their infants associated with having been randomised to MLC.

16. What should be done? Pre-conception care: (Opportunistic and planned) for women of childbearing age with pre-existing serious medical or mental health conditions that may be aggravated by pregnancy. Migrant women who have not previously had a full medical examination in the UK should have a medical history taken and a clinical assessment should be made of their overall health, including a cardio-vascular examination at booking or as soon as possible thereafter by an appropriately trained doctor. Women with genital mutilation should be sensitively asked about this during their pregnancy and management plans for delivery should be agreed upon during the antenatal period. • Accessible and welcoming ANC – full booking from 1 to 12 weeks gestation. • Midwifery care should be offered to all women without complications.

17. Maternal, neonatalandchildhealth International Perspectives

18. Global maternal health • Maternal mortality ratios range widely, from an estimated 12 maternal deaths per 100,000 live births in North America to more than 700per 100,000 in some parts of sub-Saharan Africa. • For the developing world as a whole, maternal mortality is estimated at more than 400 deaths per 100,000 live births, while the ratio is below 30 per 100,000 in the developed world. • One woman dies every minute (515,000/year). • Global maternal mortality: http://www.infoforhealth.org/pr/m12/m12chap2_2.shtml

19. Global maternal healthSafe motherhood • 99% of maternal deaths occur in developing countries. • Maternal mortality is the largest disparity between the developed and developing worlds. • Pregnancy or birth complications are the leading cause of maternal disability and death (15-49 yrs old) in developing countries – 20 times more than Maternal Death (MD) for an average woman in Developed Countries (CDs). • The huge implications for the child, family and community (e.g. care-giving, psychosocial and economic cost).

20. Global neonatal health Safe motherhood • 8.000.000 neonatal deaths (up to 1m perinatal(PN)) and stillborn babies/year, mainly due to: • Infection • Asphyxia • Prematurity and its complications • 40-80% associated with Low Birth Weight (LBW) • Almost all in developing countries. • The mother and child’s health are inter-linked. • Challenges – Interventions?

21. Interventions • Investment • Political commitment (war-peace) • Establishing reliable audit systems • Skilled birth attendants/Traditional Birth Attendants • Empowering communities: support networks • Facilitate access to care, prevent delayed referrals • Nutritional interventions (Vit A supplementation has reduced MD by 40% by reducing infection) • Emphasis on women’s health rather than just FP • Care continuum

22. To improve neonatal health • Improve mothers’ health, targeting women of childbearing age as early as possible. • Support education and provide skilled attendance at birth. • Improve health and nutrition, prevent infection. • Keep babies warm after birth. • Encourage (long-term) breastfeeding. Women and Children first available from http://www.wcf-uk.og/issues

23. References • http://www.safemotherhood.org/ • *Lawn JE, Tinker A, Munjanja SP, Cousens S. Where is maternal and child health now? Lancet, 2006; 368(9546): 474-1477 • Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwifery-led versus other models of care delivery for childbearing women. Cochrane Database of Systematic Reviews, 2008 • Lewis G. The Confidential Enquiry into maternal and child health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer 2003-2005. UK, 2007 • D'Souza L, Garcia J. Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal Mortality 2006: England, Wales and Northern Ireland. CEMACH: London, 2008 • D'Souza L, Garcia J. Improving services for disadvantaged childbearing women. Child: Care, Health & Development 2004; 30: 599-611 • Maternity Matters. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312 • Maternal Mortality. http://www.patient.co.uk/showdoc/40000301/ • Centre for Maternal and Child Enquiries (CEMACE). Improving the health of mothers, babies and children. http://www.cmace.org.uk/Programmes/Child/Child-Death-Review.aspx

24. Psychosocial aspects of pregnancy and childbirth

25. Introduction • Why psychosocial aspects are important • An analysis of contributing psychosocial factors at the different stages: • (Pre-)conception • Deciding on parenthood • Antenatal • Intrapartum, birth & postpartum • Professionals’ impact • The psychosocial preparation for birth • Conclusion

26. Psychosocial and cultural factors:preconception • Pregnancy and birth are social as well as biological events. • Pregnancy is a complex psychosocial event. • Motivations for reproduction: • Genetic immortality. • Achieving true adulthood. • A desire to emulate parental care. • To actively explore a new object/source of love. • Cultural transmission: individual and societal goals intertwine to pass on knowledge, skills, etc., so cultures develop a means to promote this. • Not only as survival but (in some cultures) children constitute wealth.

27. Deciding on parenthood • Long-term commitment with irreversible effects. • Contraception adds to the dilemma of choice and parenthood – it’s no longer possible to “leave it to fate.” • Modern life • competing professional ambitions • social and economic responsibilities on women impacting on women’s inner desire “to be like mummy” • Wanting to be pregnant: is it the same as wanting children?

28. Maternal fantasies/attachment to the unborn baby • Positive prenatal attachment: trust in the outcome; falling in love, chatting or daydreaming about the baby as well as imagining a particular infant: the child of her dreams. • Neutral: a conscious effort to have no “feeling” or an expectation of fear of something going wrong (more common in cases of a previous baby loss) – protecting the self or family. • Negative: it’s normal at times but some women are preoccupied with largely negative feelings.

29. A negative bonding experience Sometimes when I’m exhausted my baby seems so horrible, like a monster: vicious, greedy and bad. I end up like a monster myself, furious with my husband and with the pregnancy, just wanting to smash everything up, get rid of it all and force everyone out of my way. But I also feel desperate, like a screaming baby inside. What does all that do to the fetus? How will I bear its crying when it’s born, not to mention looking after it too? How will I cope without ever wanting to exterminate the baby the way I feel my mother would have liked to get rid of me?

30. The Fetus There is evidence to suggest • Fetus is sensitive and reactive • Aware of maternal reactions and affected by: • Temperature • Pressure • Sound and light • The mother's respiratory and vascular systems i.e. There is a great responsibility for Professionals in dealing with women to protect them from unnecessary impingements during investigations.

31. Professionals’ impact • Professionals appear to be the key holders. • They should know that the “mother’s eagerness to know” is a sign of health (responsibility) rather than idle curiosity.

32. Mental health and the antenatal period • Profound psychological and physical changes occur during pregnancy. • Respect the normality of alterations (e.g. anxiety, worry, mood changes, impaired concentration, regressive shifts and increased dependence). • Be vigilant for increased psycho-socio-economic stressors: a study in south London 1st ANC found: • 35% negative GHQ (general health Q) • 29% psychiatric “cases” – largely neurotic depression

33. Potential factors influencing psychological well-being • Key steps • Timely identification • Referral • Individual or group interventions • Housing & financial difficulties • Unemployment • Poor social support • Poor marital relationship Triggering hidden vulnerable areas in women who appear healthy – obtainable through looking at the AN/booking history

34. Antenatal Testing • Test interpretation – the communication of results. • Ultrasound scanning – the “Truth Test”: reliance on professionals. • Controversial evidence should be rescanned: this is normal, informative, reassuring and popular but increases anxiety. There should be a balanced use of technology – rescanning should be kept to a minimum with detailed feedback. • Amniocentesis: anxiety over • Awaiting Results • Fetal injury • Miscarriage • What to do if the fetus is abnormal… Professional Mother Scanning screen

35. Psychological preparation for birth • Emotional preparation: talking to other women, reading about labour, discussing her fears with her friends, mother, etc. • (Some) unconsciously work through their anxieties in repetitive dreams. • Daydreaming about the ideal birth: the accompanying person, the type of birth, monitoring, the birth place. • Preparation for disappointing realities rather than focusing solely on ideal situations.

36. Preparation for birth: basic approaches • Psychoprophylactic (distraction): • Introduced to the West by Dr Ferdinand LaMaze (from the Pavlovian method from Russia). • Distraction from contractions and conscious control in the 2nd stage of labour (patterned breathing). • Other methods include: • Singing songs • Envisaging a relaxing pastoral scene

37. Preparation for birth (cont) • The body harmony range • By Dr Grantly Dick-Read (1940) (the father of natural childbirth?) • The fear-tension-pain syndrome (a self-perpetuating syndrome). • The ability to overcome fear, tension and pain by a better understanding of the labour process and deep breathing and relaxation. • Jacobson’s progressive relaxation • Sheila Kitzinger’s approach: Physical and psychical education to “foster a woman’s delight in the rhythmic harmony of her body’s functioning, and training to maintain her conscious & active participation, the power of self-direction.” • Active birth:a combination of the above with changes in position (kneeling, squatting or sitting), the use of gravity.

38. Postpartum & psychosocial influences • Maternal responsibility phases (assumptions): • Taking in: preoccupied with her own needs (2-3 days) • Taking hold: tries to be in control, eager to learn but this coincides with the “blues” – appropriate support • Letting go: accepting the baby’s separation (10 days) • Blues (50%-75%): a transitory syndrome of weepiness–it coincides with rapid physiological&hormonal changes, incoming milk. • Encourage the woman to make a bridge between her pregnant self and the mother-to-be to establish a new emotional identity; early bonding helps.

39. Conclusion Keeping in mind the importance of maternal psycho-social well-being, the following skills/qualities are essential for health professionals: • Effective communication (verbal and non-verbal), eye contact, gestures • Appropriate questioning/sensitivity • Listening skills • Counselling abilities • Empathy • Acceptance • Genuineness

40. References – further reading list • Raphael-Leff J.Psychological processes of childbearing. London: Chapman & Hall,1991 • Raphael-Leff J.Pregnancy – The inside story. London: Karnac Ltd., 2003 • DH: National Service Framework for Children, Young People and Maternity Services – Executive Summary, 2004 . [Online] Available from: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/fs/en • More references in your module guidebook