It has been highlighted previously in that poverty and social need appear to play a part in maternal outcomes addressed in recent maternity services reports. In this article Jennifer Pountain, midwife and Fellow in Population Health, Health Education England, raises the importance of population health and a need for maternity services, and midwives in particular, to move away from a disease-focussed approach to one on health and wellbeing.
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Population Health – Why maternity services must take heed and act now
“There is a widening gap in outcomes for women who live in the most deprived areas compared to those who live elsewhere. In addition, there is a concerning rise in maternal suicide deaths. Many women who died had multiple disadvantages, health and social problems. It is critical that health professionals and service providers recognise and respond to the individual needs of all women during and after their pregnancies, and that sufficient resources are available to enable appropriate care across all services. This latest report shows that urgent action needs to be taken across the maternity system in its widest sense to ensure that this worrying increase in maternal deaths is reversed.”
Marian Knight Professor of Maternal and Child Population Health at Oxford Population Health https://www.npeu.ox.ac.uk/news/2328-new-report-highlights-urgent-need-for-improved-care-regarding-continued-inequality-and-mothers-mental-health.
Despite the continued implementation of a risk adverse maternity care paradigm, in the pursuance of eradicating stillbirth, maternal, neonatal morbidities and mortality rates; the latest MBRRACE report merely highlights the continued failings of an inequitable maternity system; a system in which Black and Asian ethnic communities shockingly have a two to three-fold risk of mortality than those from White ethnic communities. Moreover, those from poor socioeconomic backgrounds, and those blighted by the social determinants of health [SDH] endure an inequitable healthcare system, merely focused on the pursuance of treating rather than examining factors that affect optimal health and wellbeing.
In 2015, the U.K. stillbirth rate was ranked 24th out of 49 high income countries, with a miniscule, reported reduction in stillbirth rates of only 1.6 precent (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries– U.K [MBRRACE U.K], 2014). In comparison, the Netherlands, reported a decrease in stillbirth by 6.8 percent (Hickey, 2019). Consequently, the U.K government commissioned a plan to reduce stillbirth, maternal and neonatal deaths by 50 percent by 2030, with a reduction of 20 percent by 2020 (O’Connor, 2016), subsequently giving rise to the creation of an obstetric care bundle to meet the governmental targets (Hickey, 2019).
The Saving Babies’ Lives bundle [SBL] (NHS England, 2015) focuses on 4 key areas in the pursuance of decreasing stillbirth, including increasing smoking cessation services in pregnancy, the improvement of detecting and managing fetal growth restriction through staff training, and an increase in ultrasound scan pathways; the awareness, detection, management of reduced fetal movements, and improvements in intrapartum fetal monitoring (Widdows et al., 2018).
Yet, despite the reported increases in fetal growth restriction detection and smoking at delivery status data is reporting a decline. In August 2022 the Office for National Statistics [ONS] reported an increase in stillbirth rates from 3.8 to 4.1 in every 1000 births, with the most deprived areas of the U.K. experiencing the highest rates of stillbirth (Tommys, 2022).
The Social Determinants of health [SDH]
There is a growing body of research identifying the correlation between adverse socio-economic factors and the requisite for obstetric intervention in the U.K, (Carter et al., 2020). Furthermore, ecological research acknowledges the increase in the potentiality of caesarean section (Quach et al., 2022); in socially disadvantaged populations (Ye et al., 2017).
The World Health Organization [WHO] (2010) states SDH as non-medical factors that influence health outcomes; these include where you are born, ethnicity, how you live, poor housing, poverty, lack of employment, social exclusion, childhood development and poor educational attainment.
The SDH affect all strata of health, including life expectancy, risk of non-communicable diseases, poor mental health, and deficient maternal health outcomes. In 2020 the publication of ‘Build Back Fairer the COVID-19 Marmott review’, further outlined the inevitability of years of governmental austerity policy, the detrimental effects on society’s health, and the increasing burden of SDH. Reporting a decline in female life expectancy within the most deprived communities across the U.K. (Marmott et al., 2020).
Yet, U.K maternity policy to date remains within a risk adverse climate, with little credence to the SDH that affect health outcomes. The evidence is clear- maternity policy making is at a crossroads, the repeated implementation of a medicalised model without the recognition of social and economic factors as vital contributors to maternal and neonatal health, will, inevitably continue to exasperate adverse consequences and increase an inequitable maternity care system.
Time for a shift- Population Health
The Kings Fund declare population health as an approach that encompasses the health and wellbeing of all communities- including the equitable accessibility of health care, employment opportunities, green spaces, healthy food, optimal housing; whereby local services, community groups, commissioning groups, and local government partnerships, work together for the benefit of a community’s health and wellbeing (The Kings Fund, 2019). Population Health aims to reduce health inequity across the nation’s population, with the premise of shifting away from a health system solely focused on an intention to treat pathogenic model, but on the pursuance of the promotion of wellbeing and the prevention of ill health (The Kings Fund, 2018).
Population Health in Maternity Care Policy
The implementation of a population health approach in maternity care policy planning would require a shift away from the traditional risk management of pregnancy and birth. Policy making in maternity care must start to look at the individual factors that affect health and wellbeing. For example, we can confidently hypothesise that SDH are attributable to stillbirth rates, due to the rise in areas of high deprivation. If maternity care policy aligned with a population health approach, then the consideration of the SDH would play a fundamental role, thus the creation of care pathways that incorporates SDH as credible clinical factors alongside medical considerations.
For example, the Dalgren- Whitehead (1991) model of health determinants is a well-established public health model focusing on the determinants of health, rather than on disease causing factors. The model forces a shift in the perspective of health by inviting the healthcare provider to acknowledge the determinant influences that affect health, therefore the gateway to conversations endorsing a health and wellbeing perspective due to the lack of focus on pathogenic paradigms within the framework (Dalgren & Whitehead, 2021). Given the complexities of maternal health, this model would prove insightful when developing maternity care policy. Moreover, the model can also be utilised as a health promotion framework, endorsing healthy behaviour change such as smoking cessation, healthy weight management in pregnancy and alcohol intake, by acknowledging individual lifestyle factors and health behaviour.
The model also inevitably initiates collaboration within different sectors of society. A prerequisite for the application of population health, replacing the universal unwritten rule that health sectors and the medicalisation of health in its entirety takes precedent over determinants of health, community groups, stakeholders and local authority involvement that provide valuable contributions to health and wellbeing.
The future?
The U.K. Maternity system is unsustainable, much like the entire health system, years of austerity policy, cuts to health budgets, reduction in living standards, juxtaposed with a national rise in morbidities has, in some part fully submerged maternity care into a mix of risk adverse care, managing maternity as an acute service, without little regard to the determinants of health that affect everyone’s health and wellbeing from birth until death. The answer? It’s complex, and a population health approach is not going to drastically improve maternal and neonatal health overnight. However, instead a population health approach provides a fresh insight, rather than a system that perpetually neglects health and wellbeing for a disease-focused, intention to treat, acute model of care which, as the data portrays, is failing the women and families receiving U.K maternity care.
Figure 1– Dalgren- Whitehead (1991) model of health determinants
References–
Carter, S., Channon, A. and Berrington, A. (2020). ‘Socioeconomic risk factors for labour induction in the United Kingdom’. BMC Pregnancy and Childbirth; 20(1) : pp 1-13.
Dalgren, G., Whitehead, M. (2021). ‘The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows’. Public Health; 199: pp 20-24. https://elevateni.org/app/uploads/2022/03/Dalgren-Whitehead-model-of-health-determinants-30-years-on-and-still-chasing-rainbows.pdf.
Hickey, K. (2019). ‘Induction: First do no harm’. AIMS Journal; 31 (1). Available at- https://www.aims.org.uk/journal/item/induction-care-bundles.
Marmot, M., Allen, J., Goldblatt, P., Herd, E., Morrison, J. (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity.
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the U.K [MBRRACE-UK]. (2014). MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths from January to December 2014. Available at- www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK-PMS-Report-2014.pdf.
NHS England. (2015). Saving Babies’ lives care bundle. Available at- https://www.england.nhs.uk/mat-transformation/saving-babies/#:~:text=Saving%20Babies’%20Lives%20is%20designed,surveillance%20for%20fetal%20growth%20restriction.
Office for National Statistics [ONS]. (2021). Births in England and Wales:2021. Available at-https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthsummarytablesenglandandwales/2021.
O’Connor, D. (2016). NHS England- Saving Babies Lives A Care Bundle for reducing stillbirth. Available at-https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf.
Quach, D., ten Eikelder, M., Jozwiak, M., Davies-Tuck, M., Bloemenkamp, K.W.M., Mol, B.W., Li, W. (2022), ‘Maternal and fetal characteristics for predicting risk of Cesarean section following induction of labor: pooled analysis of PROBAAT trials’. Ultrasound Obstet Gynecol, ;59: pp 83-92. https://doi.org/10.1002/uog.24764.
Tommys (2022). Stillbirth rise in England and Wales confirmed by ONS. Available at- https://www.tommys.org/about-us/news-views/stillbirth-rise-england-and-wales-confirmed-ons.
The Kings Fund (2018). A vision for population health: Towards a Healthier Future. Available at- https://www.kingsfund.org.uk/publications/vision-population-health.
The Kings Fund (2019). What is population health? Available at- https://www.kingsfund.org.uk/audio-video/population-health-animation.
Whitehead, M., Dahlgren, G. (1991). ‘What can be done about inequalities in health?’ The lancet; 338(8774): pp 1059-1063.
Widdows, K., Reid, H.E., Roberts, S.A., Camacho, E.M., Heazell, A.E.P. (2018). ‘Saving babies’ lives project impact and results evaluation (SPiRE): a mixed methodology study’. BMC Pregnancy Childbirth ;18: pp 43 https://doi.org/10.1186/s12884-018-1672-x.
World Health Organization [WHO], (2010). A Conceptual for Action on the Social Determinants of Health. Available at- https://www.who.int/publications/i/item/9789241500852.
Ye, J., J. Zhang, R., Mikolajczyk, M.R., Torloni, A.M., G€ulmezoglu, A.P. Betran. (2017). “Association between Rates of Caesarean Section and Maternal and Neonatal Mortality in the 21st Century.” Obstetric Anesthesia Digest 37 (1): pp 17–18.
Jen Pountain, Midwife and Fellow in population health, Health education England
January 2023