Every woman is an individual with her own set of needs, wishes and concerns that need to be evaluated and acted upon. However, healthcare and social services must provide programmes of care that best meet the needs of a wide range of women, so it is necessary to identify general principles of care that will meet women’s needs at the service or organisational level.
The recommendations outlined in this section apply to services providing care for women with complex social needs.
GDG interpretation of evidence
This GDG interpretation refers to all the evidence reviewed in the following four chapters. The majority of the evidence included for each exemplar population comprised studies of very poor methodological quality, with little of it being conducted in the UK. This is explained partly by the complex nature of the interventions under investigation which makes it difficult to design studies controlling potential bias. Added to this is the almost complete absence of outcomes-based comparative data available for service innovation carried out in the UK NHS.
A new health economic model was developed for this guideline with the specific aim of assessing the cost effectiveness of additional care versus normal antenatal care services. The analysis was based on descriptions of services that are currently provided across the UK. The framework for economic analysis in this guideline is a ‘what if’ analysis due to the limited clinical evidence available to populate the model. Therefore the model can only be used to illustrate the problem as we do not know how effective specialist services will be in the real world.
There is an urgent need for future service changes to be subject to rigorous evaluation in a way that allows valid comparison to be made between different service models in terms of pregnancy outcomes and women’s views of care. Without this it is not possible to determine which models of service provision are clinically and cost effective. Furthermore, it is possible that, given the difference identified in the reviewed evidence in terms of women’s needs and preferences (for example, the preference of young women aged under 20 for dedicated services with age-specific content, and the need to help recent migrant women, refugees and asylum seekers keep in touch with services and to communicate their whereabouts effectively between service providers) different models of service provision will be needed for different vulnerable groups. Comparative outcome data for sub-groups of potentially vulnerable women are therefore needed in order to identify which service models meet these different needs and improve outcomes for these different groups. The GDG agreed this should be a key priority recommendation.
Once data are available which inform mapping of the local population in terms of level of need and prevalence of particular vulnerable populations, services can be organised to better meet those needs. Based on consensus, the GDG made a key priority recommendation that this information be collected in order to inform service planning. In order to do this effectively, the GDG highlighted the importance of involving local community groups in both data collection and service planning in order to improve the validity of the information collected and to ensure that planned service changes respond appropriately to the needs identified, and included this as a key recommendation as well.
The GDG felt that a recommendation to encourage collection of ongoing audit data for service change was a key output of this guideline. In order to monitor the effectiveness of service change in improving access to and contact with antenatal care, the GDG identified key process outcomes. These are gestation at booking and the proportion of scheduled antenatal appointments attended. For gestation at booking the GDG agreed three gestations that should be used as audit targets: 10 weeks, 12+6 weeks and 20 weeks of pregnancy. Ten weeks was chosen as this is the target set out in the NICE ‘Antenatal care’ clinical guideline update (CG62, 2008)1. The GDG acknowledged this to be a difficult target to attain, especially for women in vulnerable groups, and so added a second target for early booking; a target well recognised within maternity services, which is booking by the end of the first trimester of pregnancy (12+6 weeks).
A gestation for late booking was chosen by GDG consensus based on what the GDG recognised as a widely accepted definition and which is associated with the upper limit for carrying out serum screening for Down’s syndrome and anomaly screening using ultrasound (20 weeks). If such data are collected locally in a consistent way then recommendations for future NHS service provision can be made based on much more robust and relevant data. It was felt important to collect data to describe local populations and to identify local needs as well as audit data for all women, including women facing complex social needs. By recording which vulnerable group each woman falls into (for example aged under 20 years, substance misuser or non-English speaking) the level of need for each type of supportive service could also be measured.
Despite the poor quality of evidence it was possible to identify some recurrent themes within the findings of studies reviewed. Where these themes have been identified across all four populations and are supported by GDG expert opinion, overarching recommendations have been made.
The need for encouraging early booking has already been identified for all pregnant women (NICE clinical guideline 62 ‘Antenatal care’, 2008).1 The basis for this includes the importance of an early ultrasound scan in order to accurately date the pregnancy as accurate dating of pregnancy leads to reduced rates of induction of labour for post-maturity (NICE ‘Induction of labour’ clinical guideline, CG70, 2008)17 and the need to conduct haemoglobinopathy screening (NICE clinical guideline 62 ‘Antenatal care’, 2008).1 It is likely that early assessment of pregnancy needs and screening also lead to more appropriate antenatal care, which in turn would result in improved pregnancy outcomes, although there is little evidence to support this in income-rich counties. Based on their clinical experience, GDG members agreed that it is likely that this assertion would be even more applicable to vulnerable women with complex social problems.
One way to achieve early booking is to encourage health and social care professionals to refer women to a midwife or antenatal clinic when a pregnancy is first disclosed. The group was aware that, in general, the earlier a termination of pregnancy is carried out, the safer it is, and therefore felt that at this early stage it may also be appropriate to discuss the option of termination of pregnancy and how this might be obtained.
Evidence across all four exemplar populations highlighted the varied potential needs of women with complex social problems — including: communication and housing needs of recent migrant women, asylum seekers and refugees; the need for information regarding benefit entitlements, such as housing benefit, for women across groups on low incomes; and safety advice and emotional support for women experiencing domestic abuse — as well as varied health needs across the groups. This wide range of needs across both health and social care might be provided by either statutory or third sector agencies. This underlines the importance of effective communication between these agencies in order to ensure that women can have these needs met through best use of all available services and support.
Good communication between agencies can be promoted by assessing a woman’s health and social needs using records and documentation that is common to both health and social care providers and that can be used by both agencies. In order to carry this out effectively, health and social care professionals need to be aware of best practice* and trained in the processes currently in use, such as the Common Assessment Framework†. Many of the service descriptions included in the service survey include this component. Two examples from the service survey that illustrate how additional care can be provided for a range of vulnerable women are given in box 3.1. One of the examples, the One to One midwifery teams at the Imperial College healthcare NHS Trust, is a flexible service that provides continuity of carer with planned interagency assessment and joint care planning. The other example, the Hackney Maternity Helpline, is a much simpler intervention which aims to improve access for all women.
Service descriptions for all women with complex social factors. Imperial College Healthcare NHS Trust, London, currently has five One to One Midwifery teams totalling 27 midwives, all holding individual caseloads of 34–36 women per year. The One (more...)
The need for staff to communicate sensitively and the negative impact of poor staff attitudes on women accessing care were evident throughout the evidence reviewed, particularly for question 1b in each chapter. While training would be felt to be beneficial, both for healthcare professionals and other staff (such as receptionists), the form this training should take is less clear. It may be that in-house workshop formats would be effective in enabling staff to reflect on their attitudes and change behaviour where necessary. A research recommendation has been made, therefore, to encourage work to be undertaken in this area.
There is evidence that concern over disclosure of personal circumstances, such as substance misuse, migrant status and domestic abuse, is a barrier to women accessing antenatal care. For this reason it is vital that healthcare professionals explain the reasons why such details are needed, with whom they will be shared, and why this sharing of information is important. The GDG agreed that, in order to facilitate discussion of sensitive issues, it is imperative that all women are offered at least one opportunity, and preferably more than one, for a one-to-one consultation with a healthcare professional with no other person present (unless an interpreter is needed, in which case this should not be a partner, friend or family member).
For all four exemplar groups, some difficulty maintaining contact with services has been identified from the evidence. The reasons for this vary, depending upon a woman’s circumstances, and may be due to issues such as: frequent changes of address, which may be at short notice (for example among recent migrant women, asylum seekers and refugees); a lifestyle that means antenatal consultations are of low priority (for example among young women aged under 20 and substance misusers); or having a partner who physically or psychologically restricts the woman’s freedom (women experiencing domestic abuse).
A simple way of helping women to maintain contact with antenatal services despite missing antenatal appointments is to provide at booking a telephone number which enables 24-hour contact with a healthcare professional. The provision of a contact number was described in the evidence and endorsed as common practice by the GDG. While it will not always be possible for women to contact directly their individual healthcare professional (who may be a lone specialist in a particular area, such as substance-misuse), providing a 24-hour telephone number ensures that these women will always be able to contact a healthcare professional who should be able to provide immediate support and recognise whether a woman needs to be seen urgently by a healthcare professional. A message can be left for the specialist healthcare professional to let them know what has occurred and to enable them to plan any follow-up that may be necessary.
Healthcare professionals should also ask women to contact the hospital if they change address. In addition, the GDG was aware of instances where it is not possible for women to keep their handheld maternity records when moving from one maternity unit to another. This barrier to communication was felt to be detrimental to a woman’s care and the GDG agreed that services should be organised so that all women are able to keep their handheld notes at all times, including when they move to another area, in order to facilitate good inter-agency and cross-boundary liaison. It was also recognised that the handheld version of the records should be kept complete and up to date, including all antenatal test results.
The needs of partners of women with complex social factors, and the role they may have to play in encouraging access and contact, are not contained in the evidence. This almost complete lack of research-based information prompted the GDG to add research recommendations to address this gap in knowledge. In addition, while the GDG felt from personal experience that involving third sector agencies in antenatal care of vulnerable women was valuable, there was no comparative UK evidence to support this, particularly relating to pregnancy outcomes. Again, a research recommendation has been made to encourage further work in this area.
The following recommendations were originally drafted for each of the four exemplar populations individually, derived from the evidence base and GDG interpretation for each one. Once recommendations had been drafted for all four populations, common themes were identified across each of the populations. These themes were then drawn out in order to formulate ‘general’ recommendations to guide care for all vulnerable women.
