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

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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

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Local and national influences on maternal and
child health
UK specific
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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 Children
  days-18yrs) (n150)
• Head injury

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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 Peters 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)

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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).

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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.

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Confidential enquiry into maternal child health
(CEMACH) Lewis 2007
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CEMACH Lewis 2007
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Fetal and neonatal outcomes CEMACH 2008
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Vulnerable groups (VG)
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Identified issues in service provision
D'Souza Garcia 2004
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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.

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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.
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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.

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Maternal, neonatal and child health
International Perspectives
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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 700 per
  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.infoforhealt
  h.org/pr/m12/m12chap2_2.shtml

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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).

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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 childs health are inter-linked.
• Challenges Interventions?

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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 womens health rather than just FP
• Care continuum

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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
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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/Publica
  tionsandstatistics/Publications/PublicationsPolicy
  AndGuidance/DH_073312
• Maternal Mortality. http//www.patient.co.uk/showd
  oc/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

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Psychosocial aspects of pregnancy and childbirth
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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

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Psychosocial and cultural factorspreconception

• 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.

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Deciding on parenthood

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

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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 its normal at times but some women are
  preoccupied with largely negative feelings.

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A negative bonding experience
Sometimes when Im 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 its 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?
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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.
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Professionals impact

• Professionals appear to be the key holders.
• They should know that the mothers eagerness to
  know is a sign of health (responsibility) rather
  than idle curiosity.

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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

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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
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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
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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.

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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

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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.
• Jacobsons progressive relaxation
• Sheila Kitzingers approach Physical and
  psychical education to foster a womans delight
  in the rhythmic harmony of her bodys
  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.

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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 babys 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.

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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

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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/HealthAndSo
  cialCareTopics/ChildrenServices/fs/en
• More references in your module guidebook