ChiMat: Looking forward: Challenges in

improving outcomes in maternity and early years

Dr Helen DuncanChiMat Programme Director

June 2012

Maternal conditions

0200400600800

1,0001,2001,4001,600

Abortion Maternal hemorrhage

Hypertensive disorders of pregnancy

Obstructed labour

Maternal sepsis

Hospital admission rates for maternal conditions, 2010/11 (excludes admssions for delivery)

Hospital Episode Statistics

Maternal mortalityPercentage of maternal deaths due to direct and indirect causes, 2006-2008

Centre for Maternal and Child Enquiries, CMACE

Trends in infant mortality

3,700+ registered users

2,300+ registered users

United Kingdom

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Trend in infant mortality rate for the EU15

source: Eurostat

note: reported infant mortality rate for England & Wales for 2010 is 4

Belgium

Denmark

Germany (including former GDR from 1991)

Ireland

Greece

Spain

France

Italy

Luxembourg

Netherlands

Austria

Portugal

Finland

Sweden

Infant mortality by socio-economic group

3,700+ registered users

2,300+ registered users

Children and Young People’s Health Outcomes Forum :Role

The Forum, jointly chaired by Christine Lenehan andProfessor Ian Lewis was launched on 26 January and

will be reporting to the Government withindependent advice later this year on:

– the health outcomes that matter most forchildren and young people

– how well these are supported by the NHS andPublic Health Outcomes Frameworks

– how the different parts of the health system willcontribute and work together in the delivery of

these outcomes

The Health Reforms• NHS commissioners supported by a new NHS

Commissioning Board will authorise CCGs, commission some services including primary care, and host clinical networks and senates

• Most NHS care commissioned by Clinical Commissioning Groups

• All NHS providers to become Foundation Trusts

• A stronger role for local authorities in shaping services, with new responsibility for local population health improvement

• New Health and Wellbeing Boards within each higher tier local authority area

Children and Young People’s Health Outcomes Forum; Engagement

• The Forum is organised by the following themes and leads:

– Public Health and Prevention: Ann Hoskins & Barbara Hearn

– Acutely Sick Children: Carol Ewing & Eric Kelly

– Mental Health: Lisa Christensen & Margaret Murphy

– Long Term Conditions: Colin Green & Gillian Baird

• National Children Bureau’s work to gather evidence on the views of children & Young People

• National, regional and local events

• Focus Groups looking at specific issues and communities

• Online feedback via http://healthandcare.dh.gov.uk/category/children/

Maternal obesity

Obesity prevalence and deprivationNational Child Measurement Programme 2010/11 – Year 6 children (aged 10-11 years)Local Authorities in England

R² = 0.56

0%

5%

10%

15%

20%

25%

30%

0 10 20 30 40 50

Obe

sity

pre

vale

nce

Index of Multiple Deprivation 2010 score(High score = more deprived)

Child obesity: BMI ≥ 95th centile of the UK90 growth reference© NOO 2012

10.7%

9.1%

19.0%

15.8%

10.4%

8.8%

20.0%

16.6%

10.3%

8.9%

20.0%

16.5%

10.5%

9.2%

20.4%

17.0%

10.1%

8.8%

20.6%

17.4%

Reception boys Reception girls Year 6 boys Year 6 girls

Year of measurement

2006/07 2007/08 2008/09 2009/10 2010/11

Prevalence of obesity among children by school year and sexNational Child Measurement Programme 2006/07 – 2010/11

Child obesity: BMI ≥ 95th centile of the UK90 growth reference© NOO 2012

Impact of maternal obesity- 5 % BMI > 35- 34% in most deprived quintile- Risk type 2 diabetes in BME 3.5 X- Risk gestational diabetes in BME 1.6 X- More C-sections in BME- More deliveries before 37 weeks in BME

CMACE 2010

Measuring levels of obesity in first and subsequent pregnancies

Levels of obesity at 16 – 17 years

Smoking in pregnancy

Strongly correlated with • Deprivation

• Teenage mothers

Best in country – 3.1%

Worst in country – 32.7%

Measuring smoking quit rates during pregnancy and

establishingwhich interventions work

Breastfeeding

0

10

20

30

40

50

60

70

80

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011

Percentage breastfeeding

Initiation Total at 6-8 weeks

Breastfeeding at 3-4 months

Nutrition and vitamin D deficiency

Breastfeeding initiation, younger mothers

Breastfeeding continuation,older mothers

Breastfeeding initiationversus deprivation

Postnatal care

8

9

10

11

12

13

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Hospital admission rates per 1,000 live births, 7 - 14 days after birth

Aged 7 - 9 days Aged 10 - 13 days

0

5

10

15

20

25

30

35

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

rate

Hospital attendance rates aged under seven days in England, rate per 1,000 live births (excludes birth)

Newborn babies (well babies) coming back into hospital system more often, as outpatients and

as admissions

An issue to track andfor further investigation

Early Years – policy backdrop

Healthy Child Programme: 0- 5 years, 2009

Healthy Child Programme: 5 – 19 years, 2009

Healthy Lives, Healthy People: our Strategy for Public Health, 2010

Independent Review on Poverty and Life Chances – Frank Field, 2010

Early Intervention: the next steps – Graham Allen, 2011

Health visitor implementation plan 2011-15: a call to action, February 2011

Fair Society, Healthy Lives: the Marmot Review, 2011

NHS Outcomes Framework, 2011

Public Health Outcomes Framework, 2012

This map shows what the outcomes will be for children in five years time

Areas where children are likely to have very good outcomes

Areas where children are likely to have good outcomes

Areas where children need additional preventive interventions to achieve good outcomes

Areas where children need extra additional preventive interventions to achieve good outcomes

Areas where children need intensive preventive interventions to achieve good outcomes

How PREview evidence can be

used to show where resources should be

targeted NOW to address inequalities in outcomes in five

years time

PREview – it’s complicated

Maternal depression – persistent or episodic

√√

√X

X√Outcome Age 5 yearsChild Age 3 yearsChild Age 9 months

Maternaldepression

Maternaldepression

Maternaldepression

Health Behaviour Learning & Development

Deprivation

Maternal general health poor

Smoking

No qualifications

Multiple birth

Not homeowner

3 or morechildren in home

Living inpoverty

Low income

Morbidobesity

Feeling low(malaise)

First born

Powerlessness(low self efficacy)

Late antenatalcare (after 20 wks)

Underweight

Unhappy ornot bothered about

pregnancy

Housing difficulties

CohabitingOther language

Never employed

Age 1st birth< 20 years

Behaviour

Learning &Development

Health

Not living together

Strength of associations between maternal factors, age 9 months, and child outcomes, age 5 years.

PREview: Investing in children’s services for a fairer future• Analysis of Millennium Cohort Study• Outcomes aged 5 – health, learning &• development and behaviour• Associated factors available during

pregnancy and early infancy• Forward looking, evidence based

population modelling• Resources for professionals to use with

families and communities

Early Years - issues

• Most prevalent risk factors (from the Millennium Cohort Study)

• Forum discussionso Maternal mental health – previous history recorded during

pregnancyo Maternal mental health – postnatal depressiono Maternal self efficacyo Parent /child relationshipso Child wellbeing

Type of risk Variable % of families

Depression Either mother or father often feels depressed 19.4

Physical disability Either mother or father has a longstanding illness that limits daily activities

15.0

Alcohol At least one of the parents is at risk of alcoholism (> 14 units women, > 21 units men)

12.3

Substance misuse Mother smoked during pregnancy 11.7

Teenage parenthood Mother was < 20 years for their firstborn child 11.1

Early Years - outcomes

Child Development

Outcome, aged 2 – 21/2

years

School readiness,

aged 5 years

School attendance, aged 5 to 18

years Educational attainment,

aged 11 to 18 years

Not in Education,

Employment or Training, aged 16 to 18 years

First time entrants to

youth justice system,

aged 10 to 17 years

Self reported wellbeing

Self reported health

behaviours

The earlier the investment or interventionthe greater the Return on Investment

Child Development Outcome, aged 2-21/2 years

• Aimo Screening tool to identify additional needs at individual levelo Results can be used to track improvements at a population

level, monitor via Public Health Outcomes Framework

• Use of Healthy Child Programme 2 – 21/2 year reviewo Commissioning arrangements variableo Coverage variable – average 70 %o Age targeting and minority targeting variable

• Use of approved assessment toolso Some good practice in placeo Too many home grown tools in useo Favourites in use and in planning

o Ages and Stages Questionnaire – ASQ o Parents Evaluation of Developmental Status – PEDS

• Implementationo With expanded Health Visitor workforceo With maternity and child health secondary uses dataset

The new system

Risks Potential Solutions

Fragmented commissioning High level service specificationsCommissioning Outcomes Framework

Keeping focus on children and young people

A lead for CYP in all new organisations at both national and local level

Building in the Children’s voice In authorisation specifications

Multiple agencies involvedDeterminants of health very wide ranging

National level – cabinet sub-committee on public healthLocal level – Health & Wellbeing Board to bind all together

Urgent and primary care GPs trained in paediatrics

Some recommendations

• Linking across sectors – health, education, social careo Better sharing of informationo Use of unique identifiers

• Child Health Information Systemso Responsibility placed with NHS Commissioning Boardo Clinical specification approved and published

• Electronic child health records - technologyo Accessible by professionals, patients, parents and carerso Use in real timeo Enabled by mobile technology

• Child Health Records - contento Contains mothers background information, medical history and o record of unborn babyo Contains care plans for all children with disability, long term or o complex conditions

• Information for the patients and publico Single source, approved, evidence based

For more information

www.chimat.org.uk

helen.duncan@chimat.org.uk

Contact your ChiMat Local Specialist

http://www.chimat.org.uk/default.aspx?QN=CHIMAT_LOCAL