antenatal - Stockport Birth Services

Top Tips For Why Breathing In Birth Is Really Important

Breathing is a super important part of your giving birth toolkit. Here are some top tips why:

Relaxation: Deep breathing can help you to relax your mind and body by triggering the parasympathetic nervous system, slowing the heart rate and relaxing your muscles. Relaxing can help release the fear of labour.
Pain management: Deep breathing can disrupt the fear-tension-pain cycle. When the body begins to relax, tension and pain release from your body.
Increase oxygen flow: Proper breathing helps to maintain an adequate supply of oxygen to you and your baby, which is crucial for your wellbeing. Not only that, with an adequate supply of oxygen, lactic acid doesn’t build up – lactic acid can cause your muscles to hurt more.
Prevent hyperventilation: Rapid and shallow breathing can lead to decreased oxygen and lightheadedness, triggering the sympathetic nervous system or ‘flight or flight’ reflex. The heart rate increases, adrenalin is released into the body stimulating you out of your birth bubble and your blood pressure increases. Controlled deep breathing can help prevent this.
Focus: A focused deep breathing technique can give you the psychological benefit of having something productive and useful to bring your awareness to.

Focused, deep breathing is a really simple, easy and above all effective tool for managing your physical and mental comfort levels during labour and birth. One of the central tenets of hypnobirthing is to be able to encourage the body and mind into the calm relaxed state we practice during sessions. The more you practice in pregnancy the easier you’ll find it – especially if you do it alongside your oxytocin boosters and in a peaceful environment.

A strategic plan integrating community development concepts for the trans and non-binary childbearing population in perinatal services.

[Originally submitted as an assignment for MPH @ University of Manchester]

Community and Public Health Issue

The community in focus is the England’s transgender male and non-binary[1] childbearing community. Trans people are individuals whose gender identity falls outside the stereotypical gender norms of their biological sex. No definitive figures exist for how big the trans community is due to lack of research, fear of reprisals, no standardisation in definitions, and outdated data systems lacking recording capability[i] [ii] [iii] [iv] [v]. An approximation suggests around 600,000[vi] trans people live in the UK. We can assume the number of trans people is likely rising due to the increase in referrals to gender dysphoria clinics[vii]. Therefore, the trans childbearing community is likely rising too – although subject to the same recording and accuracy issues as the wider trans community – meaning providing gender-inclusive perinatal care is becoming more of a pressing concern for service providers.

Trans individuals are likely to have had previous negative experiences within healthcare settings and suffer from healthcare professionals (HCPs) not understanding their specific needs adequately[viii]. The trans childbearing community are trying to access services created for heterosexual ciswomen[2][ix] so information, clinical space and HCPs are usually heavily gendered, making it more difficult to access services from outside that binary. If trans people are unwilling or unable to adequately access perinatal services their and their baby’s health is risked. A public health central tenet is to prevent disease and improve health by offering services accessible to all; therefore ensuring gender-inclusive perinatal services is a public health issue.

Theory of Change

Problem:

Perinatal care is essential for the perinatal dyad; without it there are increased risks of adult and child morbidity and other serious adverse outcomes[x]. Trans people are at increased risk of not accessing healthcare services due to real or perceived stigma, discrimination and bias from HCPs, lack of cultural competency, systemic barriers such as inadequate IT systems and sociocultural barriers such as increased mental health challenges[xi] [xii] [xiii]. This is particularly an issue in perinatal healthcare where services are largely created by and for ciswomen, adding an additional cis-centric dynamic to accessing care, and where it is possible any experienced gender dysphoria can worsen.

Long-Term Goal:

Strategic aims of this health plan are to:

Reduce the real/perceived stigma faced by trans childbearing people that stops them accessing perinatal care
Improve the experience of the trans childbearing community accessing perinatal care
Improve the health of trans childbearing individuals and their infants through the perinatal period.

These goals will be met when all trans childbearing people who want to access perinatal care do so, and in doing so no harm is caused emotionally or physically to the dyad.

Key Audience:

Stakeholders involved in this strategic plan will be trans childbearing individuals, perinatal care workers (including midwives, obstetricians, infant feeding workers, health visitors), and other HCPs e.g. endocrinologists, together with representation from Clinical Commissioning Groups and the VCSE sector.

Backwards Map from Goal:

Examination of the preceding stages from the long-term goals necessitate a collaborative approach from all identified stakeholders so all necessary changes before the goal can be met are considered.

To reduce overall stigma and improve the experiences of trans individuals accessing perinatal care there needs to be:

Reduction of internalised stigma
Reduction of healthcare stigma from individual practitioners
Reduction of structural stigma

Which needs:

Motivation to change from the institution and HCPs within it
Belief from trans childbearing individuals that cultural change can occur

Which leads to accessibility of perinatal services for trans people through:

Improved understanding of the challenges faced by the trans childbearing community leading to an increase in desire to help overcome these challenges
Equipping HCPs with the skills and competencies needed to support the trans childbearing community
Cultural changes in the behaviour of HCPs which leads to a visible awareness for the trans childbearing community
Improvement in the existing structural systems
Motivation of individuals to access a changing system for health gain

No change is independent of any other or relates only to one long-term outcome; they are symbiotic in nature therefore it is unrealistic to assume that a singular change will lead to a singular outcome. Coproduction is a vital part of the plan to ensure that the assumptions and underlying logic of approaches are valid and fit for all stakeholders, but particularly the service users.

Strategies and Interventions:

There is a paucity of research about trans childbearing experiences of pregnancy care in England; what little exists are small-scale qualitative studies, often undervalued in the medical world[xiv]. This failing of research existence results in organisations having little solid evidence to base the redesign of services on[xv].

A key principle underpinning all strategies is that they will be developed through true coproduction with relevant stakeholders including service users, to ensure they best fit the needs of the community (while recognising that the trans childbearing community has not one homogenous voice).

Strategies which have been published can be broadly grouped within the following themes.

Culturally Competent Training

HCPs often lack understanding and awareness of the trans childbearing community and the specific problems they face when accessing highly gendered healthcare services. To help alleviate this, cultural competence education including use of appropriate language should be given to staff[xvi]. Cultural competency can help staff interact with people they care for in a way that does not cause mental harm; for example, using correct pronouns, not deadnaming[3], misgendering or conflating gender identity with sexual orientation[xvii]. Fit-for-purpose cultural competency training can ensure HCPs provide appropriate medical care rather than subjecting trans individuals to superfluous and sometimes voyeuristic practices[xviii], or giving incorrect medical information[xix].

Cultural competency training would be included in this strategic plan to help meet the long-term goals. Training would be offered firstly to all core perinatal HCPs and then rolled out to affiliate HCPs. The training would impact on:

improving understanding of challenges faced by the trans childbearing community by HCPs
increasing HCPs’ skills and competencies to deal with diverse challenges
increasing vocalness and visibility of trans rights and needs in pregnancy making perinatal care more accessible for the trans childbearing community
reducing healthcare stigma, discrimination, and bias
improving the experience of trans individuals accessing perinatal care
improving the health of the trans childbearing community.

Limitations recognised by the strategic plan of this intervention are that:

the trans childbearing community are not a homogenous group therefore their needs may be disparate; poorly designed training courses may give HCPs the impression that a one-size-fits-all approach is possible
this specific type of education is relatively new; no research exists to evidence its efficacy other than anecdotal feedback. However, it is likely that it will have the same level of positive impact on patient outcomes as other types of cultural competency training[xx].

Assumptions made regarding training as a strategy to meet the long-term goal of this strategic plan are that:

HCPs are not transphobic and any failings in service provision come from lack of understanding which can be overcome
HCPs are motivated to better their awareness and understanding of the challenges faced by the trans childbearing community
HCPs have the time to do additional training outside their caseloads
the interpersonal skills needed to enable HCPs to provide care to trans people are teachable
there is a supportive space for HCPs to learn in and competent experts to provide the training.

Although there may be logistical challenges in staff finding time for training these are not insurmountable, and it is likely an organisation considering such training will be supportive of people in that learning sphere. It is probably best to assume the good intentions of all workers to be motivated to do better unless proven otherwise[xxi] – which can be dealt with under an organisation’s disciplinary policy.

Individualised Care

The trans childbearing community are not a homogenous group and cannot be treated as such, needing a heterogeneric approach to care to match their diverse experiences. Personalised care is an integral to the NHS’ Long-Term Plan[xxii] and should be prioritised for the trans childbearing community through proportionate universalism.

One individualised approach needed is regarding language used. Some trans individuals have a definite preference for their gender identity, some are comfortable with a variety of terms (e.g. male, female-to-male, transman, assigned-female-at-birth)[xxiii]. Alongside this is pronoun choice; trans people have a more positive healthcare experience – and therefore less exposure to mental harm – when correct pronouns are used[xxiv]. There is also the degree of ‘outness’ both in terms of gender identity and pregnancy to consider: for some, being seen as male but not pregnant is critical to good health, for others being out as male and pregnant is important, for others passing as a cisgender woman while pregnant is how they feel safest[xxv]. Birth tends to be pathologised in England[xxvi] and it is possible that being trans in itself may put individuals onto a high-risk pathway even if there is no medical indication, increasing intervention rates with the potential of increasing physiological and mental harm[xxvii].

Specific interventions within this strategic theme to be implemented are:

ensure individualised care through thoughtful conversations between pregnant person and culturally competent HCPs
reduce the need for the “trans story” to be repeated (thereby causing mental trauma) by having continuity of carer, a strategy which itself improves perinatal outcomes for parent and child[xxviii]
have language needs clearly identified “at a glance” on notes so professional contact remains consistent and accurate[xxix]
not place on an obstetric pathway for trans status alone[xxx].

The impact on the strategic plan’s long-term goals is to:

reduce stigma for the individual by building a close, personable relationship with a small team of carers
increase the belief that ‘the system’ can meet the needs of a subjugated community, therefore making it more likely individuals within the trans childbearing community will seek future healthcare
improve individuals experience within the perinatal system, reducing mental distress
improve the health of the perinatal dyad by ensuring accessibility to fit-for-purpose services and staff.

The limitations of these interventions within this strategic plan may be that:

self-identity is complex and may change as a pregnancy progresses, and may need more time, patience, and experience than an HCP has to give
the maternity system is not resourced adequately to staff a pathway that requires more time; although continuity of carer pathways should be implemented for “most” birthing people by 2021[xxxi] there are already severe shortages in midwifery[xxxii] that means this is not happening[xxxiii].

Assumptions made with these strategic interventions are that:

it matters to trans childbearing people how they are identified by others
maternity services are resourced adequately to provide continuity of care and properly individualised care – not just lip-service.

These assumptions can be overcome by conducting transparent and open conversations with each individual. Resourcing is not so easy to challenge however the financial benefits of keeping parent-and-child healthy in the perinatal period can be used as a basis for a proposal for extra resources.

Systematic Change

The system within which perinatal services exist also needs change to meet the trans childbearing community’s need. There is institutional erasure of trans pregnant people: only one trans-inclusive maternity policy exists in England[xxxiv], IT systems do not have capacity to accurately record gender[xxxv] [xxxvi], physical space is aimed almost exclusively at women[xxxvii], and educational literature features predominantly heterosexual ciswomen.

Interventions which may positively impact on this area and will be included in the strategic plan are:

creation of perinatal guidance and policies which are gender-inclusive
redevelopment of physical space and literature to ensure representation
upgrading of IT systems so perinatal gender options are representative.

The interventions would:

improve the environment in which trans childbearing people access perinatal services, making services more accessible
make it easier to accurately record a true gender identity, helping increase visibility and break down stigma, both individual and structural.

The limitations of these interventions are that:

it may be costly to implement wide-scale change on infrastructure that is nationally devolved
systematic change takes time
there is likely to be resistance from people who lack education around the trans community[xxxviii].

Assumptions made regarding the implementation of this strategy are that:

there are resources to implement wide-scale change
there is appetite to do so on a wide-scale; national change needs a top-down approach and if the most senior leaders do not understand the importance of change it cannot happen at the scale it needs to.

Mental Health Focus

Poor mental health is a common theme for trans people navigating healthcare systems, especially perinatal services, therefore it is imperative that action is taken to improve the trans childbearing community’s mental health status.

Gender and genitalia dysphoria before pregnancy, antenatally, intrapartum, postpartum, and longer-term postnatally including infant feeding choices is a big concern for trans childbearing people, and a situation that can shift and worsen significantly as a person passes through these experiences[xxxix] [xl]. It is essential that culturally competent carers understand the impact of dysphoria during the perinatal period and that there is access to culturally sensitive specialist counselling[xli], interventions which are included in this strategic health plan. Alongside professional support is the value of peer support: feelings of isolation cause great distress for trans childbearing people[xlii] and appropriate, specific peer support can be invaluable – HCPs need to be able to signpost this support effectively[xliii].

These interventions would help:

reduce internalised stigma through visibility, reducing isolation and improving access to health education in an informal setting
improve mental health leading to greater accessing of healthcare and reducing poor physical outcomes.

The assumptions underlying these interventions are that:

trans people will want to access perinatal services if mental health is nurtured
specific peer support is accessible.

Mitigating these assumptions may take time and resources to increase knowledge and earn trust, and there may be a chicken-and-egg scenario of trans childbearing people peer support not being ‘lumped in’ with generic LGBT support groups – there needs to be volume to necessitate support but without such support the true volume of need may not be known.

Responsibilities:

Providing the space (physical and mental) and resources for the interventions listed to be adequately provided are the responsibility of the HCPs responsible for this strategic plan. The community will decide whether this is enough for them to overturn previous negative experiences and engage with perinatal services, however it is noted that it takes time for underserved communities to develop trust and engagement with a service that has historically overlooked them. There must be an element of goodwill belief from the trans childbearing community that things can change; while this will be true of some there will be others who make a choice never to engage.

Outcome Measures:

Strategic interventions will be measured and evaluated through a framework of user experience data-collection tools. Baseline data prior to the implementation of intervention will be needed so outcome metrics can be tracked against implementation.

Friends and Family Test[xliv]
CQC Maternity Services survey[xlv]
Locally designed Maternity Voices Partnership care survey[xlvi].

Wider benefits should also be seen in health outcomes for both parent-and-child, increasing positive outcomes in maternity dashboard[xlvii] figures generally.

Programme Narrative

The needs-based approach to health improvement of the trans childbearing community holds the assumption that the community face disparity in health outcomes during the perinatal period. This has been evidenced through an assumptive approach based on the wider trans community’s relationship with accessing healthcare and the limited research available on the trans childbearing community and perinatal care experience.

A big limitation of the programme is that the trans childbearing community in England is unknown due to systematic failure of data capturing and heterogeneous approaches to self-identity, exacerbated by fear of stigma, discrimination, and bias. The trans community is growing and even if not the trans childbearing people deserve to have access to appropriate healthcare.

Within the framework of perinatal services provided by the NHS in England, the programme will adopt an integrated approach to improving the health of the trans childbearing community which places individuals from the community at the heart of the proposed strategic interventions. The programme will take a symbiotic approach to the interventions of cultural competency training, individualised care, systematic change, and a focus on improving mental health.

Through partnership working of all stakeholders and in particular collaboration with the community using (or intending to use) the service, the programme will implement strategies that increase awareness and understanding of the additional vulnerabilities and challenges the community face, ensure supportive care that meets the unique needs of the community, changes the system within which perinatal care currently exists, and ensure mental health is as protected as physical health. This will allow broader goals of reducing real and perceived internalised, healthcare, and structural stigma; improve the experience of navigating the service, making it more accessible and giving HCPs the skills needed to provide care to a vulnerable and diverse community; and improving the long-term health of parent-and-child, impacting not just on them as individuals but the wider communities they exist within. Long-term one of the benefits of the programme is that this underrepresented in healthcare community group will be more likely to access perinatal care as they know their community is understood and represented.

Although the strategic themes have been identified through this programme this truly will be a collaborative community health programme and relevant stakeholders but especially the trans childbearing community themselves will coproduce the final programme strategy, implementation, and evaluation methods to ensure they are flexible and adaptable to maintain community relevancy through emerging and changing needs, priorities and in response to any future published evidence.

Sustainability of the programme will be supported through participatory actions of the community themselves and by ensuring that interventions are measured against the long-term goals of the programme with a mechanism for future growth and development of the programme as the long-term goals are achieved.

[1] For the purpose of this essay the umbrella term ‘trans’ will be used throughout unless specifically noted.

[2] A woman whose gender matches their assigned sex at birth.

[3] Using the birth (or legal name if not yet changed) of a trans person even though it is not their preferred name. This can be accidental or intentional.

[i] Nolan IT, Kuhner CJ, Dy GW. Demographic and temporal trends in transgender identities and gender confirming surgery. Transl Androl Urol. [Online]. 2019;8(3):184-190. [Accessed 26 April 2021]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626314

[ii] Office of National Statistics. Trans data position paper. [Online]. 2009. [Accessed 26 April 2021]. Available from: http://www.ons.gov.uk/ons/guide-method/measuring-equality/equality/equality-data-review/trans-data-position-paper.pdf

[iii] House of Commons, Women and Equalities Committee. Transgender Equality. [Online]. 2016. [Accessed 26 April 2021]. Available from: https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/390.pdf

[iv] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[v] Public Health England [Online]. Ensuring pregnant trans men get equal quality care. 2020. [Accessed 26 April 2021]. Available from: https://phescreening.blog.gov.uk/2020/03/13/pregnant-men-best-care/

[vi] Stonewall.org [Online]. How many trans people are there in Britain at the moment. [Accessed 26 April 2021]. Available from: https://www.stonewall.org.uk/truth-about-trans#trans-people-britain

[vii] Torjesen I. Trans health needs more and better services: increasing capacity, expertise, and integration. BMJ. [Online]. 2018;362:k3371. [Accessed 26 April 2021]. Available from: https://www-bmj-com.manchester.idm.oclc.org/content/362/bmj.k3371

[viii] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[ix] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[x] Royal College of Obstetricians & Gynaecologists [Online]. Antenatal care should be standardised to the minimum targets set out in the new guidance, say professional bodies. 2020. [Accessed 28 April 2021]. Available from: https://www.rcog.org.uk/en/news/antenatal-care-should-be-standardised-to-the-minimum-targets-set-out-in-new-guidance-say-professional-bodies/#:~:text=Maternity%20care%20has%20been%20shown,and%20other%20adverse%20perinatal%20outcomes

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[xii] Public Health England [Online]. Ensuring pregnant trans men get equal quality care. 2020. [Accessed 26 April 2021]. Available from: https://phescreening.blog.gov.uk/2020/03/13/pregnant-men-best-care/

[xiii] Berger AP, Potter EM, Shutters CM, Imborek KL. Pregnant transmen and barriers to high quality healthcare. Proceedings in Obstetrics and Gynaecology. [Online]. 2015;5(2):3. [Accessed 28 April 2021]. Available from: http://ir.uiowa.edu/pog/

[xiv] Greenhalgh, T, Howick, J, Maskrey, N, Brassey, J, Burch, D, Burton, M, Chang, H, Glasziou, P, Heath, I, Heneghan, C, Kelly, M P, Lehman, R, Llewelyn, H, McCartney, M, Milne, R, Spence, D. Evidence based medicine: A movement in crisis? BMJ [Online] 2014. Vol. 348. [Accessed 5 May 2021]. Available from: https://www-bmj-com.manchester.idm.oclc.org/content/348/bmj.g3725

[xv] Lai-Boyd, B. Maternity care for LGBTQ+ people – how can we do better? June 2020. [Accessed 29 April 2021]. In: All4Maternity. ALL4MATERNITY BLOG, NEWS & VIEWS. [Online]. Available from: https://www.all4maternity.com/maternity-care-for-lgbtq-people-how-can-we-do-better

[xvi] Berger AP, Potter EM, Shutters CM, Imborek KL. Pregnant transmen and barriers to high quality healthcare. Proceedings in Obstetrics and Gynaecology. [Online]. 2015;5(2):3. [Accessed 28 April 2021]. Available from: http://ir.uiowa.edu/pog/

[xvii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017;17,332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xviii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017,332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xix] MacDonald, T, Noel-Weiss, J, West, D. et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth [Online]. 2016,106. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-016-0907-y

[xx] Lie, DA., Lee-Rey, E, Gomez, A. et al. Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med. [Online]. 2011. 26;317–325. [Accessed 1 May 2021]. Available from: https://link.springer.com/article/10.1007%2Fs11606-010-1529-0

[xxi] Bartlett, KT. Making good on good intentions: The critical role of motivation in deducing implicit workplace discrimination. Virginia Law Review [Online]. 2009:95,8,1893:1972. [accessed 5 May 2021]. Available from: www.jstor.org/stable/27759975

[xxii] NHS England. The NHS long term plan. [Online]. 2019. [Accessed 1 May 2021]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

[xxiii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxiv] Light, AD, Obedin-Maliver, J, Sevelius, JM, Kerns, JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstetrics & Gynaecology. [Online]. 2014. 124;6;1120:1127. [Accessed 1 May 2021]. Available from: https://journals.lww.com/greenjournal/Fulltext/2014/12000/Transgender_Men_Who_Experienced_Pregnancy_After.9.aspx

[xxv] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxvi] Smith, A for AIMS. Salutogenesis – putting the health back into healthcare. [Online]. 2020. 33,1. [Accessed 5 May 2021]. Available from: https://www.aims.org.uk/journal/item/editorial-salutogenesis

[xxvii] Soet, JE, Brack, GA, Dilorio, C. Prevalence and predictors of psychological trauma during childbirth. Birth [Online]. 2003;30, 36–46. [Accessed 5 May 2021]. Available from: https://pubmed.ncbi.nlm.nih.gov/12581038

[xxviii] Sandall J, Soltani H, Gates S, Shennan A, Devane D for Cochrane. Pregnancy and childbirth review group. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. [Online]. 2016. [Accessed 5 May 2021]. Available from: https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early

[xxix] Brighton and Sussex University Hospitals. Pronoun stickers. [Online]. [Accessed 1 May 2021]. Available from: https://www.bsuh.nhs.uk/maternity/documents/pronoun-stickers/

[xxx] Brandt, J, Patel AJ, Marshall I, Bachmann, GA. Transgender men, pregnancy, and the “new” advanced paternal age: A review of the literature. Maturitas. [Online]. 2019.

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[xxxi] NHS England. The NHS long term plan. [Online]. 2019. [Accessed 1 May 2021]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

[xxxii] Royal College of Midwives. Fears for maternity as staffing shortages hit safety and morale says RCM. [Online]. 2020. [Accessed 1 May 2021]. Available from: https://www.rcm.org.uk/media-releases/2020/november/fears-for-maternity-as-staffing-shortages-hit-safety-and-morale-says-rcm/

[xxxiii] Care Quality Commission and NHS England. 2019 survey of women’s experiences of maternity care. [Online]. 2019. [Accessed 2 May 2021]. Available from: https://www.cqc.org.uk/sites/default/files/20200128_mat19_statisticalrelease.pdf

[xxxiv] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf

[xxxv] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxxvi] Berger AP, Potter EM, Shutters CM, Imborek KL. Pregnant transmen and barriers to high quality healthcare. Proceedings in Obstetrics and Gynaecology. [Online]. 2015;5(2):3. [Accessed 28 April 2021]. Available from: http://ir.uiowa.edu/pog/

[xxxvii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1

[xxxviii] Vine, S. Vilified by armies of woke…for being a woman. Daily Mail. [Online]. 13 February 2021. [Accessed 4 May 2021]. Available from: https://www.dailymail.co.uk/debate/article-9257865/SARAH-VINE-Vilified-armies-woke-woman.html

[xxxix] MacDonald, T, Noel-Weiss, J, West, D. et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth [Online]. 2016,106. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-016-0907-y

[xl] Brandt, J, Patel AJ, Marshall I, Bachmann, GA. Transgender men, pregnancy, and the “new” advanced paternal age: A review of the literature. Maturitas. [Online]. 2019.

128,17:21. [Accessed 1 May 2021]. Available from: https://www.sciencedirect.com/science/article/pii/S0378512219305845

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An Exploration of the Aetiology of UK Women’s Perinatal Mental Health Problems.

(Originally written as an assignment for Masters in Public Health/Global Women’s Public Health)

Nature of Problem:

The perinatal[i] mental health (PMH) of women[ii] in the UK is an area of significant concern, needing investment and prioritisation to protect both women and their families’ lives. Poor mental health affects not just mothers: it can affect the child’s physical and emotional health[1], as well as other members of the familial unit[2]. Poor PMH can impact a foetuses’ heart rate[3], cause pre-term birth[4], and cause epigenetic DNA changes[5]. Prevention, detection, and treatment therefore are all crucial to support wider health.

PMH problems[iii] (PMHP) affect up to 20% of perinatal women[6]. This large sample, mixed-method study of perinatal women had responses from women already likely to be thinking about perinatal mental health, however the NHS[7] [8] support these statistics, making over-representation an unlikely influencer. Suicide is the biggest cause of maternal death in the first year post-birth and the second biggest in the first forty-two days post-birth[9]. These statistics have been collated by MBRRACE-UK from NHS reporting, cross-referenced with government resources, and analysed by multiple Expert Reviewers; the methodological rigour underpins the robustness of findings. PMHP cost the UK £8.1 billion per year[10]; economic modelling which includes a robust systematic review and meta-analysis following NICE standards, increasing internal and external validity. Three-quarters of this cost is associated with childhood morbidity[11].

There are regional variances in PMH in the UK. The North East has a referral rate to support services of 35% compared to the East’s 15%[12]: there is a similar regional response rate of respondents comfortable talking about their mental health with a healthcare professional and the report concludes the difference is likely due to (lack of) care received rather than need. The UK is not alone in its concerns over PMH. High Income Countries have a prevalence of PMHP in 7-15%[13] of perinatal women, Low-Middle Income Countries have a higher frequency of 16-25%[14]. These figures are not as recent as the standalone UK percentage so although the UK seems to have a higher rate it is possible that all countries have crept up over recent years. It is also possible that countries without the infrastructure to support large data collection under-report their prevalence.

Impact of Risk Factors:

Gender is a key determinant of good mental health: in England one in five women and one in eight men suffer a mental health disorder, with this number increasing in women over recent years but remaining stable in men[15]. PMH is clearly a factor in this gender disparity; it is possible that if a gender burden were removed in all other aspects of mental health determinants a disparity in prevalence between genders would still exist due to the perinatal period.

Birth trauma is a key trigger of PMHP, affecting around 30%[16] of women who have given birth. Factors influencing development of PMHP following birth trauma include those who have experienced any type of previous life trauma, an intervention-heavy birth, perceived poor care from their healthcare team, and those whose babies are born prematurely or are admitted to neonatal units[17]. Race, ethnicity, age, low socio-economic standing, and lack of empowerment in the birth-room are themselves a risk factor of developing these outcomes[18] [19] [20]. There is a paucity in research regarding prevention of birth trauma – reducing the root cause of an outcome rather than attempting to change the outcome itself may be the necessary action needed. There is also a disparity between both the topics that have been researched and the findings of the research carried out, and the experiences that women and midwives relay. To understand why such a disparity exists, and why preventing birth trauma has not been studied in any great detail needs the context of the UK’s maternity services. Obstetricians are, by their very specialty, more likely to only experience complicated births and have therefore normalised medical births in a way many midwives have not. Obstetricians are also more likely to conduct research, and their medical, male-orientated research is more likely to be funded than research into promoting the physiological norm due to the patriarchal nature of healthcare[21]. The biases of the researcher, therefore, result in research that misses some fundamental areas of lived experience. This is a situation that is changing, however it has become quite a deep-seated divide and the recent media coverage[22] of the newly released Ockenden Report[23] using the phrase “cult of natural birth” shows just how prevalent and entrenched medicalised birth has become. It is also possible that birth trauma figures are even higher as individuals may not count ‘feeling traumatised’ as a specific mental health problem if a diagnosis of PTSD has not been made, and a diagnosis might not be sought when the narrative around birth expects it to be a traumatic event[24].

Ethnicity is another key consideration of PMPH. Minority ethnic groups have a higher prevalence of PMHP while simultaneously being less likely to have them detected or treated[25]. Suffering a higher burden of poor mental health already from other determinants such as poverty, inequity in education and healthcare access, English as a second language, and community and cultural environments factor in these figures, however much current research ignores racism – both institutional and direct – in being a trigger for poor PMH. Since the 2018 MBRRACE report [26] a light has been cast on racial inequities in maternal mortality (including mental health) and grass-roots campaigns like FiveXMore[27] are championing change. Challenging deep-seated inequalities is an ongoing and lengthy process; the uncomfortable dissonance felt by maternity service workers has not fully receded to a point where research can be conducted into this with bias eliminated. It is, perhaps, not the ethnicity of a woman that is the determinant of poor mental health per se, but rather the intersection of a lifetime of socioeconomic factors that are underpinned by structural racial discrimination mixed with a healthy dose of individual ethnically-motivated prejudices. Consideration also need to be given to cultural stigma around mental health, which may exacerbate illnesses[28] [29] and ethnicities such as Travellers who commonly underutilise healthcare[30] meaning true data may be under-represented.

Strong links exist between socioeconomic status and mental health illness[31], a link continuing in the perinatal period[32]: This study by Ban et al shows women in the most deprived quintile are up to 2.63 times more likely to develop PMHP compared to those in the least deprived quintile. It is, perhaps, unsurprising that women who have existing financial pressures would find them exacerbated by having a new addition to the household and that this increased pressure could trigger a PMHP. Linking in not meeting breastfeeding goals (discussed below) adds an additional financial pressure of circa £10 per week for a can of formula powder – doubly critical that when a woman wants or needs to breastfeed she is supported to do so. The large-scale cross-sectional analysis by Ban et al also correlates age and socioeconomic status: the older a woman is and the more deprivation she is in, the higher her chance of developing PMHP. The large sample size of 116,457 increases validity; although it is possible that those younger, those in higher deprivation or those in some minority ethnic groups are under-represented as they may be less likely to seek intervention.

Society has a role in supporting PMH. New mothers face pressure about how they and their baby should be feeling and behaving from multitudes of sources with many losing self-efficacy, triggering episodes of poor mental health due to a lack of empowerment. The decentralisation of extended families can result in a higher reliance on parenting books whose profit-driven priority is to sell a problem to be fixed by their method; reliance and ‘solutions’ that can trigger poor PMH[33]. How a mother feeds her baby is also a risk factor in triggering a PMHP. While breastfeeding is a protective factor against postnatal depression[34], poor mental health can be triggered if a mother does not meet her breastfeeding goals[35] [36].

The current Covid19 pandemic is limiting access to mental health services. A rapid response study has found that depression has increased by 26% and anxiety by 43% in perinatal women during the pandemic compared to perinatal women before the pandemic. Families feel they do not know where to access information and support[37] and service changes have contributed to suicide deaths[38]. With pandemic stressors on top of the ‘normal’ risk factors for poor PMH there is a big risk of a huge mental health crisis, swamping already underfunded and under-resourced services. Where usually women would have face-to-face appointments that would provide the opportunity to detect issues, these are not always happening (occurring virtually, where women have indicated that they are not comfortable talking about mental health issues over the phone[39]) or at all (where the healthcare team have been redeployed).

Preventative Strategies:

Current detection of PMH relies on three access-points: pro-active requests for support; positively answering a wellbeing request from their healthcare professional; an existing complex mental health need resulting in a referral to a specialist pathway[40], however these are not without their potential pitfalls, the biggest being the woman being capable of vocalising her need – something which may be hard during a PMHP. The NHS has prioritised mental health in their Five Year Forward View for Mental Health[41], transforming their Perinatal Mental Health Care Pathway[42] guidance, investing to meet greater need, and greater significance on mental health being placed on all contact points of perinatal women, including the newly contracted six-week postnatal maternal check via GP services[iv][43], although as this started at the peak of the pandemic the service has been oft-overlooked[44] this year.

Detection of PMHP could be improved by services strengthening their links; the NHS is not an homogenous entity and siloed working[45] between services creates gaps that women can slip through[46], especially in an under-resourced, over-worked environment where wellbeing checks become tick box exercises through time constraints, relationships between healthcare professional and service user do not have the opportunity to develop, and referred services have lengthy waiting times if a woman does manage to get that far. Healthcare professionals who interact with perinatal women need to have specific PMH training to help identify issues and be able to confidently manage a PMHP caseload in line with evidence-based pathways.

Prevention is better than cure: optimising preventative strategies is needed to reduce the burden of PMHP. The intersection and correlation of risk factors means that reducing prevalence of PMHP is no small task, starting with reducing long-term health inequalities in at-risk groups: gender, socioeconomic status, race, ethnicity, and LGBT+ status. If a woman is less likely to develop a mental health problem in a wider context it will only help in a perinatal context. However, much is to be done specifically in the perinatal period too. Reducing birth trauma – changing the narrative around how childbirth is ‘horrendous’ so people expect better[47], reducing unnecessary intervention[48], establishing strong relationships through continuity of carer[49], increasing doula use[50], good quality feeding support[51], and supporting new mothers instead of adding pressure to them[52] will all reduce a woman’s chance of developing a PMHP. Indeed, continuity of carer during pregnancy, the intrapartum and postnatal periods is of great benefit not just in preventing birth trauma and detecting mental health problems themselves, but also in detecting other psychosocial factors that can increase a woman’s chance of developing PMHP. Intimate partner violence increasing during pregnancy[53], poor social support, financial pressures and life stresses are all risk factors for developing PMPH[54] [55] and can all be reduced by a woman being cared for by a trusted midwife over the entire period.

The cost of funding sufficient PMH services is £0.28 billion per year compared to an annual cost to the UK of £8.1 billion[56] – a compelling argument for public health strategic intervention. Key to all prevention strategies is the co-creation of services with experts-through-experience, paying particular attention to the most at-risk cohorts of women giving birth. World-beating PMH services are useless if mothers cannot attend[v]; women’s lived experiences and needs must be listened to. Although the NHS commits to co-production of services in all the guidance documented in this essay, the reality is that services are so fragmented and under resourced that co-production is often lip service at best.

It is inevitable that some PMHP will exist no matter how stringent the prevention and detection measures put in place are. Treatments need to be timely and accessible, and they need to take into consideration the family constraints a new mother has on her, including high-needs inpatient services. If drug treatment is deemed necessary it is important that prescribers consider a woman’s desire to continue breastfeeding and ensure that the prescribed medication is suitable for breastfeeding mothers, otherwise not meeting her breastfeeding goal could trigger poor mental health.

Peer support as well as medical care is a useful intervention in the treatment of PMHP[57]. It can help reduce feelings of isolation, validate feelings, and provide signposting to specialist services. Peer support services tend to be charity or third-sector led, a wary consideration that may lead to reduced public spending on essential services as the gaps are plugged by volunteers. Peer support is also a useful tool in encouraging under-represented groups to seek additional support, helping to validate feelings in demographics where taboos exist about talking about mental health[58].

There is a wealth of data showing facts and figures around PMH: qualitative research is needed – and the importance of findings acknowledged – to prevent and detect PMHP and create services fit for purpose at treating. Only a multi-factorial position that puts women at the heart of the framework will reduce prevalence of PMHP.

Conclusion

PMHP are a changing burden on women in the UK. Women bear the brunt of the burden for obvious gender reasons, and the burden is increasing over time. Birth trauma is increasing, driven by increasing medicalisation of birth, advancing maternal age, and pandemic restrictions[59] [60]. Non-white-British population is increasing[61], and although work is being done to combat health inequities in ethnic minority populations it is yet to be seen whether this will offset an increase in racially motivated prejudice[62]. Women continue to bear the burden of socioeconomic deprivation, a trend not declining[63]. The intersection of all these risk factors seems set to continue to adversely impact the burden of PMH. Existing strategies for prevention need to be strengthened and optimised to reduce prevalence – including society changing to meet its obligation in reducing the burden on women.

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[i] Using the widely used definition being from conception to one year post childbirth unless explicitly stated.

[ii] This report recognises that not all people who give birth are women, however for stylistic purposes ‘women’ has been used throughout.

[iii] ‘Problems’ has been used rather than ‘disorders’ as disorders implies a medical diagnosis which may not be true for all women.

[iv] A check that has been done for years but has not been contracted – therefore GP’s paid for and obliged to complete – until April 2020.

[v] A conversation with a new mother in 2019: a need specialist PMH support was detected, a local service available and had capacity – the mother unable to attend as babies not allowed to attend appointments. Her partner worked and could not take time off without financial impact. Financial strain would have added to the poor mental health situation. No family available to assist and baby was exclusively breastfed anyway.

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[60] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. 2020. [https://babiesinlockdown.info]

[61] Office for National Statistics. Population of England and Wales. 2020. [https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest]

[62] Home Office. Official Statistics; Hate Crime, England and Wales: 2019-2020. 2020. [https://www.gov.uk/government/publications/hate-crime-england-and-wales-2019-to-2020/hate-crime-england-and-wales-2019-to-2020]

[63] Reis S. DWP data reveals: women and children continue to be worst affected by poverty. Women’s Budget Group. 2019. Available at https://wbg.org.uk/blog/dwp-data-reveals-women-continue-to-be-worst-affected-by-poverty/. Accessed 5 January 2020.

Discussing the Impact on Pregnant Families in the UK Following Restrictions in Maternity Services Due to Covid-19.

[Initially written and submitted for a postgrad course which goes someway to explaining the dryness, and the full way of explaining the lack of swearing]

The Covid-19 pandemic has impacted most lives. While every sector has suffered detriment and every negative consequence is of course harmful, maternity services[1] is potentially the locus of the most far-reaching consequences, causing stress not just to the affected persons but also harm to the new generation of ‘lockdown babies’ including through transgenerational trauma[i]. This essay will examine the restrictions in place within maternity care, discuss their impact on pregnant families and question why new parents have been so badly let down. As the situation is ongoing and rapidly changing, if insufficient evidence exists from the UK, research from other high-income countries has been used. The essay also highlights the disparity in trust given to different types of evidence; we have countless real-world experiences[ii] [iii] [iv] which run the risk of being dismissed by the scientific community, policy makers and governments for not conforming to the hierarchy of quantitative evidence.

Maternity service restrictions were implemented early in the pandemic, affecting most NHS Trusts with obstetric units.

Area of Service Provision Affected	Percentage of Trusts Implementing Restrictions
Reduction of antenatal appointments	70%
Partner restrictions at non-routine antenatal appointments	95%
Gestational diabetes screening pathway	70%
Partner restrictions at 12-week scan	90%
Partner restrictions at 20-week scan	88%
Partner restrictions in labour (inc. all labour, early labour, induction of labour)	86%
Home birth or midwifery-led unit provision	59%
Reduction of postnatal appointments	56%
Partner restrictions at postnatal appointments	50%
Remote consultation methods	89%

Table One: Restrictions on access to maternity services March/April 2020[v] [vi]

These figures show the conditions of those who responded (42% and 63% respectively); it’s possible that the on the ground reality was different – for better or worse, although it seems likely that those who did not respond would be those enforcing stricter restrictions, especially taken together with the lived experiences already referred to and elsewhere in this essay. The impact on the amount of and type of care provided during the first wave of the pandemic is evident, and these constraints are continuing (43%) or would be reinstated if cases rise again (24%)[vii]. It is notable that 32% of Trusts did not work with service users to co-produce the implementation of their policies even though there is an obligation on the NHS to involve patients in service production[viii]. That 89% of Trusts use remote consultation methods, and 32% of Trusts do not co-create services runs the risk of ‘losing’ families who do not have access to these mean of communication, either through ownership (those in poverty) or safely (those in coercive relationships).

Data shows most perinatal families in the UK have had restricted service provision, but more important is how they have been affected by them. 38% of pregnant women are concerned about getting reliable, accurate information about their pregnancies without having face-to-face contact with their care providers, 34% believe care at birth was not how they had planned because of the restrictions, and 38% believe that the restrictions impact their ability to cope[ix]. Worryingly, 86% of Trusts experienced a reduction in emergency antenatal care being sought [x]. Data from April to June 2020 shows the stillbirth rate rose from 24 to 40 from the same period in 2019[xi] and although causation is not yet linked to the decrease in care being sought, clinicians do seem to be treating it as such[xii].

Partner exclusion is having a big emotional and physical impact on both parents. Women have better birth outcomes through reducing induction of labour, reducing labour length, decreasing intervention rates, reducing maternal pain, reducing fear, reducing postnatal depression rates and improving birth satisfaction[xiii] when properly supported by their partners; without their presence there is more chance of adverse outcomes occurring. Partner participation in maternity care is so important to health outcomes that the World Health Organisation have reiterated their call for their continuous involvement[xiv]. It is plausible that excluding co-parents from pregnancy and birth will impact their ability to bond with their child and increase paternal postnatal depression[xv] [xvi]. Their being ‘locked out’ of maternity care is not merely a question of a nice-to-have not happening but a health crisis in and of itself.

How babies are fed has also been impacted by the pandemic:

Area of Concern	Percentage of mothers affected
Lockdown helped protect breastfeeding relationship	41%
Felt support was lacking	27%
No longer exclusively breastfeeding	41%
Of the above, felt ready to stop breastfeeding	14%
Introduced unwanted formula	69%

Table two: impact of maternity restrictions on breastfeeding[xvii]

The lack of infant feeding support is not merely a perception of parents: infant feeding teams have closed their services entirely with staff redeployed from the service; reduced service capacity; changed service provision away from face-to-face; and/or restricted access to those in most need[xviii]. Not breastfeeding has a health impact on the child and on the mother, both physically and mentally[xix] [xx], this reduction in service could have costly long-term health impacts on mother and baby, costing the NHS financially in the long-term[xxi] as well as costing the family to use formula milk: effectively disadvantaging lower-income families to a greater extent and increasing socio-economic disparity.

Unsurprisingly an increase in perinatal anxiety has been observed: women reporting higher levels of depression and anxiety, disassociation, post-traumatic stress and health anxiety for themselves and their unborn child[xxii] [xxiii] [xxiv]. 68% lack confidence that they could find appropriate support for their mental health[xxv] with 14% being reluctant to talk about their mental health over the phone[xxvi]. This is a huge mental health crisis on top of an existing one: suicide is already the biggest cause of maternal death in the first year post- birth, the second biggest in the first forty-two days post- birth and the fifth biggest during pregnancy[xxvii] –the removal and changes to services on top of increased stressors could create a massive mental health crisis in mothers. Indeed, we have already sadly seen the consequences with four women dying by suicide between March and May 2020 whose deaths were wholly attributable to changes in service provision[xxviii]. Maternal stress hormones can affect children as well as mothers, causing low birth weight, earlier gestational age, altered neurobehavioural development, psychopathology, poorer cognitive and socioemotional development and increased neonatal stress hormones in the child[xxix] [xxx].

The pandemic also appears to be widening the gap in care that already vulnerable groups receive, putting babies in those groups at greater long-term disadvantage[xxxi]. Women from Black and Asian backgrounds, and those living in areas or households with poverty are more likely to be infected with and have more serious cases of Covid-19[xxxii]. Clinicians should be considering women in these categories with a lower threshold of risk[xxxiii] and implementing a four-point action plan[xxxiv] to offer additional support to women of these ethnic backgrounds, however in many Trusts this is not happening[xxxv]. Fewer Black and Asian women feel they have the information they need during pregnancy and postnatally than White women, and Black women are less likely to have accessed information and support[xxxvi]. These factors will almost certainly have an adverse impact on families.

It is important communities work together to support maternity services to protect health[xxxvii] yet we saw earlier that 32% of Trusts are not working with their users to create or implement new policies, causing concern that the service is very quickly losing its co-production culture[xxxviii], potentially leading to a long-lasting quietening of women’s voices – ground that has been hard gained[xxxix]. Not listening to or involving those with lived experience of the issues causes unnecessary harm: Liverpool Women’s NHS Foundation Trust wrote and shared information with no involvement from their community. The backlash received ran into thousands of social media comments and an appearance in the press – not helpful to the information they were trying to release[xl] or the anxiety of the women in their care. Is one of the barriers to the consideration given to maternity services, its users, and the importance of the messages they give across one of the gender imbalances within NHS senior teams[xli]?

Keeping people safe from the disease is rightly a priority for the NHS, but what happens when the cure is greater than the disease[xlii]? Separating the familial unit when receiving bad news, through labour and after a child is born is cruel and has a demonstrable impact on the health of all. Despite affecting so many across the UK, the impact of these restrictions barely reached the nation’s consciousness until grassroots campaign #butnotmaternity launched in September, igniting attention from the Daily Mail[xliii]. There has been no government-fronted campaign to ease harm, as there has been with the hospitality industry’s Eat Out to Help Out campaign. It is easy to conclude that ‘women’s issues’ are lower in the food chain than ‘men’s issues’ of drinking in a pub from the coverage given to both in the media[xliv] and at policy-making level – especially when there is no immediate visible economic benefit.

The situation is so new and fast-changing that research must rely on rapid-return forms of evidence; there just has not been time for longer-term research to take place. However, bountiful qualitative evidence exists; to ignore it would be a huge disservice to those lived experiences.

There has been a big impact from the restrictions on pregnant families in the UK, and there continues to be so for many while the pandemic continues. The immediate impact is clear to see, however the longer effects may take years to be realised. Does the lack of women’s voices at a senior level impact the value given to righting this wrong? And we must give thought to low- and middle-income countries where the impact must surely be felt more deeply[xlv]. The consequences could be reduced by finding a way to lift restrictions without compromising safety. With so many already affected, it seems necessary to ensure there will be sufficient healthcare provisions, especially in mental health, to deal with the consequences of these restrictions.

[1] From the initial booking in appointment through antenatal, intrapartum, and postnatal care to 10 days, alongside specialist infant feeding and perinatal mental health support.

[i] Chan JC, Nugent BM, Bale TL. Parental Advisory: Maternal and Paternal Stress Can Impact Offspring Neurodevelopment. Biol Psychiatry. 2018 May 15;83(10):886-894. doi: 10.1016/j.biopsych.2017.10.005. Epub 2017. PMID: 29198470; PMCID: PMC5899063

[ii] Johnson, S. ‘There are more births in the car park’: a midwife’s experience of the Covid-19 crisis. [Online]. Available from: https://www.theguardian.com/society/2020/jun/04/more-births-car-park-midwifes-experience-covid-19-crisis [Accessed 2 November 2020]

[iii] Shuttleworth, P. Covid-19: ‘How lockdown stopped me from breastfeeding’. [Online]. Available from: https://www.bbc.co.uk/news/uk-wales-54369912 [Accessed 2 November 2020]

[iv] https://www.facebook.com/informedchoicematters

[v] Jardine, J, Relph, S, Magee, L A, von Dadelszen, P, Morris, E, Ross‐Davie, M, Draycott, T, & Khalil, A. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics & Gynaecology, 1471-0528.16547. https://doi.org/10.1111/1471-0528.16547. 2020

[vi] Iacobucci, G. Partners’ access to scans and birth is a postcode lottery, data show. BMJ (Clinical Research Ed.), 371, m3876. Available from: https://doi.org/10.1136/bmj.m3876. 2020

[vii] Iacobucci, G. Partners’ access to scans and birth is a postcode lottery, data show. BMJ (Clinical Research Ed.), 371, m3876. Available from: https://doi.org/10.1136/bmj.m3876. 2020

[viii] NHS England. Personalised Care. [Online]. Available from: https://www.england.nhs.uk/personalisedcare/ [Accessed 5 November 2020]

[ix] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[x] Jardine, J, Relph, S, Magee, L A, von Dadelszen, P, Morris, E, Ross‐Davie, M, Draycott, T, & Khalil, A. Maternity services in the UK during the COVID‐19 pandemic: a national survey of modifications to standard care. BJOG: An International Journal of Obstetrics & Gynaecology, 1471-0528.16547. https://doi.org/10.1111/1471-0528.16547. 2020

[xi] BBC. Stillbirths rise during pandemic leads to safety review. [Online]. Available from: https://www.bbc.co.uk/news/health-54779857 [Accessed 2 November 2020]

[xii] NHS England. www.twitter.com. [Online]. Available from: https://twitter.com/NHSEngland/status/1323218707741614080?s=20 [Accessed 5 November 2020]

[xiii] Walsh, S. Re: Care during covid-19 must be humane and person centred – Partner attendance at maternity services. [Online]. Available from: https://www-bmj-com.manchester.idm.oclc.org/content/370/bmj.m3483/rr-1 [Accessed 3 November 2020]

[xiv] World Health Organization. Companion of choice during labour and childbirth for improved quality of care: evidence-to-action brief. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/companion-during-labour-childbirth/en. 2020

[xv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xvi] Singley, D B, & Edwards, L M. Men’s perinatal mental health in the transition to fatherhood. Professional Psychology: Research and Practice. Available from: https://doi.org/10.1037/pro0000032. 2015

[xvii] Brown, A, Shenker, N. (2020). Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support. Maternal & Child Nutrition. Available from: https://doi.org/10.1111/mcn.13088

[xviii] [redacted]

[xix] Victora, C G, Bahl, R, Barros, A J D, França, G V A, Horton, S, Krasevec, J, Murch, S, Sankar, M J, Walker, N, Rollins, N C, Allen, K, Dharmage, S, Lodge, C, Peres, K G, Bhandari, N, Chowdhury, R, Sinha, B, Taneja, S, Giugliani, E, Richter, L. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. https://doi.org/10.1016/S0140-6736(15)01024-7. 2016

[xx] Brown, A. What do women lose if they are prevented from meeting their breastfeeding goals? Clinical Lactation, 9(4), 200–207. https://doi-org.manchester.idm.oclc.org/10.1891/2158-0782.9.4.200. 2018

[xxi] NHS. [Online]. Available from: https://www.nhs.uk/news/pregnancy-and-child/more-breastfeeding-would-save-nhs-millions/#:~:text=Overall%2C%20if%20the%20proportion%20of,the%20three%20reduced%20infant%20infections. [Accessed 6 November 2020]

[xxii] Berthelot N, Lemieux, R, Garon-Bissonnette, J, Drouin-Maziade, C, Martel, É, Maziade, M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 848–855. https://doi.org/10.1111/aogs.13925. 2020

[xxiii] Corbett, G. A, Milne, S J, Hehir, M P, Lindow, W, & O’connell, M P. Health anxiety and behavioural changes of pregnant women during the COVID-19 pandemic. European Journal of Obstetrics and Gynecology and Reproductive Biology (Vol. 249, pp. 96–97). Elsevier Ireland Ltd. https://doi.org/10.1016/j.ejogrb.2020.04.022. 2020

[xxiv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxv] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxvi] Karavadra, B, Stockl, A, Prosser-Snelling, E, Simpson, P, & Morris, E. Women’s perceptions of COVID-19 and their healthcare experiences: A qualitative thematic analysis of a national survey of pregnant women in the United Kingdom. BMC Pregnancy and Childbirth, 20(1). https://doi.org/10.1186/s12884-020-03283-2. 2020

[xxvii] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2019

29 Knight, M, Bunch, K, Cairns, A, Cantwell, R, Cox, P, Kenyon, S, Kotnis, R, Lucas, N, Lucas, S, Marshall, L, Nelson-Piercy, C, Page, L, Rodger, A, Shakespeare, J, Tuffnell, D, & Kurinczuk, J. Saving Lives, Improving Mothers’ Care Rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK Maternal, Newborn and Infant Clinical Outcome Review Programme. Available from: www.hqip.org.uk/national-programmes. 2020

[xxix] Su Q, Zhang H, Zhang Y, Zhang H, Ding D, Zeng J, Zhu Z, Li H. Maternal Stress in Gestation: Birth Outcomes and Stress-Related Hormone Response of the Neonates. Pediatr Neonatol. 2015 Dec;56(6):376-81. doi: 10.1016/j.pedneo.2015.02.002. Epub 2015 Apr 20. PMID: 26363772

[xxx] Berthelot N, Lemieux, R, Garon-Bissonnette, J, Drouin-Maziade, C, Martel, É, Maziade, M. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 848–855. https://doi.org/10.1111/aogs.13925. 2020

[xxxi] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxxii] Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369 :m. 2107

[xxxiii] The Royal College of Midwives, Royal College of Obstetricians & Gynaecologists. Information for healthcare professionals Coronavirus (COVID-19) Infection in Pregnancy. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf. 2020

[xxxiv] Dunkley-Bent, J. NHS England. [Online]. Available from: https://www.england.nhs.uk/2020/06/nhs-boosts-support-for-pregnant-black-and-ethnic-minority-women. [Accessed 6 November 2020]

[xxxv] Multiple authors. 2020. Personal Conversations from [redacted] [Accessed 6 November 2020]

[xxxvi] Best Beginnings, Home-Start UK, Parent-Infant Foundation. Babies in Lockdown: Listening to Parents to Build Back Better. Available from: https://babiesinlockdown.info. 2020

[xxxvii] Osanan, G C, Vidarte, M F E, & Ludmir, J (2020). Do not forget our pregnant women during the COVID-19 pandemic. In Women and Health (Vol. 60, Issue 9, pp. 959–962). Routledge. https://doi.org/10.1080/03630242.2020.1789264. 2020

[xxxviii] Coulter, A, & Richards, T. Care during covid-19 must be humane and person centred. In The BMJ (Vol. 370). BMJ Publishing Group. https://doi.org/10.1136/bmj.m3483. 2020

[xxxix] Temmerman, M, Khosla, R, Laski, L, Mathews, Z, & Say, L. Women’s health priorities and interventions. BMJ (Clinical Research Ed.), 351, h4147. https://doi.org/10.1136/bmj.h4147. 2015

[xl] Jaleel, G. Liverpool Echo. [Online]. Available from: https://www.liverpoolecho.co.uk/whats-on/family-kids-news/mums-dreading-giving-birth-liverpool-19050290 [Accessed 6 November 2020]

[xli] Sealy, R. Action for Equality: The time is now. University of Exeter Business School. Available from: https://www.nhsconfed.org/resources/2020/09/action-for-equality-the-time-is-now. 2020

[xlii] Kapila, M. Trading-off human rights with public health in the name of COVID-19. Flesh & Blood: The Blog of Mukesh Kapila. Weblog. [Online] Available from: https://mukeshkapilablog.org/2020/09/25/trading-off-human-rights-with-public-health-in-the-name-of-covid-19/ [Accessed 2 November 2020]

[xliii] Mikhailova, A. Daily Mail. [Online]. Available from: https://www.dailymail.co.uk/news/article-8726417/Covid-rules-forcing-thousands-mothers-endure-labour-without-loved-ones-side.html [Accessed 6 November 2020]

[xliv] Kassova, L. The Missing Perspectives of Women in COVID-19 News A special report on women’s under-representation in news media. Available from: https://www.iwmf.org/women-in-covid19-news. 2020

[xlv] Kimani RW, Maina R, Shumba C, Shaibu S. Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model. Hum Resour Health. 2020 Oct 7;18(1):75. doi: 10.1186/s12960-020-00518-3. PMID: 33028347; PMCID: PMC7539267. 2020

Advanced Maternal Age and Stillbirth

This is an interesting subject to write about because nobody likes to think that they’ve crossed over into the advancing age category. Remember before we start you’re only as old as you feel (which in my case sees me hitting oldest ever living person age, especially as we’re halfway through a rainy half term!)

I’m talking here specifically about maternal age and stillbirth, but there areother things to be thinking about it you’re older than 35, including genetic risks and miscarriage. It’s also really, really, really, really, really important that when you read this or any discussion of risks, you remember that these are stats made up (usually) from studies looking at one thing. Your own individual circumstances and risk factors have a big impact, as does your own personality, values and experience to date.

One of the largest reviews of evidence happened in 2008 where Huang et al took 31 studies and largely found that there was a consistent risk of stillbirth in an older mother of 1.2-2.23 times higher than in younger mothers. There are, however, concerns that have been raised with the results including:

What age they used as their cut off date between younger and older (some used 35, some 40)
Categorising risk in binary ‘older’ or ‘younger’ categories, which failed to show slowly increasing risk making it look instead like a substantial jump at a particular age
Definitions of stillbirth
The age of the study, as medical care has changed considerably over recent years.

So this seems to be a case of yes there is an increased risk but…

In 2000, Jolly et al released the following figures as a result of their study:

Women aged 18-34 had a stillbirth rate of 4.7/1000
Women aged 35-40 had a stillbirth rate of 6.1/1000
Women aged 40+ had a stillbirth rate of 8.1/1000

In 2006, Reddy et al looked at whether the increased risks were for all women over a certain age, or if it was first time mothers. They found the risks were (all out of 1000):

Women under 35: 3.72 (first time mothers) / 29 (given birth before)
Women between 35-39: 6.41 (first time mothers) / 99 (given birth before)
Women aged 40+: 8.65 (first time mothers) / 29 (given birth before)

They also found that if a woman was healthy her chances of stillbirth reduced but were still higher than her comparator of a younger person.

Now, the reason I’m writing this now is because one of my clients has had a conversation with her consultant about being induced on or soon after her EDD due to her age.

Reddy et al found that there is a difference in the age of the mother, length of gestation and risk of stillbirth. But, perhaps, not one that is quite so clear cut a trajectory as you’d imagine. Their research showed that:

The largest spike in number of stillbirths in all age groups was between 38-39 weeks pregnant, while the lowest was between 32-33 weeks
For those aged under 39 the number of stillbirths decreased from week 40-41
For those aged 40+ the number of stillbirths continued to rise (to 2.48)

Evidenced Based Birth found that induction rates are around 20-24% regardless of maternal age (although bear in mind that current UK induction rates are around 30-40% nationally) however caesarean rates rose from 29.5% (aged 25-29), 33% (30-34), 45.5% (40-44) to 57.1% (45+) Again, this is US data from 2014 so a slightly different climate to the UK today, where midwifery-led care can bring its own benefits and good birth outcomes.

A small UK study by Walker in 2016 looked at whether there was a rise in caesarean rates in older women who had been induced. The study found no difference in caesarean rates between induced and not-induced groups but caesareans increased with maternal age. Interestingly complication rates were similar across groups so it seems as though the caesareans happened because of maternal age rather than maternal age influencing complications which led to caesareans. All other comparators were very similar too including maternal satisfaction, birth weight and baby’s health. There’s another but coming though and that’s because the study was a really small sample and although showed some interesting things there just aren’t the numbers to get good quality evidence from.

One of the thought-to-be causes of stillbirth in women over 40 is hypoxia, which is not enough oxygen for baby (Pasupathy et al). However, one of the risks of induction of labour from an artificial oxytocin drip is hypoxia. Sara Wickham calls this a birthillogic. Induction of labour and caesareans all have their own risks associated with them so we need to loop back to the very start of these 1000 words (this was meant to be a whatsapp message to quickly answer a question, by the way. Succinct is and never has been my strong suit!) where I said this has GOT to be YOUR decision and to be able to make YOUR decision you need transparency of information. Being told your risk increases because of your age may well be true, but you can’t make a decision without understand what the risk is, how it applies to your own situation, and what the risks of action you may agree to are.

Most of the data I’ve looked at has come from Evidence Based Birth and any misinterpretations of the data are mine. I would encourage you to read the original as there’s loads more information there than I’ve written in this post. I’d also suggest reading Sara Wickham’s article about this, and also the RCOG guidelines for Induction of Labour At Term In Older Mothers.

Informed Decision Making Pregnancy Birth