Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors

In order to inform mapping of their local population to guide service provision, commissioners should ensure that the following are recorded:

• The number of women presenting for antenatal care with any complex social factor. Examples of complex social factors in pregnancy include: poverty; homelessness; substance misuse; recent arrival as a migrant; asylum seeker or refugee status; difficulty speaking or understanding English; age under 20; domestic abuse. Complex social factors may vary, both in type and prevalence, across different local populations.

• The number of women within each complex social factor grouping identified locally.

Commissioners should ensure that the following are recorded separately for each complex social factor grouping:

• The number of women who:

  • attend for booking by 10, 12+6 and 20 weeks.

  • attend for the recommended number of antenatal appointments, in line with national guidance, see the NICE guideline on antenatal care.

  • experience, or have babies who experience, mortality or significant morbidity. Significant morbidity is morbidity that has a lasting impact on either the woman or the child.

• The number of appointments each woman attends.

• The number of scheduled appointments each woman does not attend.

Commissioners should ensure that women with complex social factors presenting for antenatal care are asked about their satisfaction with the services provided; and the women's responses are:

• recorded and monitored

• used to guide service development.

Commissioners should involve women and their families in determining local needs and how these might be met.

Those responsible for the organisation of local maternity services should enable women to take a copy of their hand-held maternity notes when moving from one area or hospital to another.

Healthcare professionals should be given training on multi-agency needs assessment and national guidelines on information sharing. See information sharing advice for safeguarding practitioners.

Consider initiating a multi-agency needs assessment, including safeguarding issues, so that the woman has a coordinated care plan. See information sharing advice for safeguarding practitioners, information sharing to protect vulnerable children and families and Multi Agency Risk Assessment Conference.

Respect the woman's right to confidentiality and sensitively discuss her fears in a non-judgemental manner.

Tell the woman why and when information about her pregnancy may need to be shared with other agencies.

Ensure that the hand-held maternity notes contain a full record of care received and the results of all antenatal tests.

For women who do not have a booking appointment at the first contact with any healthcare professional:

• discuss the need for antenatal care

• offer the woman a booking appointment in the first trimester, ideally before 10 weeks if she wishes to continue the pregnancy, or offer referral to sexual health services if she is considering termination of the pregnancy.

At the first contact and at the booking appointment, ask the woman to tell her healthcare professional if her address changes, and ensure that she has a telephone number for this purpose.

At the booking appointment, give the woman a telephone number to enable her to contact a healthcare professional outside of normal working hours, for example the telephone number of the hospital triage contact, the labour ward or the birth centre.

In order to facilitate discussion of sensitive issues, provide each woman with a one-to-one consultation, without her partner, a family member or a legal guardian present, on at least one occasion.

Healthcare commissioners and those responsible for providing local antenatal services should work with local agencies, including social care and third-sector agencies that provide substance misuse services, to coordinate antenatal care by, for example:

• jointly developing care plans across agencies

• including information about opiate replacement therapy in care plans

• co-locating services

• offering women information about the services provided by other agencies.

Consider ways of ensuring that, for each woman who misuses substances:

• progress is tracked through the relevant agencies involved in her care

• notes from the different agencies involved in her care are combined into a single document

• there is a coordinated care plan.

Offer the woman a named midwife or doctor who has specialised knowledge of, and experience in, the care of women who misuse substances, and provide a direct-line telephone number for the named midwife or doctor.

Healthcare professionals should be given training on the social and psychological needs of women who misuse substances.

Healthcare staff and non-clinical staff such as receptionists should be given training on how to communicate sensitively with women who misuse substances.

The first time a woman who misuses substances discloses that she is pregnant, offer her referral to an appropriate substance misuse programme.

Use a variety of methods, for example text messages, to remind women of upcoming and missed appointments.

The named midwife or doctor should tell the woman about relevant additional services (such as drug and alcohol misuse support services) and encourage her to use them according to her individual needs.

Offer the woman information about the potential effects of substance misuse on her unborn baby, and what to expect when the baby is born, for example what medical care the baby may need, where he or she will be cared for and any potential involvement of social services.

Offer information about help with transportation to appointments if needed to support the woman's attendance.

Commissioners should monitor emergent local needs and plan and adjust services accordingly.

Healthcare professionals should ensure they have accurate information about a woman's current address and contact details during her pregnancy by working with local agencies that provide housing and other services for recent migrants, asylum seekers and refugees, such as asylum centres.

To allow sufficient time for interpretation, commissioners and those responsible for the organisation of local antenatal services should offer flexibility in the number and length of antenatal appointments when interpreting services are used, over and above the appointments outlined in national guidance (see NICE's guideline on antenatal care).

Those responsible for the organisation of local antenatal services should provide information about pregnancy and antenatal services, including how to find and use antenatal services, in a variety of:

• formats, such as posters, notices, leaflets, photographs, drawings/diagrams, online video clips, audio clips and DVDs

• settings, including pharmacies, community centres, faith groups and centres, GP surgeries, family planning clinics, children's centres, reception centres and hostels

• languages.

Healthcare professionals should be given training on:

• the specific health needs of women who are recent migrants, asylum seekers or refugees, such as needs arising from female genital mutilation or HIV

• the specific social, religious and psychological needs of women in these groups

• the most recent government policies on access and entitlement to care for recent migrants, asylum seekers and refugees (see the Department of Health and Social Care and Maternity Action).

Offer the woman information on access and entitlement to healthcare.

At the booking appointment discuss with the woman the importance of keeping her hand-held maternity record with her at all times.

Avoid making assumptions based on a woman's culture, ethnic origin or religious beliefs.

Provide the woman with an interpreter (who may be a link worker or advocate and should not be a member of the woman's family, her legal guardian or her partner) who can communicate with her in her preferred language.

When giving spoken information, ask the woman about her understanding of what she has been told to ensure she has understood it correctly.

Commissioners should work in partnership with local education authorities and third-sector agencies to improve access to, and continuing contact with, antenatal care services for young women aged under 20.

Commissioners should consider commissioning a specialist antenatal service for young women aged under 20, using a flexible model of care tailored to the needs of the local population. Components may include:

• antenatal care and education in peer groups in a variety of settings, such as GP surgeries, children's centres and schools

• antenatal education in peer groups offered at the same time as antenatal appointments and at the same location, such as a 'one-stop shop' (where a range of services can be accessed at the same time).

Offer the young woman aged under 20 a named midwife, who should take responsibility for and provide the majority of her antenatal care, and provide a direct-line telephone number for the named midwife.

Healthcare professionals should be given training to ensure they are knowledgeable about safeguarding responsibilities for both the young woman and her unborn baby, and the most recent government guidance on consent for examination or treatment. (See the Department of Health and Social Care.)

Offer young women aged under 20 information that is suitable for their age – including information about care services, antenatal peer group education or drop-in sessions, housing benefit and other benefits – in a variety of formats.

Commissioners and those responsible for the organisation of local antenatal services should ensure that local voluntary and statutory organisations that provide domestic abuse support services recognise the need to provide coordinated care and support for service users during pregnancy. (See also the NICE guideline on domestic violence and abuse: multi-agency working.)

Commissioners and those responsible for the organisation of local antenatal services should ensure that a local protocol is written, which:

• is developed jointly with social care providers, the police and third-sector agencies by a healthcare professional with expertise in the care of women experiencing domestic abuse

• includes:

  • clear referral pathways that set out the information and care that should be offered to women

  • the latest government guidance on responding to domestic abuse (see the Department of Health and Social Care's guidance on domestic abuse: a resource for health professionals)

  • sources of support for women, including addresses and telephone numbers, such as social services, the police, support groups and women's refuges

  • safety information for women

  • plans for follow-up care, such as additional appointments or referral to a domestic abuse support worker

  • obtaining a telephone number that is agreed with the woman and on which it is safe to contact her

  • contact details of other people who should be told that the woman is experiencing domestic abuse, including her GP.

Commissioners and those responsible for the organisation of local antenatal services should provide for flexibility in the length and frequency of antenatal appointments, over and above those outlined in national guidance (see NICE's guideline on antenatal care) to allow more time for women to discuss the domestic abuse they are experiencing.

Offer the woman a named midwife, who should take responsibility for and provide the majority of her antenatal care.

Commissioners of healthcare services and social care services should consider commissioning joint training for health and social care professionals to facilitate greater understanding between the two agencies of each other's roles, and enable healthcare professionals to inform and reassure women who are apprehensive about the involvement of social services.

Healthcare professionals need to be alert to features suggesting domestic abuse and offer women the opportunity to disclose it in an environment in which the woman feels secure. Healthcare professionals should be given training on the care of women known or suspected to be experiencing domestic abuse that includes:

• local protocols

• local resources for both the woman and the healthcare professional

• features suggesting domestic abuse

• how to discuss domestic abuse with women experiencing it

• how to respond to disclosure of domestic abuse.

Tell the woman that the information she discloses will be kept in a confidential record and will not be included in her hand-held record.

Offer the woman information about other agencies, including third-sector agencies, which provide support for women who experience domestic abuse.

Give the woman a credit card-sized information card that includes local and national helpline numbers.

Consider offering the woman referral to a domestic abuse support worker.