Evidence

2018 surveillance of pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (NICE guideline CG110)

Overview of 2018 surveillance methods

Overview of 2018 surveillance methods

NICE's surveillance team checked whether recommendations in pregnancy and complex social factors (CG110) remain up to date. The 2018 surveillance followed the static list review process, consisting of:

  • feedback from topic experts via a questionnaire

  • a search for new or updated Cochrane reviews and national policy

  • a search for ongoing research

  • examining related NICE guidance and quality standards

  • examining the NICE event tracker for relevant ongoing and published events

  • consulting on the decision with stakeholders.

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

Search and selection strategy

Using the static list process, we searched for new Cochrane reviews related to the whole guideline. We found no relevant Cochrane reviews published between September 2010 and April 2018. Topic experts identified 1 eligible study that was considered to have no impact on recommendations.

In addition, the evidence update in 2012 identified 12 studies that were considered to have no impact on recommendations.

Ongoing research

We checked for relevant ongoing research; of the ongoing studies identified, one study was assessed as having the potential to change recommendations. NICE is now tracking this ongoing National Institute for Health Research (NIHR) funded piece of work on Improving maternity care for immigrant women in England. The impact of results on NICE guideline CG110 will be assessed when available.

Intelligence gathered during surveillance

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline. We sent questionnaires to 10 topic experts and received 5 responses. The topic experts either:

  • participated in the guideline committee who developed the guideline

  • were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty and personality disorders.

We have also received additional comments from 2 other experts in the area. Topic experts recommended that NICE guideline CG110 could be expanded to include wider groups of women with social factors in pregnancy (involving a range of complex social factors that they consider are not captured in the guideline), including:

  • Wider definition of domestic abuse.

  • Mental health and personality disorders.

  • Women with no social support (for example, with no family or social network, who move frequently or are homeless).

  • Human trafficking and child sexual exploitation.

  • Asylum seekers and refugees.

  • Female genital mutilation.

  • Gender queer and gender re-assignment.

Other suggested factors by topic experts that are beyond the scope of NICE guideline CG110 were as follows:

  • STIs (sexually transmitted infections) risk and use of LARC (long-acting reversible contraception).

  • Forced marriage and women who have had an Islamic marriage in the UK without a civil ceremony leading to legal marriage.

  • Fetal alcohol spectrum disorders (FASD).

Views of stakeholders

Stakeholders are consulted on all surveillance decisions except if the whole guideline will be updated and replaced. Because this surveillance decision was to not update the guideline, we consulted on the decision. See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual, for more details on our consultation processes. Full details of stakeholders' comments and our responses are included in appendix A: stakeholder consultation comments table.

Overall, 16 stakeholders commented (including representation from royal colleges, charities, universities and an NHS health board): 2 agreed with the decision; 10 disagreed with the decision and 4 did not provide an answer.

The following issues were raised in disagreement with the proposal not to update:

  • Guideline awareness. Two stakeholders commented that there is a low level of awareness about the guideline.

  • Sexual assault and abuse. Two stakeholders commented that the guideline needs to be updated to reflect current understanding and focus on women and girls affected by childhood sexual abuse of any form whether in a family, institutional or exploitation setting.

  • Alcohol and smoking. One stakeholder highlighted the latest UK Chief Medical Officers' Low Risk Drinking Guidelines published in 2016. One stakeholder noted that support for smoking cessation in pregnancy was not addressed.

  • Women in the criminal justice system. Three stakeholders commented that women in the criminal justice system are omitted from the guideline.

Additional evidence

A stakeholder highlighted new evidence of the effectiveness of the Family Nurse Partnership (FNP) programme in England, which indicated that adding FNP to usual health and social care provided no additional short-term benefit. The new evidence is unlikely to impact on the guideline recommendation which states that 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.

A stakeholder highlighted the Birth Companions' Impact Report 2017–18 which includes women with a variety of complex social issues. The issues are covered in related NICE guidelines on physical health of people in prison (NG57), domestic violence and abuse (PH50) and antenatal and postnatal mental health (CG192) as well as NICE guideline CG110. Additional evidence highlighted by stakeholders was either outside the scope of NICE guideline CG110, was consistent with current recommendations, or was ongoing and will be tracked for publication of results.

Refreshing the guideline

Guideline awareness

As women can experience multiple complex social factors, the guideline will be refreshed to make the links with related guidelines in the area much clearer and to promote awareness. NICE has also produced an interactive flowchart on pregnancy and complex social factors and any refreshes made to the guideline on pregnancy and complex social factors will also be reflected in the flowchart.

Uptake of services and providing information and support for women is addressed by the NICE guideline on antenatal care for uncomplicated pregnancies (CG62) which is currently being updated. A link will be added between the pathways for CG62 and CG110. When the update of CG62 is published in July 2020, the surveillance team plan to undertake another review of the guideline on pregnancy with complex social factors.

NICE has published a number of guidelines that cover some of the complex social factors raised by the topic experts and stakeholders. The 'related NICE guidance' section of CG110 will be updated to include reference to these NICE guidelines and links will be added between the guidelines.

Populations additional to the exemplar populations

We will emphasise that the populations listed in CG110 are exemplar populations and principles can be extrapolated to wider populations of women experiencing complex social factors.

Sexual assault and abuse

CG110 already includes a recommendation for supporting women who experience domestic abuse (this can include sexual abuse) in accessing maternity services. As stated above, NICE has published a guideline on domestic violence and abuse (PH50) which aims to help identify, prevent and reduce domestic violence and abuse among women and men in heterosexual or same-sex relationships, and among young people and links will be added between the 2 guidelines. The NHS England 5-Year Strategy, Strategic direction for sexual assault and abuse services which aims to improve service provision for victims and survivors of sexual assault and abuse, will also be tracked for any implications for CG110. In terms of forced marriage and female genital mutilation, the full version of CG110 already makes specific reference to these issues. In the absence of new evidence it was deemed that additional content in these areas is not warranted at this time.

Although victims of trafficking were suggested as potentially omitted from the guideline, the cited reports do not suggest any additional influence of trafficking on poor birth outcomes for mothers and babies. In terms of mental health care in this population, the NICE guideline on antenatal and postnatal mental health (CG192) also applies to pregnant women with complex social factors. Links will be added between the 2 guidelines and between the pathways.

Alcohol and smoking

The latest UK Chief Medical Officers' Low Risk Drinking Guidelines published in 2016 were noted. However, as these are guidelines for low risk drinking as opposed to alcohol misuse, a cross-referral to Chief Medical Officers' recommendations is not warranted but the information around drinking in pregnancy will be considered as part of the update to antenatal care for uncomplicated pregnancies (CG62). In addition, antenatal and postnatal mental health (CG192) includes recommendations on identification and management of alcohol misuse in pregnancy. Links will be added between the 2 guidelines and between the pathways.

Smoking cessation support is not covered in CG110 but NICE's guideline on stopping smoking in pregnancy and after childbirth (PH26) includes recommendations on identifying women who smoke during pregnancy and interventions to help them stop. This guideline is already listed as a guideline related to CG110 but links will be added between the 2 guidelines and between the pathways.

Women in the criminal justice system

Women in the criminal justice system are out of scope for CG110. The focus of NICE guideline CG110 is about improving access to antenatal care and improving service organisation and pfregnant women in the criminal justice system are addressed in NICE's guideline on the physical health of people in prison (NG57). Links will be added between the 2 guidelines and between the relevant pathways.

Additional evidence

A stakeholder highlighted new evidence of the effectiveness of the Family Nurse Partnership (FNP) programme in England, which indicated that adding FNP to usual health and social care provided no additional short-term benefit. The new evidence is unlikely to impact on the guideline recommendation which states that commissioners should consider commissioning a specialist antenatal service for young women aged under 20 years, using a flexible model of care tailored to the needs of the local population.

A stakeholder highlighted the Birth Companions' Impact Report 2017–18 which includes women with a variety of complex social issues. The issues are covered in related NICE guidelines on physical health of people in prison (NG57), domestic violence and abuse (PH50) and antenatal and postnatal mental health (CG192) as well as CG110. Additional evidence highlighted by stakeholders was either outside the scope of CG110, was consistent with current recommendations, or was ongoing and will be tracked for publication of results.

Safeguarding

One expert noted that the safeguarding world and information sharing for those with abuse has substantially changed over the last few years. It is proposed that a cross-reference (from recommendation 1.1.7) to government publications, Information sharing advice for safeguarding practitioners, Information sharing to protect vulnerable children and families and Multi Agency Risk Assessment Conference (MARAC), will be made.

Equalities

A potential equalities issue was raised during consultation which relates to access to care for both vulnerable migrant women who might not access care for fear of being charged (correctly or incorrectly), and on women who are entitled to free care who lack identification and/or may be subject to profiling in hospitals and dissuaded from accessing care. The 2018 Summary of changes made to the way the NHS charges overseas visitors for NHS hospital care states that within England, free NHS hospital treatment is provided on the basis of someone being 'ordinarily resident' and is not dependent upon nationality, payment of UK taxes, national insurance contributions, being registered with a GP, having an NHS number or owning property in the UK. Treatment in A&E departments and at GP surgeries remains free for all. This issue is covered under recommendation 1.3.6 in CG110 which states that healthcare professionals should be given training on the most recent government policies on access and entitlement to care for recent migrants, asylum seekers and refugees.

Editorial amendments

During surveillance of the guideline we identified the following points in the guideline that should be amended.

Recommendations

Related NICE guidance

Overall decision

After considering all evidence and other intelligence and the impact on current recommendations, we decided that no update is necessary. The guideline will be refreshed to ensure that users are aware that the populations cited are exemplar populations and principles can be applied to pregnant women with other complex social factors and with improved linkage between relevant NICE guidelines. We plan to review the guideline again when the updated antenatal care guideline publishes (July 2020).

ISBN: 978-1-4731-3102-6


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