Implementation support toolkit
Attendance at, and content of, routine antenatal appointments
Why this is important
Supporting women and pregnant people to attend their first antenatal ("booking") appointment by 10 weeks of pregnancy will enable early identification of potential risks and ensure that care is planned according to their needs.
Nationally, the proportion of booking appointments held by 10 weeks of pregnancy has remained relatively steady at just over 60% for the last few years. However, there is notable integrated care board (ICB) and provider variation. In 2023/24 the percentage of booking appointments held by 10 weeks ranged from 39 to 78% between ICBs, and 20 to 86% between providers.
Figure 1: Percentage of booking appointments held by 10 weeks of pregnancy, split by integrated care board (ICB), England, April 2023 to March 2024.
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Statistics also show there is also substantial variation in attendance when broken down by ethnicity of the mother. White women have consistently been the most likely (67% in 2023/24) to attend booking by 10 weeks, and black women have been the least likely (46% in 2023/24).
Figure 2: Percentage of booking appointments held by 10 weeks of pregnancy, split by ethnicity, England, 2019 to 2024.
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Insight provided to NICE from the healthcare system indicates that some of the reasons for the variation in practice identified may be:
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health inequalities (for example, demographics, diverse ethnic minority populations, vulnerable groups),
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differing processes for arranging bookings,
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lack of awareness in both service users and providers around the importance of booking in early, and of the process to follow,
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women and pregnant people cancelling or not attending appointments,
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women and pregnant people not monitoring period dates,
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variation in workforce capacity and necessary skills to be able to deliver appointments,
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the quality of data available, and consistency of data being recorded (including ethnicity data).
The booking appointment and subsequent routine antenatal appointments are also important opportunities for ongoing risk assessments on the health and wellbeing of the woman or pregnant person and their baby. Early identification of potential medical, genetic, social and emotional risk factors enables organisation of additional, specialist management and support. Ongoing risk assessment and monitoring helps reduce the risk of adverse outcomes for both parent and child.
Data showed that, in 2023/24, 93% of booking appointments included a risk assessment for previous obstetric history (previous live births, caesareans, stillbirths and miscarriages) recorded. However, only 58% and 56% included a risk assessment for mental health or social and personal circumstances (complex social factors, disability, employment status of woman and partner and feeling supported in pregnancy), respectively.
Figure 3: Percentage of booking appointments with a record of a risk assessment for mental health issues, England, 2019 to 2024.
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Insight provided to NICE from the healthcare system indicates that some of the reasons for the variation in practice may be:
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Lack of time in the appointment
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The risk assessment was carried out, but not recorded
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Staff felt uncomfortable in their ability to carry out non-obstetrics-related risk assessments correctly, or were unsure of exactly what questions to ask based on the person's circumstances
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Staff did not feel comfortable in asking non-obstetrics related questions as they were unsure about, or felt unable to provide, the follow-up support that would be needed if a risk was identified and were concerned this could in turn damage trust and reduce engagement.
Supporting uptake and adoption of NICE guidance
Support from NICE
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NICE has produced an interactive schedule of antenatal appointments resource which details best practice regarding the scheduling and content of the routine antenatal appointments that should be offered during pregnancy, including what questions to ask about mental health and social and personal circumstances. Providers and practitioners can use this resource to review what routine antenatal appointments should be scheduled for both nulliparous and parous women and pregnant people, and what the content of each of these appointments should consist of. The resource also directs users to additional guidance and support where relevant.
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NICE has published 2 clinical knowledge summaries (CKS) on antenatal care.
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The first knowledge summary is for the care of an uncomplicated pregnancy. It covers recommendations on baseline clinical care for all women and pregnant people, and management of healthy women and pregnant people with an uncomplicated singleton pregnancy, as well as the management of common minor ailments that may be experienced during pregnancy. It also discusses the antenatal appointments and the screening tests which are offered during pregnancy.
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The second knowledge summary is on antenatal and postnatal depression. It covers the management of pre-existing or newly diagnosed depression in pregnancy and the management of depression in the postnatal period, including in people who are breastfeeding.
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NICE has developed an interactive mental health checklist that provides specific information regarding the mental health assessment, and any follow-up actions that may need to be taken, which should be used at both the first and subsequent antenatal appointments.
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Quality statement 1: Access to antenatal care and quality statement 2: Risk assessment in the NICE quality standard on antenatal care include information on the level of quality to aim for, and how to measure performance regarding access to antenatal care, and risk assessments respectively.
Support from our partners
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The NHS England maternity services dashboard aims to bring together maternity information from a range of different sources including the NHS England Maternity Services Data Set (MSDS). The dashboard includes data on attendance and content of the 10-week booking appointment and enables providers of maternity services to compare their performance with their peers on a series of national indicators (including those from the NICE indicators menu) for the purposes of identifying areas that may need local clinical quality improvement.
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Making better use of digital technology in maternity and neonatal services is one of the 12 objectives in NHS England's Three Year Delivery Plan for Maternity and Neonatal services, with the ambition that clinicians are supported to make best use of digital technology and that women and pregnant people, and their families, can access their records and interact with digital plans and information to support informed decision making. Supported by the NHS England, What Good Looks Like framework and the Professional Records Standards Body, Digital Maternity Record Standard, many providers now use electronic maternity notes including Badger, K2, Cerner and Epic. These systems have the ability to build templates and prompts into them.
Please see the separate section on addressing ethnic health inequalities for further advice in relation to this topic.
Note that external websites and resources have not been produced by NICE. NICE has not made any judgement about the methodology, quality or usability of the websites or resources.
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