Quality standard

Quality statement 2: Risk assessment

Quality statement 2: Risk assessment

Quality statement

Pregnant women have a risk assessment at routine antenatal appointments. [2012, updated 2023]

Rationale

The booking appointment and subsequent routine antenatal appointments are opportunities for ongoing risk assessments on the health and wellbeing of the woman and her 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 the woman and her baby.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) The proportion of booking appointments which included a risk assessment.

Numerator – the number in the denominator which included a risk assessment.

Denominator – the number of booking appointments.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from antenatal care records. NHS Digital's Maternity Services Data Set includes recording risk factors such as obstetric history, medical (including mental health) history and social history. Recording risk factors at the booking appointment also supports the NHS England Saving Babies' Lives Care Bundle.

b) The proportion of routine antenatal appointments (excluding the booking appointment) which included a risk assessment.

Numerator – the number in the denominator which included a risk assessment.

Denominator – the number of routine antenatal appointments (excluding the booking appointment).

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from antenatal care records.

Outcome

a) Rates of maternal mortality.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from antenatal care records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of maternal deaths attributed to pregnancy and non-pregnancy related causes.

b) Stillbirth rates.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from antenatal care records. Trusts report on stillbirth rates as part of reporting on perinatal mortality rates using the MBRRACE-UK-National Perinatal Mortality Review Tool for ongoing audit. NHS Digital's Maternity Services Data Set includes data on stillbirths and the NHS Digital Maternity Services dashboard can be used to monitor performance and compare services.

c) Neonatal mortality rates.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from antenatal care records. Trusts report on neonatal mortality as part of reporting on perinatal mortality rates using the MBRRACE-UK-National Perinatal Mortality Review Tool for ongoing audit. NHS Digital's Maternity Services Data Set includes data on neonatal mortality and the NHS Digital Maternity Services dashboard can be used to monitor performance and compare services.

What the quality statement means for different audiences

Service providers (NHS hospital trusts and community providers) ensure that local protocols include risk assessment as part of each routine antenatal appointment and that time is allocated for this to be done. They also ensure that referral pathways are in place so that healthcare professionals can make referrals for further management of specific risks at the earliest opportunity.

Healthcare professionals (such as midwives or obstetricians) carry out a risk assessment for pregnant women at each routine antenatal appointment and record the outcomes. They refer pregnant women for further management of specific risks at the earliest opportunity. Healthcare professionals involve the woman's partner according to her wishes.

Commissioners (integrated care systems) ensure that they commission antenatal care services that have risk assessment protocols and referral pathways in place, and the capacity to include a risk assessment at each routine antenatal appointment. They monitor providers to ensure that pregnant women have a risk assessment at routine antenatal appointments and that additional care is planned at the earliest opportunity.

Pregnant women have ongoing risk assessments at each antenatal appointment. This is so that additional personalised care can be planned at the earliest opportunity, if it is needed.

Source guidance

Antenatal care. NICE guideline NG201 (2021), recommendation 1.2.10

Definitions of terms used in this quality statement

Risk assessment

At every antenatal appointment, carry out a risk assessment as follows:

  • ask the woman about her general health and wellbeing including risk factors for venous thromboembolism, gestational diabetes, pre-eclampsia and fetal growth restriction

  • ask the woman (and her partner, if present) if there are any concerns they would like to discuss; this could include discussing risks relating to parental genetic conditions, including consanguinity, and factors relevant to the environment in which she lives, at the booking appointment

  • provide a safe environment and opportunities for the woman to discuss topics such as concerns at home, domestic abuse, concerns about the birth (for example, previous traumatic birth) or mental health concerns

  • review and reassess the plan of care for the pregnancy

  • identify women who need additional care.

The assessment should recognise that women's needs can change during pregnancy. It should be broad-based and holistic, aiming to recognise if 1 or more elements of the woman's physical and mental health (taking into account her medical history) and wellbeing represents a risk to her or her baby's health or wellbeing.

It is important, after discussion and agreement with the woman, that information about the pregnancy and potential concerns or complications during pregnancy are shared between the maternity unit and the woman's GP. [NICE's guideline on antenatal care, recommendations 1.2.9, 1.2.10, 1.2.18, 1.2.21, 1.2.23, 1.2.29 and expert opinion]

Routine antenatal appointments

All pregnant women are offered the booking appointment (by 10 weeks), and appointments at 16, 28, 34, 36 and 38 weeks, and 41 weeks (for those who have not yet given birth). Pregnant women who have not given birth before have 3 additional appointments, at 25, 31 and 40 weeks. [Adapted from NICE's guideline on antenatal care, recommendations 1.1.7, 1.1.8, schedule of antenatal appointments and expert opinion]

Equality and diversity considerations

MBRRACE-UK reports on maternal and perinatal mortality highlight that pregnant women and babies from Black, Asian, and mixed ethnic family backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring and additional support.

Pregnant women should be supported to communicate effectively with healthcare services. They should have access to an interpreter, link worker or advocate if needed. Interpreters, link workers or advocates should not be a member of the woman's family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.

It is important for providers to make reasonable adjustments to support pregnant women with a physical, sensory, cognitive or learning disability to participate effectively in risk assessments. For example, independent British Sign Language interpreting services may be needed. Healthcare professionals may need to plan longer appointments to enable pregnant women (and their partner, if applicable) to raise concerns as part of the risk assessment process, confirm correct understanding of information given and how it relates to them, and to ask questions. [Adapted from NICE's guideline on antenatal care, recommendations 1.1.11 and 1.3.6 and NICE's guideline on pregnancy and complex social factors, recommendations 1.3.10 and 1.3.11].