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CHAPTER TWO: PREGNANCY

2.1 Introduction

There is a large body of evidence to suggest that risk for many chronic conditions is set, at least in part, in foetal life or immediately after birth. Asthana and Halliday (2006) summarise the effects of under-nutrition and other adverse influence on the body's structure, physiology and metabolism. For example:

• Airway and alveolar growth can be impaired in the lungs of a foetus deprived of calories or oxygen. This may have an important effect on childhood respiratory illness and risk for chronic bronchitis in later life
• Low protein intake during pregnancy has been linked to impaired development of the kidneys that may in turn lead to raised blood pressure in adult life
• Early under-nutrition adversely affects healthy brain development
• Growth retardation in utero has been linked to important metabolic changes that increase risk for later obesity, cardiovascular disease, hypertension and diabetes

Maternal substance misuse has a range of direct and indirect effects on foetal growth and development. Smoking is associated with low birth weight, intrauterine growth restriction, placental abruption, premature rupture of the membranes and pre-term delivery. Alterations in lung functions have been reported with in utero exposure to smoking and an increased risk of asthma, pneumonia and bronchitis reported in children of smokers. Smoking causes direct damage to the blood vessels of the placenta and affects the flow of oxygen to the foetus. Carcinogens are carried across the placenta and individuals exposed to tobacco smoke in the womb may be at increased risk of developing certain types of cancer. The development of ovaries and testes also appear to be affected by smoking: a woman whose mother smoked has a greater chance of starting her periods early and of having a miscarriage, while boys are more likely to have undescended testes. Thus, smoking has an impact on more than one generation (Selwyn, 2000, p 27).

Alcohol can also interfere with normal foetal development. Foetal Alcohol Syndrome ( FAS), the main features of which are poor growth, abnormal facial features and cognitive impairment, appears only to arise in a small percentage of cases where sustained heavy drinking occurs throughout all three trimesters of pregnancy. However, the foetus is susceptible to alcohol's toxicity throughout its development and exposure to high levels of alcohol (particularly binge drinking) during critical periods has been linked with adverse pregnancy outcomes (Whitty and Sokol, 1996).

Drug use during pregnancy has also raised concerns about persistent adverse effects (Arendt et al, 1999; Chiriboga et al, 1999) and these are not limited to the use of illegal substances. Evidence suggests that maternal use of paracetamol in late pregnancy increases risks of wheezing and elevated Immunoglobulin E in children of school age (Shaheen et al, 2005).

Foetal growth is also influenced by factors such as uterine blood flow and the capacity of the placenta to metabolise key nutrients, transfer nutrients to the growing foetus and produce hormones that influence foetal and maternal nutritional supply. For example, stress-related hormones may constrict blood flow to the placenta, so the baby may not receive the nutrients and oxygen it needs for optimal growth. Stress may also indirectly increase risk of adverse exposure to the foetus, by influencing maternal behaviours such as cigarette smoking and alcohol consumption, both of which interfere with normal foetal development. High levels of stress have also been linked with elevated levels of a hormone associated with early delivery, with implications for low birth weight (Hobel et al, 1999; Schulkin, 1999).

The rate of preterm birth has risen over time in Scotland, from 5.5% in 1990-02 to 6% in 2000-02 ¹. Strong links are known to exist between low birth weight and inequality. For example, in a ten year study in England, Smith et al (2007) found that women from very deprived areas were at twice the risk of very preterm birth as those living in the least deprived areas.

In addition, a number of risk factors for children's subsequent behaviour and mental health problems relate to pregnancy. In a major longitudinal study involving 7,500 women in England, Glover and O'Connor (2002) found that women who experienced high anxiety at 32 weeks gestation were twice as likely as other mothers to have a child with behavioural and/or emotional problems at age four. However, this was not found to be the case with mothers who were anxious at 18 weeks and not thereafter (quoted by Sutton et al, 2004).

This chapter considers the evidence base in relation to four major risk factors for foetal development, where women from low socio-economic groups are particularly vulnerable:

• Pregnancy at a young age
• Maternal nutrition during pregnancy
• Smoking during pregnancy
• Stress during pregnancy

It should be noted that, in contrast to smoking, poverty does not appear to be strongly associated with alcohol consumption among British women (Marmot, 1997). The picture in Scotland does not differ from the rest of the UK: data from the Scottish Health Survey indicate no clear relationship between Scottish Index of Multiple Deprivation ( SIMD) quintiles and drinking behaviour (Scottish Health Survey, 2003). In the first sweep of the Growing Up in Scotland ( GUS) survey, lone parents and younger mothers were less likely to say they drank while pregnant than parents in couple families and older mothers; and mothers living in more deprived areas were less likely to say they drank while pregnant than those living in less deprived areas (Anderson et al, 2007).

Naturally, however, alcohol and other drugs have major impacts on life in deprived households. In the GUS survey, one in ten respondents in the lowest income quartile said they had used drugs in the last year, compared with 2% in the highest and second highest quartiles. Nine percent of parents in routine and semi-routine households used drugs in the last year, compared with 2% of those in managerial or professional households (Anderson et al, 2007). GUS data also indicate that mothers in the most deprived areas were significantly more likely to say they drank five or more units on one occasion than those in less deprived areas. For these reasons, alcohol and other drugs are included in Chapter Seven, where initiatives targeting specific vulnerable groups are considered.

2.2 Pregnancy at a young age

Figure 2.1: Teenage pregnancy: GROS registered births, stillbirths and Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967

Teenage pregnancy has been associated with prenatal depression and anxiety, risks that reflect both cumulative life course exposure to stressors and current circumstances. Teenage mothers are more likely to have suffered separation, divorce, step-parents, and the early transition to motherhood can cause stress on adolescent relationships, compromise antenatal health and further affect educational attainment and longer-term opportunities, often resulting in long-term benefit dependency and poverty (Chevalier and Viitanen, 2003; Swann et al., 2003).

In Sweep 1 of the GUS study, mothers in the highest income quartile were over twice as likely as those in the lowest income quartile to say that the pregnancy had been planned (78% compared with 35%). Pregnancy is also less likely to be planned in the teenage years than in later life. The majority of mothers under 20 (61%) said their pregnancy had not been planned at all ( GUS, 2007).

While teenage pregnancy is strongly associated with socio-economic disadvantage, the relationship is even more pronounced for early motherhood. Several studies have shown that young women in areas that are socially deprived are less likely to use abortion to resolve unplanned pregnancy than their counterparts in wealthier areas (Lee et al, 2004; Social Exclusion Unit, 1999). The latter report suggests possible reasons for this:

'a teenager who has a financially and emotionally secure background; and sees a clear future for herself through education or work; has something to lose from early parenthood.' 'But the alternatives will look very different to a teenager who has grown up in poverty and possibly on benefits, has had difficult family relationships, is in care, or is under pressure to move out; and sees no prospect of a job and expects to be on benefit one way or the other. For such a teenager, being a parent could well seem to be a better future than the alternatives.'

The GUS study found that, in terms of attendance at antenatal classes, there was marked variation by socio-economic group and by maternal age at birth:

• Around two thirds of those aged under 20 did not attend any classes; three quarters of those aged 30-39 went to most or all classes
• Women from non-white ethnic groups were less likely than women from white ethnic groups to have attended classes
• Women with lower levels of educational attainment were less likely to attend classes than those with higher qualifications (mothers who had a degree were six times more likely to attend classes than those with no qualifications) ( GUS, 2007)

2.2.1 What works to improve sexual health and avert pregnancy at a young age? Evidence and practice (Asthana and Halliday)

• There is good evidence to support school-based sex education; education linked to contraceptive services alongside the community-based delivery of education, development and contraceptive services; youth development programmes; and family outreach (although this is not supported by evidence from Randomised Controlled Trials ( RCTs)) ²
• Campaigns to address sexually transmitted infections ( STIs) increase condom use and can delay initiation and reduce the frequency of sexual activity, potentially reducing unintended pregnancy as well
• Programmes that offer educational support or improve job prospects may motivate young people to avoid pregnancy
• Parenting programmes and antenatal care programmes may be effective in improving outcomes for both teenage mothers and their infants (see below and Chapters Four and Five)

2.2.2 Lack of Review-level evidence

There is a lack of review-level evidence in the following areas;

• Focus on early fatherhood
• Upstream interventions versus poverty and disadvantage
• Interventions relating to Scotland and the rest of the UK (most of the evidence comes from the US)

In addition, there are more general limitations to the evidence base;

• Poor methodological quality of many of the studies covered and focus on different outcomes, making synthesis difficult
• A diversity of approaches makes it difficult to assess the efficacy of universal programmes as opposed to initiatives targeting particular vulnerable groups ( e.g. non-school attendees, looked-after children, the homeless, children of teenage parents, black and minority ethnic groups)

The Report of the Expert Working Group on Infant Mental Health (HeadsUpScotland, 2007) includes reference to the Baby Think It Over ( BTIO) programme, in which young people are given a realistic, computerised model baby to care for during 72 hours as part of a parenting education package in secondary schools. Although there is no good evidence that the programme reduces pregnancy rates directly, it has been shown to reduce the wish of teenagers to become parents at an early age.

There is currently no UK evidence of the effectiveness of BTIO, but the Expert Working Group suggest that it could provide a valuable source of realistic feedback on the demands of caring for a young baby. However, ad hoc use of baby simulators, without the support of lessons plans to deliver key messages around relationships and self-development, has received unfavourable press in the media in the past. It is known that an educational initiative with secondary school pupils which uses baby simulators as one part of a programme linked to the curriculum is being piloted in Glasgow. This programme is about to undergo academic evaluation to assess its effectiveness.

The Expert Working Group also suggests that the 'computer games culture' and the wide familiarity of such games to children and young people opens up new options for introducing health education material to children and young people. The popularity of games such as NINTENDOGS and BABYZ, in which the player has to take care of animals or children, suggests that these games are accessible and interesting to quite young children. If professional input was included to ensure the correct messages are being given and a commercial games manufacturer undertook the production and distribution of a more sophisticated game, the Expert Working Group suggests that this could have a wider and sustaining impact.

Summary: what do we know about averting pregnancy at a young age?

• Evidence supports school-based sex education and community-based education and contraceptive services
• Campaigns to increase condom use can delay initiation and reduce the frequency of sex
• Educational support and improved job prospects may motivate young people to avoid pregnancy
• Parenting programmes and antenatal care programmes may improve outcomes for both teenage mothers and their infants
• However, there is little evidence relating specifically to Scotland; and inadequate focus on early fatherhood and on interventions tackling broader 'upstream' issues of poverty and disadvantage
• The methodological quality of many existing studies is poor and/or focused on a range of outcomes, making it difficult to draw meaningful messages about the effectiveness of individual interventions
• A promising initiative, although not yet evaluated in the UK, is the 'Baby Think It Over' programme, in which a young person is given a computerised model baby to care for. A pilot programme in Glasgow, which uses baby simulators as part of the secondary school curriculum on relationships and self-development, is about to undergo evaluation
• The popularity of computer games offers opportunities to engage young people in games involving the care of young babies

2.3 Maternal nutrition

A rapid evidence review carried out for the Scottish Government by NHS Health Scotland in August 2007 explored the potential for health improvement offered by dietary improvement in women of childbearing age and pregnant women and highlighted means which have been shown to be effective in achieving such improvement.

The review considered literature from 1995 onwards and specifically focused on women on a low income/living in low-income communities. However, the paper makes it clear that this was a very rapid appraisal of the evidence, intended to bring out key points only for consideration in developing Spending Review proposals ( NHS Health Scotland, 2007).

2.3.1 Summary of possible reasons to intervene to improve maternal nutrition, and detail of the evidence to support them

• Reducing the incidence of neural tube defect ( NTD) pregnancies - good evidence
• • there is strong evidence to link the taking of the recommended levels of folate/folic acid during the periconceptual period and first 12 weeks of pregnancy with reduced incidence of NTD-affected pregnancies
• Reducing incidence of low birth weight - little evidence
• • evidence linking dietary improvement during pregnancy with reduced incidence of low birth weight is equivocal, but there is unlikely to be a link between the two. Weight at outset of pregnancy, and maternal weight gain during pregnancy, may be more important predictors of the baby's weight at birth
• Improving the later health of offspring - good evidence
• • existing justifications for improving maternal diet, in particular maternal nutritional status at the onset of pregnancy, appears to be more critical than nutritional adequacy during pregnancy for foetal growth
  • there is good evidence to support a role for diet in foetal programming in utero for later adult chronic disease. Emerging evidence suggests that maternal nutrition may also have long term effects in offspring which are not reflected in birth weight or any other measure of body size at birth
• Improving management of pregnancies in nutritional terms ( e.g. less excess maternal weight gain) - no evidence to support or refute this
• Increasing likelihood of breastfeeding - no evidence to support or refute this
• Encouraging healthy weaning and other healthy dietary behaviours in the new family and as children grow up - no evidence to support or refute this
• Improving general nutritional health and hence reduce diet-related risk factors for CHD, cancer, stroke - good evidence exists, but was not searched out specifically for this paper

The paper concluded that the nutritional and health-related outcomes policy makers might reasonably hope to influence through are focus on maternal nutrition are:

• Incidence of NTD affected pregnancies
• General nutritional intake and nutritional status of women of childbearing age in low income areas
• Reduced risk in offspring of chronic disease in later life

The key international policy document which relates to maternal nutrition is the European Strategy for Child and Adolescent Health Development: Action Tool ( WHO, 2005). This sets out a number of actions recommended by W.H.O. and other international agencies, presented as a menu of policies and interventions from which national and local authorities can select according to need. Areas judged relevant to maternal nutrition policy in Scotland (by the author of the rapid evidence review) are:

• Setting up food fortification programmes of iron, folic acid and iodine
• Setting up information, education and communication programmes on healthy motherhood and prevention of congenital abnormalities
• Providing advice on nutrition during antenatal visits and as part of health advice to parents
• Preventing micronutrient deficiencies through supplements when food fortification is not ensured
• Ensuring provision of micronutrients to primary health care services and maternity services
• Providing training in nutritional advice and intervention of first line health professionals

Evidence from Scotland: Review of the Scottish Diet Action Plan 1996-2005 (Lang et al, 2006)
The review team considered that 'Minor' progress had been made by the Health Education Board for Scotland (now NHS Health Scotland) and Health Boards between 1996 and 2005 towards ensuring that health promotion activity includes regular campaigns to alert potential parents to the need for good nutrition prior to, as well as during, pregnancy.
However, Lang et al estimated that 'Substantial' progress had been made towards the provision of dietary information from frontline professionals to expectant mothers about their own nutritional needs, and the nutritional needs of their babies. This includes both provision of literature and individual counselling.

2.3.2 Evidence with a focus on women in low income groups

The author of the rapid evidence review noted that there is little good quality evidence from the UK about interventions to improve the nutrition of low income women of childbearing age. One good quality study among inadequately nourished low income women in the UK concluded that dietary counselling alone is unlikely to improve nutritional intakes and that consideration should be given to the provision of free folate and iron supplements to all women in low income groups during the inter-pregnancy interval.

The key initiative targeting women on a low income which has been evaluated is the US Women, Infants and Children Program. However, the quality of the evaluation was compromised by non-compliance in the control groups, meaning that there was insufficient high quality evidence to demonstrate the benefit of the initiative.

No studies on increasing folic acid intake among low income women specifically were identified, either in the UK or in other developed countries.

2.3.3 Evidence with a focus on low income pregnant women

One recent UK study indicates success in a scheme which provided vouchers to pregnant women to increase their fruit juice consumption. The same study reported that midwife advice on dietary improvement during pregnancy had no great effect.

An intervention comprising several informal food preparation sessions in a community centre setting failed to attract interest from the pregnant young women on low income who were invited to participate. The authors noted the challenges of working with the most disadvantaged groups.

2.3.4 What works to improve maternal nutrition during pregnancy? Evidence and practice (Asthana and Halliday)

• Calcium supplements reduce preterm birth and the incidence of low birth weight, especially among women at risk of hypertensive disorders
• Dietary supplementation based on balanced protein and energy content consistently improves foetal growth.

2.3.5 Lack of review-level evidence re maternal nutritional supplements

• The evidence base is weak on targeted evaluations focusing on particular socio-economic, ethnic or vulnerable groups, those subject to multiple risks from smoking, poor diet and negative psychosocial factors.

• Most trials are conducted in mid to late pregnancy, which may be too late to compensate for long-standing nutritional deprivation. Changes to maternal nutrition before conception and in early pregnancy may have a greater influence on foetal growth
• Studies tend to focus on single interventions which are unlikely to reduce the rate of a multicausal outcome, such as intrauterine growth retardation, and which ignore the potential for nutrient-on-nutrient interactions.
• Factors such as stress may have a more pronounced effect on foetal nutrition and hence birth weight than has been acknowledged to date

Summary: what do we know about the effectiveness of initiatives to address improving maternal nutrition?

• Good quality evidence relevant to Scotland is very limited
• There are significant challenges in engaging young, low income mothers-to-be
• There is strong evidence to suggest that certain dietary supplements reduce risks in pregnancy and preterm birth.
• Maternal nutritional status at the onset of pregnancy appears to be more critical than nutritional adequacy during pregnancy for foetal growth
• Maternal nutrition may also have long term effects in offspring, which are not reflected in any measure of body size at birth
• Providing advice and information alone is not enough to change dietary behaviour; the more intensive and direct the intervention ( e.g. as vouchers, provision of food or provision of supplements) the greater the chance of success in improving nutritional status
• Factors such as stress may have a more pronounced effect on foetal nutrition and hence birth weight than has been acknowledged to date

2.4 Smoking cessation

The use of tobacco in pregnancy is one of the most important risk factors for foetal growth and development. A considerable number of women give up smoking without assistance during pregnancy, with the largest group (up to one quarter) stopping before their first antenatal visit (Lumley et al, 2001). However these tend to be light and moderate smokers (Jane et al, 2000). The proportion of pregnant women who smoke not only remains substantial, but is also significantly associated with socio-economic disadvantage. The GUS study found that about a quarter of women sampled said they smoked while pregnant: 4 in 10 mothers in areas in the most deprived quintile smoking during pregnancy, compared with just 9% in the least deprived quintile. ( GUS, 2007). An inequalities dimension is also evident in the proportion of infants exposed to smoking in their own homes. A detailed study of lone parents living in rented accommodation and relying on social security benefits found smoking levels in excess of 75% (Dorsett and Marsh, 1998).

Figure 2.2: Smoking during pregnancy: ISD Scotland ( SMR02 maternity records)

2.4.1 What works to help smoking cessation during pregnancy? Evidence and practice (Asthana and Halliday)

• Advice and support tailored for pregnant women has been shown to have only a modest effect on cessation rates; and a tendency not to reach, or to be acceptable to, those at highest risk (potentially exacerbating the inequalities dimension)

• Prenatal counselling, combined with at least 10 minutes person-to-person contact and written material tailored to pregnancy can double cessation rates, although self-help literature on its own tends to be ineffectual
• The frequency of contact with health professionals in the prenatal period offers increased opportunities for intervention but, historically, this potential has been under-utilised.
• Recent large-scale studies suggest that results in real-life settings are often less favourable than those conducted in clinical trials, and that attrition rates are highest among those on a low income and among the most mobile populations
• Even reducing smoking in pregnancy can improve health outcomes
• There is some evidence that increasing support for smoking cessation during pregnancy and its subsequent maintenance could affect breastfeeding rates and thus be a legitimate component of a breastfeeding support programme
• Evidence relies too heavily on self-reported behaviour and does not take into account the different experiences of heavy and light smokers.

Evidence from Scotland: Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down (Tappin et al, 2005)

• A large controlled trial of the use of motivational interviewing with pregnant smokers in the West of Scotland was carried out between 2001 and 2005. (Motivational interviewing is a one-to-one counselling style designed for treating addictions)
• Women in the intervention group were offered two to five home visits from midwives (in addition to standard services)
• The study found that good quality motivational interviewing did not significantly increase smoking cessation among pregnant women
• The research is particularly interesting because participants' self report was corroborated by plasma or salivary cotinine concentration
• It is not clear whether outcomes for women in more deprived circumstances were better or worse than for those with fewer disadvantages

Promising initiative in Scotland: Smoking cessation incentive scheme

• A pilot scheme in Dundee encourages pregnant women to give up smoking by offering vouchers that allow smokers to buy fresh fruit and vegetables, have free access to leisure centres, crèche facilities, relaxation classes and cinema tickets providing they do not smoke during pregnancy
• To qualify, expectant mothers have to prove they are staying smoke free, by passing weekly breath tests for carbon monoxide levels in their lungs
• The programme is intended to target 10 women per month. Between May and November 2007, 33 women were attracted to the scheme
• The scheme was hoped to double or triple one-year cessation rates (from 13-15%). Early signs from the pilot indicate good levels of client compliance
• Early findings from the initiative were discussed at a meeting of Angus Community Health Partnership Committee in November 2007, at which plans to introduce a similar scheme within Angus were highlighted
• It is not known whether a formal evaluation of the Dundee pilot is taking place

Summary: what do we know about the effectiveness of initiatives to address smoking cessation during pregnancy?

• Evidence indicates that multi-faceted initiatives are more likely to be effective than those offering a single service
• Advice and support for pregnant women may not reach, or be acceptable to, those at highest risk
• Routine contact with health professionals during the prenatal period offers opportunities for intervention that have been under-utilised to date
• Increasing support for smoking cessation during pregnancy and the immediate postnatal period may affect breastfeeding rates, so could be a legitimate part of a breastfeeding support programme
• Evidence relies too heavily on self-reported behaviour and does not take into account the different experiences of heavy and light smokers

2.5 Maternal stress during pregnancy

No study has yet evaluated a programme or service designed to reduce maternal stress during pregnancy. However, this is an area where a well-designed and professionally-delivered home visiting programme, such as the Nurse-Family Partnership (described and evaluated in the United States) appears especially promising.

2.5.1 Nurse-Family Partnership

This programme offered to young, disadvantaged pregnant women, most of whom are unmarried and without previous children comprises regular home visits by purpose-trained nurses throughout pregnancy and, in some cases, the first two years of their children's lives. The support provided includes:

• parenting and health education
• referrals to other services
• employment advice
• help forming mutual support networks

The three longitudinal studies detailed below evaluated the programme as typically implemented in a low income community, thus providing evidence of the intervention's effectiveness in a real-world setting. All three studies achieved a follow up rate of at least 80%. However, when considering the evidence from these studies, it should be borne in mind that comparison with the programme comprised minimal routine intervention which, in the US, would be very different from UK health visiting services. (The Nurse-Family Partnership is currently being implemented in 10 test sites in England, but it is not known whether there are plans to submit the initiative to rigorous evaluation.)

The first longitudinal evaluation of the intervention was conducted by Olds et al (1998). This was a randomised controlled trial involving 400, mostly white, women, most of whom were unmarried and of low socioeconomic status. Women were allocated to one of three regimes: fortnightly visits during pregnancy; fortnightly visits in pregnancy and during the first two years of the child's life; a comparison group that had no visits.

The nurse visitors focused on three aspects of the mothers' experiences:

• positive health-related behaviours during pregnancy and the early years of the child's life
• competent care of the children
• maternal personal development (including family planning, educational achievement and opportunities to gain employment)

Not only did the home visiting yield positive early results in terms of lower levels of child abuse, fewer premature babies and heavier babies born to teenage mothers, (compared with control groups) but it also had long-term effects on children's behaviour, including fewer arrests and convictions by the age of 15.

The follow-up study also found that the adolescent children of the mothers who had received support had fewer behavioural problems relating to the use of alcohol and other drugs and smoked less than the children of mothers in the comparison group. Positive changes were also noted among the mothers who received support from the programme in respect of lower dependence on state benefits, fewer subsequent births, fewer arrests and fewer convictions than mothers in the comparison group mothers. There was also suggestive evidence that the above effects were largest for the subgroup of unmarried women of low socioeconomic status, and their children (Olds et al, 1998).

The second study involved a randomised controlled trial of 743 low income, mostly African-American women, who were randomly assigned to an intervention group that received nurse-visits and a control group which did not. This study measured outcomes when their children were aged 2 and again at the age of 6.

There were no significant effects on children's birth weight, or mental development or behavioural problems at aged 2, but the intervention group had 20% fewer health care encounters for children's injuries or ingestions and 80% fewer injuries and ingestions requiring hospitalisation. At the second follow up at the age of 6, children in the intervention group were much less likely to exhibit severe behavioural problems (1.8% vs. 5.4%). For the subgroup of nurse-visited women with poor mental health, low self-confidence and low intelligence, their children demonstrated superior intellectual functioning compared to control group counterparts. Nurse-visited women had fewer subsequent births and fewer months on welfare than women in the control group. However, the programme had no effect on the women's education, employment, substance use, rate of marriage or partnership, or experience of domestic violence (Kitzman et al, 1997; Kitzman et al, 2000; Olds et al, 2004a).

A third major randomised controlled trial (735 low income women, half of whom were Hispanic) involved random assignment to nurse visitation; visitation by a paraprofessional (who underwent the same training and provided the same services as the nurse); or a control group. This study measured outcomes when the children reached the age of 4.

At the follow up, there were no significant effects on child outcome measures for the whole sample of nurse-visited women, but the children of women with poor mental health, low self-confidence, low intelligence has superior language skills, better capacity for sustained attention, impulse control, sociability and motor skills than their control group counterparts.

Women who received nurse visits had longer intervals between the births of their first and second children, and were less likely to report being victims of domestic abuse (7% versus 14%) but there were no significant effects on the women's educational achievement, welfare receipt or employment, or likelihood of being married or living with a partner.

Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control group counterparts, but there were no other statistically significant paraprofessional effects (Olds et al, 2002; 2004b).

Summary: what do we know about the effectiveness of the Nurse-Family Partnership programme?

• Evidence from randomised controlled trials show a major impact on life outcomes for socio-economically deprived mothers and their children
• Evidence comes from the programme as typically implemented in a low income community
• Children of nurse-visited mothers were less likely receive health care for injuries and ingestions in the first two years of life
• Although the programme had no significant effect on children's behavioural problems at age 2, a much lower percentage of children of nurse-visited mothers exhibited severe behavioural problems at the age 6 follow up
• The study that included a 15 year follow up found that the children of nurse-visited women experienced fewer arrests and fewer incidents of child abuse and neglect.
• Mothers who had received nurse visits experienced fewer arrests and convictions, spent less time on welfare and had fewer subsequent births
• Visits from trained paraprofessionals did not achieve the same effects as the nurse-visiting programme
• The programme is particularly interesting because outcomes for both mothers and children are most promising for the most disadvantaged groups
• In the absence of UK replication research, this is important evidence of the potential effectiveness of an intensive, antenatal home visiting programme that offers 'multiple' support - as long as that support is sustained during the first years of life.
• However, it is not clear whether findings are transferable to countries where health services are provided free at the point of delivery. The service received by mothers in the US comparison groups would also be very different from health visiting services in the UK

2.6 Antenatal classes

There is a wide availability of antenatal classes and other supports from the health service in Scotland during pregnancy. However, the Growing Up in Scotland ( GUS) survey suggests that a key issue is the degree to which teenage parents and those living in disadvantaged areas access the support that is available, and whether the support that is offered meets their needs.

In the first sweep of the GUS survey, around one third of mothers aged under 20 attended some antenatal classes, compared with approximately three-quarters of those aged 30 to 39 and two-thirds of those aged over 40. The most common reason given for non-attendance was that mothers had experienced a previous pregnancy and had attended classes at that time, but mothers in the youngest age group were significantly more likely than mothers in the older age groups to cite reasons such as not liking classes or groups, and not knowing where classes were run ( GUS, 2007).

The Expert Working Group on Infant Mental Health noted that evidence of the effectiveness of psychosocial information introduced into antenatal education is poor. Little research has been carried out on the content of antenatal classes, and what there is gives little support to the inclusion of information on parenting. Most antenatal classes are offered in the last trimester of pregnancy, concentrate on delivery and are used preferentially by more middle class parents. The Expert Working Group's report highlights the Sunderland Infancy Project, which has been able to engage parents identified by the midwifery or health visiting service as being at risk of difficulties with their children. Parents participate in 6-session antenatal groups with a psycho-social and developmental theme at around 20 weeks, before the impending birth becomes imminent and all consuming. The authors claim that families engaged in this group have shown an increased involvement in supportive postnatal services, although no reference to evaluation material is included (HeadsUpScotland, 2007).

Initiatives which include antenatal contact and support as part of a wider portfolio of support are specifically addressed in Chapters 4 and 5. However, it is worth mentioning here that part of the work of a literature review carried out as part of a national audit of parent education (McInnes, 2005) specifically focused on initiatives which aim to change or improve parenting skills in the antenatal period. The original literature review that was included in the national audit included studies published between 1992-2003. This literature review was updated in 2006 to include studies published between 2003-2006.

Findings from both the original literature review and the update can be summarised as follows:

• Nine studies were identified: six from the USA, four from Australia, three from the UK (including one from Scotland) and one from Latin America
• All studies addressed an aspect of parenting via the provision of knowledge, education or information.
• Educational or informational interventions were shown to improve knowledge, but had less impact on behaviour or psychosocial wellbeing.
• The most successful interventions appeared to be those providing a range of health education topics in the antenatal clinic (although the studies focusing on these were not assessed as high quality)
• There was some evidence that involving the mother's partner and/or using a flexible approach contributed to the intervention's success

Both the author of the original literature review and the update note that despite some positive findings, there remains significant gaps in the evidence base. In particular, evidence concerning hard to reach groups or groups with special educational needs is lacking. The author also noted that the interventions set out to measure a diverse range of outcomes, using assorted methods to deliver interventions. This makes it difficult to extract firm conclusions or recommendations for practice.

2.6.1 PIPPIN

PIPPIN is included here because it is a UK-based initiative and has received international commendation as an example of excellence.

PIPPIN is designed to improve and maintain parents' emotional and psychological wellbeing and help them prepare for parenthood. The focus on emotional aspects of adjusting to parenthood is not usual in antenatal classes, which typically focus on the birth and physical aspects of looking after a baby.

Staff from a variety of professions, and volunteers, are trained for 50 hours to deliver group meetings and individual, home based sessions. Groups are intended to include fathers as well as mothers, and meetings take place from the 24 ^th week of pregnancy, continuing at regular, infrequent intervals until the infant is 3-5 months. Each new family receives approximately 35 hours of support in all.

PIPPIN targets both mainstream and hard-to-reach families. The initiative appears to be operating in England only at present, but it is an element of individual Sure Start programmes.

It appears that only one evaluation has been carried out to date. This compared 49 couples who completed the course with 57 similar couples who were not involved. No differences were found before the course, but afterwards participating parents were significantly more confident, less anxious or vulnerable to depression and better able to cope with parenthood. They enjoyed more positive relationships with their babies and with each other (Parr, 1996). Two or three years later, their children appeared calmer and more confident than those in the comparison group (Parr, 1997, 1998). Apart from findings from this study, the only other evidence relates to internal auditing in areas where the programme has been implemented. These indicate that the positive outcomes in the original study have been maintained (Sure Start, 2002).

Despite the rather thin evidence base, the programme was recommended by the Health Select Committee Report as 'an important and effective preventative child mental health initiative, which local authorities and trusts as well as central government should encourage and support in order to ensure its long-term development.' The Expert Committee for the European Regional Council of the World Federation for Mental Health commended PIPPIN as an example of excellence in its 1998-99 report and PIPPIN is also recommended by the Sure Start Guide to Evidence Based Practice (Hosking and Walsh, 2005).

Summary: what do we know about the effectiveness of antenatal provision?

• A key issue is the degree to which parents living in disadvantaged areas are able to access the support that is available, and whether they feel it meets their needs
• Educational/informational interventions can improve knowledge, but are less likely to have an impact on behaviour or psychosocial wellbeing
• Providing a range of health education, psycho-social and developmental topics in antenatal clinics, and looking at the stage in pregnancy when parents are likely to be most receptive appears to be a promising approach, but better quality evaluation of initiatives is required
• PIPPIN uses a variety of professionals and volunteers to engage fathers as well as mothers in preparing for (and adjusting to) parenthood. Support begins during the last 3 months of pregnancy and continues until the infant is 3-5 months old. A single, small sample evaluation indicated that the initiative helped parents to enjoy more positive relationships with their babies and with each other
• Little research has been carried out on the content of antenatal classes, and there is little evidence relating to Scotland or the rest of the UK

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