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CHAPTER THREE: PRE-CONCEPTION, ANTE AND POST-NATAL CARE
Introduction
3.1 Life chances can be influenced at the very earliest stages of a child's life and even before that, during the pregnancy and in the pre-conception period. There are some common threads that run through all three of these areas, for example diet and exercise and informal versus formal sources of advice and information.
3.2 We asked parents about their needs and the services available during these stages although for obvious reasons, we did not explore them with children.
Pre-conception
Service needs
3.3 We asked all parents about the services that are needed by parents at the preconception stage. We did not put a specific time limit on pre-conception. The findings cover family planning and services for people facing fertility issues.
3.4 The majority of people in the focus groups did not believe there were any major service needs in this area and a typical comment was "you just get on with it".
3.5 However they did report that it would benefit families if there was advice about how to eat healthily at the preconception stage to increase fertility and influence the health of the mother and the baby. Most people knew that folic acid is good to take if you are planning a pregnancy but they believed that there could be more readily available information about the benefits of appropriate diet and exercise. This should be available from GPs and health practitioners as well as in libraries and on the internet.
3.6 Two people reported that they had experienced fertility issues and had gone through IVF treatment. They said that what people need at this stage is good information from hospitals and that this is already available. They said that there should be sources of support from other people who are facing the same issues and that a readily available, accessible support group would have benefited them. It was reported to us that in some hospitals, fertility clinics are very close to labour and maternity wards which can add to the distress faced by people with fertility problems.
3.7 There was a strong feeling amongst all groups in the study that there should be more work done with young women at an earlier stage to divert them away from becoming pregnant. There was recognition that young women can become pregnant for a number of different reasons, sometimes intentionally and sometimes not. The reasons can be complex and multi-faceted which can make it difficult to do this effectively because one set of interventions will work for some but another set will be more appropriate for others.
3.8 One group of young mothers said that the young women should be educated in what it is like to be a parent and in particular, a lone parent. They said "we thought it would be great to go to the park with your pram and meet your friends".
3.9 This group talked about the Stepping Stones project which goes in to schools to give young people information to help them make an informed choice about having a baby and believed that this type of service should be universally available and provided to young people at an early stage for example at 12 and 13 years of age.
Existing pre-conception services
3.10 The consultees had had very little experience of any formal pre-conception advice or support and so did not have views on existing services. The majority said that they received information from family and friends but some questioned whether the information they got was accurate and found they could receive contradictory advice. People who are isolated in their communities do not have access through this informal route and they may be the ones who would benefit most from formal pre-conception information, advice and support.
Gaps and issues in pre-conception services
3.11 As discussed, key gaps are:
- Information on pre-conception diet and exercise;
- Support groups for people with fertility problems; and
- Diversionary work with young people.
Ante-natal care
3.12 We talked to adults in the focus groups about their ante-natal care needs, their experiences of existing provision and any gaps.
Ante-natal service needs
3.13 Overall, parents and carers want to have access to high quality, consistent ante-natal care and this runs through to post natal care. They want positive, non-judgemental and informative public health practitioners. They stressed that the approach and attitudes of staff are crucial at this time when many people, particularly when it is a first pregnancy, can feel vulnerable and unsure of themselves. This view was strongly voiced in all of the groups.
3.14 In a minority of groups there was a strong feeling among a significant number of participants that ante-natal classes should start earlier in the pregnancy, they tend to start sometime around week 30.
3.15 Parents commonly stated that they want information that is clear and concise. They can feel overwhelmed by the number of leaflets, books and packs they are given with no real direction on how to prioritise and use the information.
3.16 Some parents said they need better information about diet and exercise. They reported that dietary information tends to focus on what to avoid eating rather than what to eat and there is little advice about whether the foods that they should avoid in pregnancy (eg peanuts, soft cheese, pate) should also be avoided when they are breastfeeding. Others disagreed with this and felt that there is too much information on diet and exercise, which they find overwhelming.
3.17 A small number mentioned that they would like clear information on the best exercise to take during pregnancy at what stages and on the types of exercise they should avoid. A more common view was that there is very limited availability of exercise provision for pregnant women.
3.18 A significant minority thought that local support groups for pregnant woman would be useful to enable women and potentially men, to share their experience of pregnancy and support each other.
Existing ante-natal care
3.19 Experiences of services were generally positive although some people reported that they had felt a bit "abandoned" during the first few months of pregnancy. They would like more reassurance and contact with healthcare staff in these early stages, particularly during a first pregnancy.
3.20 A fairly common and strongly held view was that women should have the option of having more scans, more easily, than they currently do. The main motivation seems to be to provide reassurance on the health of the baby. One woman reported that the additional support needs of her child would have been detected by a more detailed scan.
3.21 There is a perception that the timing, number and types of scans vary in different areas, for example detailed nuchal fold scans are routinely available free of charge in some areas and are not available or have to be paid for in others.
3.22 Some women in the study had been sent home from hospital in the early stages of labour and others felt that they had been left on their own in the hospital without anyone checking on them. In both scenarios, they felt insecure and those who had been sent home found it traumatic as it had resulted in hurried trips back to hospital. They believed that this treatment was because of limited resources in maternity units and did not reflect their needs, but the needs of the hospital.
3.23 We spoke to a number of people who had experienced problems in pregnancy, for example multiple miscarriages. Experiences varied. Some of them had received what they describe as excellent, sensitive and supportive treatment at the time of the miscarriage and during subsequent pregnancies. This was particularly true with multiple miscarriages and relatively late miscarriages. Women who had experienced a miscarriage in early pregnancy (up to 12 weeks), frequently reported less sensitive treatment from health practitioners. They were often told that they should put the experience behind them and try to get pregnant again. They felt that the importance of the miscarriage was not recognised by staff.
3.24 A big message coming through in almost all of the groups is that ante-natal care currently focuses on the pregnancy and the birth but does not prepare parents for having a new baby. The study participants reported that it can leave parents ill prepared and ill informed about what to expect and what to do once the baby arrives.
Gaps and issues in ante-natal care
3.25 In summary, parents and carers reported the following gaps in ante-natal services.
- There is a lack of contact in the earlier stages of pregnancy;
- There should be more comprehensive advice on diet and exercise in pregnancy;
- Parents and carers want clear, concise ante-natal information that is not overwhelming;
- Parents would value more ante-natal classes that start earlier in the pregnancy and cover the post natal period more fully; and
- Linked to the point above, more support to prepare for the period after the birth.
Post-natal care
Post-natal service needs
3.26 Parents and carers frequently reported that they can feel vulnerable after the birth of a child both physically and emotionally. The majority reported having quickly developed a relationship with their midwife who they saw daily for the first one to two weeks and who may have provided some of their ante-natal care. It was very common for women to find it difficult when the midwife care stopped and it passed to the health visitor who they didn't know. The success of this transition depends on the attitude of the health visitor. Parents want a smooth handover with the midwife being there the first time the health visitor comes.
3.27 Parents commonly said that they need a tailored service where the health visitor can spend as long as necessary observing various aspects of care, monitoring the baby's behaviour, and supporting the mother to breast feed successfully. A minority talked about wanting health visitors to be able to give them a firm appointment time for their visit.
3.28 This theme of tailored support runs throughout the findings on post-natal care. Parents want advice that is tailored to them, their baby and their family. They want their particular problems to be addressed fully as there is a perception that the care and advice is more generic than it should be. They want tailored help and advice on feeding, weaning and establishing sleep patterns.
3.29 Some women can find it difficult to establish breastfeeding and whilst they may know that there are breastfeeding workshops, they often think that there is a need for more intensive, one to one support to help them to breastfeed successfully.
3.30 Some parents said that they want practical help to prepare healthy food quickly for themselves and the rest of the household during the first few months of giving birth. They want this advice to be provided before the birth.
3.31 Pregnancy and the birth of a baby brings financial pressures to many households. A number of parents in the study, particularly those in disadvantaged areas, reported that there should be specific money, debt and benefits services in the ante and post-natal periods. Often parents don't get this advice unless they are receiving job seekers' allowance. In some cases midwives have provided parents with money advice.
3.32 A small number of mothers in one of the groups wanted there to be more advice on what exercise they can take during each stage of the post-natal period both to improve their health and to help them get back in to shape. They suggested that a post natal fitness DVD would be helpful and that there should be more exercise classes that are free and include childcare or involve the baby in the class.
3.33 A small number of male and female parents and carers in the study believed that there should be support to help fathers who find it difficult to adjust to having a new baby and to help them develop parenting skills such as practical skills and knowledge.
Existing post-natal services
3.34 Post-natal care was criticised in every focus group and people who had a number of children perceived that the quality has declined since their first child was born. In general, the majority of parents felt that health visitors and other health professionals give them very rigid instructions on what they should do, for example they felt under pressure to breastfeed exclusively and to wait until a certain time to wean their children on to solids. They wanted there to be a more flexible approach whereby they are given the advice and the reasons why they should do certain things but to be supported to make their own decisions and follow them through. They do not want to feel pressurised (as they currently do) or feel judged if, for example, they don't breastfeed, start their baby on solids earlier than advised, choose different sleeping arrangements or decide not to have their child immunised.
3.35 Parents commonly stated that health visitors do not visit them frequently enough and it is difficult to get in touch with them to arrange for them to visit. For example one parent said "you just get an answer machine and no-one gets back to you."
3.36 A very big issue for parents in this period is the diagnosis and treatment of post -natal depression. A significant proportion of parents and carers in the study had experienced post- natal depression ( PND) either personally or as the partner of someone who had suffered from it. The overwhelming view was that PND should be discussed in the ante-natal period. The parents and carers in the study had very little faith in the Edinburgh Test which is designed to identify PND. They wanted more information about PND at an earlier stage, they want to know what signs to look for and they want there to be earlier identification and intervention.
3.37 People in the study who had been diagnosed with PND said that they were offered medication but no therapy or counselling. One woman had been referred for counselling but there was a 6 month waiting list.
3.38 In subsequent pregnancies, when women told their health practitioners about their previous PND, they felt that they had been well supported.
3.39 A small number of men and women in the study reported that men can find it very hard to deal with a partner who is suffering from PND and think that there should be advice, information and someone to go to for help in this situation. They consider the most appropriate source of support should be a referral through the GP.
3.40 There were also three reports of men having experienced PND and recognition that there is very little information or support available for new fathers. This is considered to be a gap.
Gaps and Issues in Post-natal Care
3.41 The discussions with parents and carers showed that there are gaps in post natal services and some of the services that are currently provided should be provided differently. Gaps and issues are as follows:
- There need to be locally available exercise and healthy eating advice and services in the post-natal period;
- A smooth transition from midwife to health visitor care is essential;
- Flexible, individualised breastfeeding support;
- Relevant, accessible money debt and benefits advice;
- The need for comprehensive, flexible, tailored and non-judgemental advice and the support to make choices; and
- Support for men whose partners are suffering from post-natal depression and for men who are suffering from PND.
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