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Health of women before and duringpregnancy: health behaviours, riskfactors and inequalitiesAn updated analysis of the maternityservices dataset antenatal bookingdata

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesAbout Public Health EnglandPublic Health England exists to protect and improve the nation’s health and wellbeing,and reduce health inequalities. We do this through world-leading science, research,knowledge and intelligence, advocacy, partnerships and the delivery of specialist publichealth services. We are an executive agency of the Department of Health and SocialCare, and a distinct delivery organisation with operational autonomy. We providegovernment, local government, the NHS, Parliament, industry and the public withevidence-based professional, scientific and delivery expertise and support .Public Health EnglandWellington House133-155 Waterloo RoadLondon SE1 8UGTel: 020 7654 @PHE ukFacebook: queries relating to this document, please contact: [email protected] Crown copyright 2019You may re-use this information (excluding logos) free of charge in any format ormedium, under the terms of the Open Government Licence v3.0. To view this licence,visit OGL. Where we have identified any third party copyright information you will needto obtain permission from the copyright holders concerned.Published November 2019PHE publicationsgateway number: GW-868PHE supports the UNSustainable Development Goals2

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesContentsExecutive summaryMain gyLimitations and data quality1213Analysis of risk factorsSmoking at time of bookingFormer smokersFolic acidMaternal body mass indexAlcoholSubstance misuseAntenatal booking within 10 weeks of pregnancyConclusions on risk factors191920212223232425First and subsequent pregnanciesMethodologyAge of motherDeprivationComplex social factorsSmoking in pregnancyFolic acidObesityConclusions on first and subsequent pregnancies272728282828293031The health of all womenMethodologyCharacteristics of the datasetsConclusions on comparison to health of all women32323234Next steps35Glossary36References38Appendix 1: data comparisons40Comparison of the number of MSDS booking records to other data sources40Comparison of the distribution of MSDS booking records across inequality factorsto other data sources42Appendix 2: detailed analysisAppendix 2.1: SmokingAppendix 2.2: Folic acidAppendix 2.3: Maternal body mass index (BMI)Appendix 2.4: Alcohol34848677481

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesAppendix 2.5: Substance misuseAppendix 2.6: Antenatal booking within 10 weeks of pregnancy8696Appendix 3: First and subsequent pregnancy103Appendix 4: Comparison to health of all women1094

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesExecutive summaryGood health both before a woman conceives and while she is pregnant improvesoutcomes for mother and baby, the benefits of which continue well beyond birth.Understanding patterns in health before and during pregnancy is important if we are tonarrow the health gap for those who are most vulnerable. Inequalities in maternal andinfant outcomes exist, with poorer outcomes experienced by certain groups of womenand their babies.This report gives a detailed picture of the distribution of risk factors present when awoman attends her first appointment with a midwife (booking appointment). The reportcontains 3 pieces of analysis.The first section of the report presents an analysis based on twelve months’ data forpregnancy booking (January to December 2017) from the Maternity Services Dataset(MSDS). This section of the report builds on the analyses presented in 2018 andinvestigates risk factors in pregnancy which are associated with poorer outcomes.These factors are experienced at higher levels by particular groups of women and theirbabies. Following improvements in data quality, an analysis of substance misuse hasalso been included.The second section of the report compares women booking for their first pregnancywith those booking for a subsequent pregnancy. It focusses on how prepared a womanis for a healthy pregnancy in terms of lifestyle factors such as smoking, obesity andtaking a folic acid supplement which can be altered by changes in behaviour or, inother words, are modifiable.The third section compares the maternal population in MSDS to the general femalepopulation using data from the Health Survey for England (HSE) and the Office forNational Statistics (ONS) with particular focus on the proportions of women smokingand who are obese.Main findingsThere are some gaps in the records (see Table 2 for detailed breakdown) for examplesmoking status may not be recorded in some instances. These gaps predominantlyoriginate from individual provider trusts and are distributed across all subgroups (suchas age, deprivation and ethnicity, as shown in table 2a) such that the data is still arepresentative sample. Due to the limitations of the data, statistical tests for differenceswere not performed but the distributions for mother’s age, mother’s ethnicity anddeprivation decile were tested to ensure the patterns were consistent for both valid andmissing or non- useful data such as ‘unknown’. The large number of women included5

Health of women before and during pregnancy: health behaviours, risk factors and inequalities(644,030) in the sample means that even when some of the records have missing ornon-useful data, meaningful conclusions can still be drawn about the likely prevalenceof the different behaviours in the population overall.Smoking in pregnancyWhere a known smoking status was available, 56.8% women reported that they hadnever smoked; 23.8% had stopped before becoming pregnant; 6.7% stopped whenthey found out they were pregnant; and 12.7% reported that they were current smokersat their booking appointment (table A5).Younger women were more likely to smoke at the time of their booking appointment,with almost 1 in 4 women (24.8%) aged under 25 smoking compared to 7.1% ofwomen aged 35 and over (table A5a).Rates of smoking in pregnancy in the most deprived areas of England were nearly 6times those in the least deprived areas (24.7% and 4.1% respectively) (table A8b).Women of white (15.9%) and mixed (13.9%) ethnicity were most likely to smoke whencompared to women from other ethnic groups (table A11b).Nearly a third of women aged under 18 continue to smoke in their first pregnancy,rising to almost 40% for those booking for a subsequent pregnancy in the same agegroup (table A32a).A higher proportion of women aged 16 to 19 smoked while pregnant (32.7%) whencompared to the general population of women of the same age (14.1%) (table A36a).there was no smoking status recorded for 12.2% of records in MSDS (table 2).Folic acidOf the women for whom the folic acid supplement use was known, 28.2% of womentook a folic acid supplement in preparation for pregnancy (table A14).Young women were the least likely to be taking a folic acid supplement in preparationfor pregnancy; 6.5% of women aged under 18 and 14.0% of women aged 18 to 24 hadtaken a folic acid supplement in preparation for pregnancy (table A14b).Folic acid supplement use in early pregnancy varied by the level of deprivation, withmore women in the least deprived areas taking supplements (42.5%) in comparison tothose in the most deprived areas (15.2%) (table A15b).6

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesThere is variation by ethnic group, 17.6% of with women of black ethnicity had taken afolic acid supplement in preparation for pregnancy in comparison to 34.4% of womenwith Chinese ethnicity. (table A16b).Women were more likely to take a folic acid supplement for their first than subsequentpregnancies; 30% of women booking for a first pregnancy took a folic acid supplementin preparation for their pregnancy compared to 26% for those booking for a subsequentpregnancy (A31a).In more than a third of records in MSDS (34.5%), information on folic acid supplementuse was missing (table 2).Maternal body mass indexFor women with a known body mass index (BMI), 27.4% of women were overweight,18.3% were obese and 3.3% were severely obese when they attended their firstbooking appointment. There were also 4.5% of women who were underweight and46.5% with a healthy weight. (table A17).The proportion of women who were overweight or obese during pregnancy increaseswith age, with the highest proportion being among those aged 40 or over (55.4%) (tableA17b).The proportion of women who were overweight or obese in early pregnancy rises asthe levels of area deprivation increase (table A18b).When looking at different ethnic groups, black women were the most likely to beoverweight or obese (66.6%) in early pregnancy (table A19b).The highest proportions of women who were obese were seen in women aged 40 orover (21% first pregnancy, 26% subsequent pregnancy) (table A30b).A higher proportion of women booking for a subsequent pregnancy (23%) were obesethan those booking for their first pregnancy (18%) (table A30b).Higher proportions of pregnant women aged under 25 were obese (16.3% aged 16 to19, 23.5% aged 20 to 24) when compared to non-pregnant women of the same age(11.9% aged 16 to 19, 17.8% aged 20 to 24) (table A39a).Around 19% of women did not have their BMI recorded on MSDS (table 2).7

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesAlcohol and substance misuseVery few women reported that they drank more than a unit of alcohol a week inpregnancy (2.9% of women for whom alcohol usage was known), although the fact thatthis is self-reported means that it may be an underestimate. Most women (97.1%)reported that they drank little to no alcohol a week (1 unit or fewer). (table A20).older women were more likely to drink as well as to drink higher volumes in pregnancythan other age groups. The highest proportions of women who drank alcohol inpregnancy were seen in women aged 35 to 39 (3.6%) and aged 40 or over (3.4%)(table A20b). Women aged 35 to 39 also drank the most units of alcohol with 16.0% ofwomen who drank reporting that they consumed more than 8 units per week (tableA20c) .around 1.2% of women reported that they were currently misusing illicit drugs, solventsor medicines and over 3.3% described themselves as previously misusing thesesubstances. The majority of women (95.5%) reported that they had never taken drugs.(table A21).substance misuse was more common in women in the most deprived areas, with 2.5%reporting misusing illicit drugs, solvents or medicines compared to 0.5% of women inthe least deprived areas (table A23b).nearly a third of records (29.5%) were reported as ‘unknown’ or ‘not stated’ whenlooking at data on substance misuse (table 2). There was an ‘unknown’ number ofalcohol units drunk in the week for 43.1% of women when they attended their bookingappointment (table 2).Antenatal booking within 10 weeks of pregnancyMore than half (53.9%) of pregnant women attend their booking appointment within 10weeks (table A27).Where women are not booking for antenatal care within the recommended 10 weeks,28.7% booked between 10 and 12 weeks and 9.3% between 13 and 20 weeks. For8.1% of pregnant women, their first appointment with a midwife comes when they areover half way through their pregnancy (the baby or babies have a gestational age of 20weeks or more). Data was nearly universally known for gestational age with only 0.1%of women having data recorded as ‘unknown’ (table A27).Pregnant women aged under 25 attend antenatal care at a later stage than olderwomen, with a fifth of women attending when they are 13 weeks or more (table A27b).8

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesWomen in their mid-twenties and early thirties were most likely to attend their antenatalbooking appointment within 10 weeks of their pregnancy (55.7%) when compared toother age groups (table A27b).Booking after 10 weeks is also more likely for women living in the most deprived areas(48.9%) when compared to areas with lower levels of deprivation (table A28b).Black women (61.5%) and women whose ethnicity is given as ‘other’ (58.6%) were theethnic groups most likely to book after 10 weeks (table A29b).This report provides additional analyses and reinforces findings from the reportpublished in 2018. The comparisons made between the MSDS data and otherestablished data sources suggests that at the time of analysis the dataset was reachinga point where data was being recorded for the vast majority of women in England usingmaternity services. It can, therefore, be used to provide information about the riskfactors which are associated with poorer outcomes and how those risks are distributedwithin different groups of women. The dataset is still classed as experimental as it isundergoing evaluation so this analysis should be interpreted with care due to knownbut improving issues with data quality and coverage (table 2). While data quality isvariable, the findings are in accordance with what is known from the literature. For thisreason, this analysis can be used by commissioners and service leaders to increasetheir understanding of their local population’s demographics and risk factors of womenusing services as well as analyse variation between providers.AcknowledgementsPHE is grateful to the advisors whose contributions guided the approach and content ofthe report. This included NHS Digital and the membership of the MaternityTransformation Programme (MTP) Work stream 9 – Improving Prevention. This groupincludes maternity and infant health professionals from NHS England and NHSImprovement, Health Education England, representation from the Family NursePartnership, midwives, health visitors, nurses and consultants. It also includesrepresentation from the Local Government Association, and the charities SANDS (thestillbirth and neonatal death charity) and Best Beginnings together with public healthand programme managers, policy leads and other teams within PHE and theDepartment of Health and Social Care.9

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesIntroductionGood health both before a woman conceives and while she is pregnant improvesoutcomes for mother and baby, the benefits of which continue well beyond birth.Understanding patterns in health before and during pregnancy is important if we are tonarrow the health gap for those who are most vulnerable. Inequalities in maternal andinfant outcomes exist, with poorer outcomes experienced by certain groups of womenand their babies. Based on such analysis, services can be designed across carepathways which encourage changes in behaviour to improve the health of everyone ofreproductive age so that when women do conceive they are fit and well with the bestpossible chance of a healthy conception and pregnancy.A woman’s maternity booking appointment should take place within the first 10 weeksof pregnancy. It is the point at which the woman meets a midwife for the first time todiscuss antenatal care. During the booking appointment a range of information iscollected about the mother and her family’s health, her social support and herpregnancy and tests, such as screening for sickle cell disease and thalassaemia, whichneed to be done before 10 weeks, are scheduled. It is also the opportunity to discussthe best way to ensure a healthy pregnancy including information andrecommendations on diet and the need to take folic acid supplements, smoking andantenatal screening.Many factors affect a woman’s health in pregnancy. The extent to which these can bealtered or modified varies. For example, once a woman is pregnant, factors such as theage at which she will become a mother cannot be altered. There are, however, lesshealthy behaviours which are often established well before pregnancy. This is the casefor dietary and exercise habits, smoking, alcohol and substance misuse and manyother factors. Effective action to reduce these risk factors before and during pregnancycan improve outcomes for mothers, babies and their families. As with many aspects ofpublic health, inequalities in maternal and infant outcomes exist, with poorer outcomesexperienced by certain groups of women and their babies. These risk factors and theirunequal distribution are the focus of this report.Maternal age is an important factor for pregnancy outcomes, with a maternal age of 35or above associated with higher rates of stillbirth (1-4), caesarean section (5) andcongenital abnormalities (6) when compared to younger women.Younger women can also be at higher risk. For example, they are less likely to take afolic acid supplement (7) which protects against the risk of neural tube defects such asspina bifida (8). Women are advised to take daily folic acid supplements of 400µgbefore conception and throughout the first 12 weeks of pregnancy (9).10

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesBabies born to women aged under 20 also have around a 20% higher risk of lowbirthweight (10) which can be partly explained by higher smoking rates in pregnancy inthis age group than the national average. Women are advised not to smoke beforeconception and while pregnant as smoking in pregnancy is generally associated withhigher risk of stillbirth and infant mortality (11) and is the single largest modifiable riskfactor for poor birth outcomes (12).Social factors can also play a role. Women in routine and manual occupations havehigher smoking rates (13) and, in the general population, rates of smoking are higher inmore deprived areas (14). When considering area-based deprivation, babies living inthe most deprived areas have a higher rate of congenital anomalies as well as neonatalmortality associated with congenital anomalies (15).A woman’s weight can have a bearing on outcomes in pregnancy. Women who areoverweight or obese are more likely to have a stillbirth (16) as well as complications inpregnancy and labour which place themselves and their babies at greater risk of harm(17). At the other end of the spectrum, women who are underweight are also morelikely to experience poor outcomes. Women are encouraged to maintain a healthyweight before, during and after pregnancy.Recent reviews have shown that the risks of low birthweight, preterm birth, and beingsmall for gestational age may all be increased in mothers drinking above 1-2 units perday during pregnancy (18). The consumption of alcohol in pregnancy also carries therisk of a baby developing fetal alcohol spectrum disorders or fetal alcohol syndrome(18). These conditions can result in physical, mental and behavioural problemsincluding learning disabilities which can have lifelong effects (18). For these reasons,encouraging women to abstain from alcohol in pregnancy is important. UK chiefmedical officers' advice to pregnant women is that the safest approach is not to drinkalcohol at all, to keep risks to the baby to a minimum (18). Illicit drugs, medicines orsolvents also should not be misused during pregnancy due to the risk of clinical andneonatal complications, including increased risk of death, and the risk of poorbehavioural and developmental outcomes in drug-exposed children (depending on thedrug(s) misused).11

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesMethodologyThe Maternity Services Dataset (MSDS) is a national dataset which collects and reportsinformation on maternity care in England. It has been implemented by all maternityservices in England, including acute trusts, foundation trusts and private servicescommissioned by the NHS. The dataset is currently classed as experimental, publishedin order to involve stakeholders in its development. More information about the datasetis available from NHS Digital.Maternity care providers began submitting data for activity from April 2015. There hashowever been variation in how quickly and how successfully providers have managedto flow their data to the national dataset. For the latest month in the period covered inthis analysis (December 2017), 123 providers successfully submitted data to thedataset. This included 122 of the 132 providers identified as providers of maternityservices based on hospital delivery data. Data for a limited subset of the overall MSDSrelating to information collected at pregnancy booking appointments has been madeavailable in an anonymised form through NHS Digital’s iViewPlus tool.This report analyses data from all maternities in England during early pregnancy:antenatal booking data from the MSDS. It presents information on the mother’s health,lifestyle and risks in early pregnancy as well as her age, ethnicity and the level ofdeprivation of the area in which she lives.At the booking appointment many questions are asked about a woman’s health andlifestyle including her smoking habits and history. Ex-smokers at their bookingappointment were asked when they had quit – in advance of pregnancy or shortly afterdiscovering they were pregnant.Women are weighed and their height is measured in order to calculate their body massindex (BMI) and if required advice given around how weight related risks can beminimised and any additional care the woman may require if she has weight problems.Women are also asked if they took a folic acid supplement either before conception orsince their pregnancy has been confirmed.Questions are also asked about how many units of alcohol the women have drunk inthe last week and whether or not they have used or are misusing illicit drugs, solventsor medicines. If a woman says that she is has drunk alcohol; is using illicit drugs suchas cocaine, crack, heroin, cannabis and new psychoactive substances (NPS); ismisusing medicines such as morphine or other prescribed opioids; or is misusing12

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiessolvents such as glue or aerosols, this is recorded1. If a mother misuses alcohol, illicitdrugs, solvents or medicines this can place her baby at greater risk of pooreroutcomes.The midwife also identifies whether complex social factors are present and this isrecorded in the MSDS. Complex social factors include women aged under 20, womenwho experience domestic abuse, women who are recent migrants, asylum seekers orrefugees, or who have difficulty reading or speaking English or women who misusesubstances including alcohol. Women in these groups may have additional needswhich should be considered when planning services (22). For example, women agedunder 20 may be reluctant to use antenatal services because they feel uncomfortablewhen most of the other women attending are older or encounter practical difficultieswith getting to such services (22).Limitations and data qualityTo assess the quality of the MSDS data and its suitability for further analysis, thenumber of records for booking appointments for January to December 2017 werecompared to other data sources for associated time periods (appendix 1.1). Resultsshowed that there were more records in the MSDS maternity booking system than birthregistrations from the Office for National Statistics (ONS). The ONS data however onlyincludes maternities where live or stillbirth were the outcome; women who haveterminated their pregnancy or lost their baby before 24 weeks are not included in theONS maternity figures.There were also more records in MSDS than appear in PHE-reported health visitorantenatal contacts (appendix 1), which only cover live births and also excludeadmissions to neonatal care. Comparing the MSDS data to other established datasources suggests that the dataset is reaching a point where data was being recordedfor the vast majority of women in England using maternity services (table 1). As thedataset is recently established, not all data items are flowing successfully from allproviders. The results should therefore be interpreted with caution, and alongside thedata quality assessments (table 2).Maternal age and residence (allowing deprivation decile to be calculated) were wellpopulated within the dataset. Ethnicity was less well populated, with approximately 14%of records having no recorded ethnicity (table 2). This data quality is similar to other,more established data sources such as Hospital Episode Statistics.Tobacco and alcohol are recorded as separate data items and so are not included in the analysis of ‘substance misuse.’Prescribed medication is also excluded.113

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesWhen looking at the details of when known ex-smokers quit there were a significantnumber of missing records (more than 40%). Nearly a third of records (29.5%) werereported as ‘unknown’ or ‘not stated’ when looking at data on substance misuse. 43.1%of women had an ‘unknown’ number of alcohol units drunk in the week they attendedtheir booking appointment.Table 1: Maternity booking records in the MSDS compared to other sources ofpregnancy-related countsData sourceNumber of recordsONS maternities 2017638,629NHS Digital Maternity booking appointments 2017 (MSDS)644,030NHS Digital Hospital Deliveries 2017/18 (HES)626,20314

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesTable 2: Data quality summary for maternal demographics and risk factors used inanalysis from MSDSData qualityOverallDataset likely to benearly 100%complete (table 1).Mother’s age 1% of records withmissing maternalageMother’s ethnicity14% of records withmissing maternalethnicitySmokingstatus12.2% of recordswith missingsmoking status.Approximately 12%of records in eachage group withmissing smokingstatus – nosuggestion thisvaries by age.Around 11% to 12%of records for eachethnicity had missingsmoking status.Records withethnicity not known orstated have poorestrecording of smoking.Exsmokers:point ofquitting46.0% of recordswith missing pointof quittinginformation.39% to 49% ofrecords withmissing point ofquitting information.No clear pattern bymother’s age.76% of records forwomen with Asianethnicity recorded asex-smokers do notcontain informationabout point ofquitting. This is 44%for white women.34% to 39% ofrecords in each groupwith missing folic acidsupplement use.Records withethnicity not known orstated also have poorrecording of folicacid.Around 14% to 20%of records in eachgroup with missingBMI information.Records withethnicity not known orstated have poorrecording of BMI.Around 42% to 50%of records in eachgroup with unknownalcohol informationOverallFolic acid34.5% of recordssupplement with missing folicuseacid supplementuse.MaternalBMI18.7% of recordswith missing BMIinformation.Alcohol use 97.1% of recordswith known statushave lowest alcoholuse ( 1 unit perAround 34% to35% of records ineach age groupwith missing folicacid supplementuse. Slightly moremissing records inyounger agegroups.22% of records foryoung women agedunder 18 withmissing BMIinformation – 18%to 20% of missingrecords in older agegroups.Around 42% to44% recordscontain unknown15Deprivation decile 2% of recordswhich cannot beassigned to a decile(based onresidence)11% of records inthe least depriveddecile with missingsmoking status,rising to 13% in themost depriveddecile.No clear pattern bydeprivation decile,although highestproportion ofmissing records inmost depriveddecile (53%).No clear pattern bydeprivation decile.No clear pattern bydeprivation decile.No clear pattern bydeprivation decile.

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesData qualitySubstancemisuseAntenatalbookingOverallweek) recorded.43.1% havemissinginformation.29.5% of recordswith missingsubstance misusedata.Mother’s agealcohol informationfor all age groups.Mother’s ethnicityDeprivation decileAround 29% toAround 28% to 31%No clear pattern by30% recordsrecords containdeprivation decile.contain missingmissing substancesubstance misusemisuse data for alldata for all ageethnic groups.groups. 1% of records with unknown date of antenatal booking in all groups.The distribution of appointments by various inequality factors (age of mother, ethnicity,deprivation decile) were compared, where possible, to these other data sources(appendix 1). With one exception (maternal ethnicity, where the proportion of whitewomen was slightly lower than would be expected), the distributions of the records inthe MSDS in each group were similar to the distributions in these other datasets. Onthis basis, the MSDS can be considered a reliable source of inequality information forthese factors. Behavioural risk factors were then analysed by these inequalities for thetwelve-month period January to December 2017 (as improvements in data quality wereso rapid that this data is likely to be more complete than data from 2016). At all stages,data quality was assessed and noted.The literature suggests that risk and inequality factors are interrelated with little knownabout associations between individual factors and outcomes, independent of otherfactors. The findings within this report must therefore be interpreted with this limitationin mind.16

Health of women before and during pregnancy: health behaviours, risk factors and inequalitiesTable 2a: Distribution of data quality for maternal demographics and risk factors usedin analysis from MSDSPercentage in each categorySmokingBMIMissingdata Valid dataMissingdata Valid 3%16.9%3.9%100.0%

Of the women for whom the folic acid supplement use was known, 28.2% of women took a folic acid supplement in preparation for pregnancy (table A14). Young women were the least likely to be taking a folic acid supplement in preparation for pregnancy; 6.5% of women aged under 18 and 14.0% of women aged 18 to 24 had

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