Every year UK community midwives develop hundreds of individual professional relationships with their clients. Mostly, happy-to-be-pregnant women are seen at their homes or in the health centre antenatal clinic. The midwife will not be able to predict for the woman exactly what date her baby will be born. What she tells her is that it is very likely her baby will be born at full term. This is recognised as greater than 37 weeks of pregnancy. Any sooner than this and the baby is classed as premature. Women like to know a date to work with and very few are thinking that their baby will be born much earlier than this unless they've had a previous experience of it or know someone close to whom this has happened. Midwives may usually touch on the subject but don’t emphasise it, as part of their job is help women worry less and enjoy their pregnancy.
Yet the midwife knows that if she works in an area where she meets pregnant women living in cramped housing conditions, no helpful support networks and very little income there may already be some things for the women to worry about. If a pregnant woman smokes, drinks a lot of alcohol and/or uses street drugs, then she and her midwife have even more to worry about and this pregnancy appears to be increasingly vulnerable. She may be in an abusive relationship. On top of this, if she has not had much education and does not know to eat a range of good nourishing foods on a daily basis then the placenta and baby will not grow well.
Add to this the possibility that she may be from a minority ethnic group where there may be language and access barriers to maternity care then the midwife will be alerted to most of the features that are associated with a possible poor outcome for mother and baby. So the woman may become ill herself and give birth prematurely. The earlier the baby is born, the lower the chances of survival and the chances of the baby having something seriously wrong with it for the rest of its life are increased. A woman with only a few of the above life aspects may already be twice as likely to have a premature baby than a woman who has a good income and few stressful events in her life. The elements which may affect different likelihood of results are in government documents called ‘health inequalities’. The World Health Organisation defines health inequalities as ‘difference in health status or in the distribution of health determinants between different population groups’.
Public health debates focus on what the statistics may reveal about social and economic deprivation. Various ways of measuring deprivation have developed over the years and some surveys illustrate more clear-cut associations with premature neo-natal deaths than others. Population statistics are often criticised as flawed for not revealing localised individual factors. However, the most reliable large scale data does show that the more deprivation factors you have the poorer you and your family’s health will be. This leads to questions being asked about what health and social interventions can be made to help reduce the neo-natal tragedy of premature baby deaths or of children having long-term physical and learning problems. For any family of any situation having a premature baby is a traumatic experience, but for a family with very few resources it can make life almost unbearable and coping skills may not exist.
Research in the public health area is inconclusive about what type of social support will help improve outcomes. And what about the contributing overall multi-factorial influences often individually related? Infection, stress, high blood pressure, previous premature labours or abortions - these also appear to be more common amongst socio-deprived groups of pregnant women. However this is not well documented on a national data set that supports the public health agenda activity. The only circumstances that run counter to this are in relation to fertility treatment and multiple pregnancies. Well-off women have been more likely to access treatment but if carrying twins or triplets they are more likely to give birth prematurely.
Some government statements refer to low birth weight babies. Their babies are not necessarily premature but more of them are born to socially deprived groups. Hard evidence is not entirely clear about why but there are some indicative features. Smoking is associated with low birth weight babies and giving up inhaling all the poisons that cigarettes contain will help women have healthier babies. Some evidence suggests that supplements of calcium may be preventative and therefore supports the nutritional intervention arguments.
Medical practitioners look to using scanning, pharmaceutical and medical techniques to try and predict and reduce low birth weight and prematurity events. Nevertheless, the UK continues to have one of the highest rates of low birth weight babies in Europe. Health practitioners would like to know what the very best things they can advise and do to reduce the risk of small and premature births, deaths and damage. Some evidence was revealed in the CESDI report (Confidential Enquiries into Stillbirth and Neo-natal Deaths), but this was mainly in terms of improving medical care and not much with public health preventative activity.
Dilemmas in Practice
A woman that the midwife meets for the first time is an individual who is often very excited about being pregnant. She also usually has a number of anxieties but not necessarily any which may have been mentioned in public health documents that the midwife has read. Nor has she the sort of knowledge which many maternity service consumer activists would like to alert women to as soon as possible. Most of the women on an average community midwife’s caseload of 100 to 150 a year, whatever their circumstances or health inequalities factors, will enjoy a fairly healthy pregnancy with a live healthy baby at the end of it.
The midwife in any situation needs to use her skills to try and form a meaningful, helpful, classless, trusting and affirming professional relationship with the woman whomever and however she is. Honesty and humour is certainly a good starting point. As the relationship grows a midwife tries to work with women with individual issues around nutrition, stopping smoking, drugs, housing, debt, domestic violence, social exclusion, learning difficulties, stress, access, language and communication barriers.
So, in terms of addressing health inequalities and premature birth, at what point do you explain to a woman in socio-deprived circumstances that she has a certain statistical chance of something going terribly wrong? And how do you tell a mother that her chances of a healthy pregnancy will be increased if those around her cut down their drinking, smoking and junk food, thereby making it easier for her to change her own lifestyle habits?
Education and awareness-raising is thought to be the key to this but what works and whether it will take on-going individual or social solutions, reforms or a revolution is unclear. Pregnant women can be highly motivated for a short period of time to make some individual changes but cultural norms often have more influence, especially if women have plenty of friends with the same lifestyle habits where nothing has gone wrong with their babies! What the midwife or doctor cannot do is look any woman in the eye and say if you do or don’t do something in particular you will definitely avoid a premature birth.
Relationship between Premature Birth and Disadvantage
Before the huge reliance on dating scans, a baby’s maturity was assessed more carefully by a number of physical and behavioural features that attracted a score which indicated the level of prematurity, These charts still help midwifery and neo-natal staff today.
Categories used are:
- Extremely premature: born between 24 and 28 weeks,
- Very premature babies; born between 29 and 34 weeks,
- Moderately premature: born between 35 and 37 weeks.
Birth statistic collection is an expensive activity and practitioners would hope that they would reveal inequality links that would help to determine best practice. However, they don’t! What is known is that around seven per cent of babies born in the UK are premature. Some Scottish figures illustrate that the disadvantage link may be more than twice as many premature babies are born to the most deprived groups. This has huge social and economic implications for the families themselves as well as for the NHS and Departments of Education. Even mildly premature babies may have physical and learning challenges which require extra resources to achieve the aim that all UK children are given access to opportunities to fulfil their potential. If resources aren’t available then the infant is doubly disadvantaged.
The earlier the baby is born the more problems may be encountered. Breathing difficulties, infection, oxygen deprivation, gut problems, eyesight problems, heart conditions and brain abnormalities among them. Survival rates for babies without abnormalities at 23 weeks are around 17per cent, at 25 weeks there is a 50 per cent chance of survival and much better chances after 30 weeks, depending on the weight of the baby. There are miracle stories of the 23 week baby that survived without any long-term problems but increasingly researchers find that this is the exception rather than the rule. They are finding that many of these infants carry long term disability with them. Babies may need up to a three month stay - or longer - in hospital and parents have to get used to their lifestyle being hospital-centred during this time. You must expect huge amounts of stress and worry and a roller coaster ride and maybe you will be the lucky one at the end of it with a relatively healthy living baby. However, infants who go home to disadvantaged circumstances are more likely to end up back in hospital. It is again unclear in relation to the evidence and the public health agenda what significant interventions would make a difference for those infants, apart from successful breastfeeding. There are also support groups which parents who feel socially at ease with are able to access.
There are current academic trends to identify and discuss behaviours that appear to lock people into social deprivation. These need to be understood and worked with if any of the public health agenda wishes are to be achieved. For example, one behaviour discussed is something called ‘learned helplessness’. Whole new forms of behavioural education may need to be introduced in order to improve outcomes that reduce health inequalities of the social gradient. People may need to learn ways that give them desire for utilising ‘enabling knowledge’, to live healthily rather than having do-gooders trying to impose lifestyle changes upon them!
At the moment some health practitioners feel that they may be involved with an expensive public health experiment that only reflects historical activity in other parts of the world. There is neither convincing statistical nor intervention evidence that shows that the money being spent will make a difference. Yet, intuitively, practitioners know that anything that may help to eliminate poverty and its effects has to be a good thing.