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What should be done and what is being done in Wales?

What should be done and what is being done in Wales?. Reproductive and Early Years. Siobhan Jones. What is the evidence base we should be implementing? What are we doing about this in Wales?. Evidence synthesis.

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What should be done and what is being done in Wales?

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  1. What should be done and what is being done in Wales? Reproductive and Early Years Insert name of presentation on Master Slide Siobhan Jones

  2. What is the evidence base we should be implementing? • What are we doing about this in Wales?

  3. Evidence synthesis • High level mapping of UK national guidelines covering preconception through infancy (2yrs) • BAPM, NICE, CMACE, Royal Colleges • Initial scoping - Approx 300 guidelines – clinical & PH • Synthesised to cover mainly NICE/RC to produce core recommendations for discussion today • Not all evidence based recommendations captured in this presentation – overview to stimulate discussion on next steps

  4. Mapping of Interventions • Mapping exercise - maternal & child health interventions in place at national and health board level • Gaps in information • Valuable in giving overview of interventions in place & highlighting areas of variation & similarity

  5. What should be done? - Preconception Health promotion / education initiatives: • smoking • alcohol • recreational drug use • folic acid supplementation • safe medication during pregnancy • benefits of breast feeding • more specific advice for special groups (e.g. obesity, chronic conditions, mental health disorders) [DoH NSF, CEMACE, NICE, RCOG]

  6. Preconception • Maternity services, GPs, family planning and sexual health joint working to identify women at high risk to ensure access to specialist pre-pregnancy advice. [DoH NSF, NICE, RCOG]

  7. Preconception - obesity • Preconception counselling to women of child bearing age with BMI >30 • Folic acid & vitamin D supplementation • Public health service for effective weight management including pathways for referral [CEMACE, NICE]

  8. Hierarchy of evidence Grading of recommendations • A: systematic review, meta-analysis, RCT. • B: Well designed controlled trial, observational study • C: Well designed descriptive studies. • D: Expert reports, clinical consensus and opinion

  9. Examples interventions - high grade evidence • Interventions to promote smoking cessation in pregnancy • NHS stop smoking services for pregnant women • Financial incentives for pregnant women to stop smoking • Use of folic acid to prevent NTD in pregnant women with obesity

  10. What is being done? Preconception • WAG all Wales obesity pathway • Smoke free homes • Condom C Card Scheme • Healthy Schools • Sex and Relationships Education strategy • Annual operating framework

  11. What should be done? Antenatal • Early access to antenatal care - plan of care to be established before the 12th completed week of pregnancy. [NICE, RCOG Standards for Maternity Care] • Identify women with complex social factors and ensure their needs are met through the appropriate service models [NICE] • Engagement of the father [NICE] • All women informed about Folic acid, vitamin D or maternal Healthy Start vitamin supplements and foods rich in folic acid, particularly women at greatest risk [NICE] • Flu vaccination should be offered to all pregnant women

  12. Antenatal screening • Sickle cell diseases and thalassaemias (ideally by 10 weeks) • Down’s syndrome • Infectious diseases • Risk factors for gestational diabetes (Women with risk factors should be offered testing for gestational diabetes) • History of mental health illness and family history of perinatal mental illness • Depression [NICE]

  13. Antenatal - smoking • Risks of smoking to the unborn child and the hazards of exposure to secondhand smoke, advice and support on how to stop smoking • Identify pregnant women who smoke and refer them to NHS Stop Smoking Services – including CO monitoring • Initial & ongoing support from NHS stop smoking services • Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond  [NICE]

  14. Antenatal - Obesity • Information giving - risks & how minimised • BMI at booking – recorded in notes • Folic acid – recorded in notes • Clinical risk – anaesthesia, preclampsia, diabetes, VTE [NICE, CEMACE] 

  15. What is being done? Antenatal • Antenatal screening • Antenatal hand-held record • Antenatal Screening Wales Information Booklet • Low uptake Flu vaccination across Wales

  16. Antenatal - smoking • Brief intervention training for midwives • Referral pathways into SSW by midwives • National referral pathway under development

  17. Antenatal - obesity • Implementation of recommendations from CMACE guidance - variation • Obesity in pregnancy clinical pathways - variation • Cluster Randomised Controlled Trial: Healthy Eating and Lifestyle in Pregnancy (HELP)

  18. What should be done? Early years 0-2 • Newborn screening (PKU, CHT, Scickle cell, CF, MCADD, Hearing •  Postpartum Vitamin K, anti-D immunoglobulin, MMR • Immediate physical examination after birth, at 6-8 weeks and a health and development review before one year of age, with appropriate referral [WAG NSF, DH NSF/Healthy Child Programme, NICE Postpartum care 2006]

  19. Early years Assessment and referral of parents for • Smoking cessation interventions • Mental health needs and postnatal depression • Drug or alcohol misuse • Domestic violence [WAG NSF, DH NSF/Healthy Child Programme, NICE Quitting smoking in pregnancy and following childbirth 2010, NICE Postpartum care 2006]

  20. Early years • Breastfeeding advice & support – BFI as minimum standard - external evaluation (NICE) • Childhood immunisation programmes

  21. Early Years Parental support and activities to promote infant development and parent-baby relationship • Promote sensitive parenting • Additional support for at-risk first time mothers, parents with learning difficulties, parents in conflict [DH NSF/Healthy Child Programme]

  22. What is being done? Early years • Newborn screening programme • National newborn hearing screening • Physical examination, 6 week baby check, 8 month check • UK baby friendly initiative (breastfeeding) - variation • Breastfeeding peer support programmes & Wales Welcome Scheme

  23. Early years • National childhood immunisation programme • Edinburgh postnatal depression screen • Welsh Network of Healthy Schools Scheme • Pregnancy and early years health improvement research project (ORS) • WAG led midwife appointed for refugee and asylum seeking women • WAG project currently being undertaken looking at improving access for Polish speaking women

  24. Early years - Family interventions • Flying start – most vulnerable 0-3 year olds • Families First – new model integrated working to better support children & families in poverty • Integrated family support service – support vulnerable families with complex needs arising from substance misuse, domestic violence or learning disabilities • Strengthening Families – substance misuse in broader context family functioning, parenting and young peoples’ skill development (RCT underway)

  25. Opportunities for public health leadership • Preconception • Maternal obesity • Perinatal mental health • Robust evaluation of outcomes of established programmes e.g. smoking in pregnancy

  26. Opportunities for public health leadership • Further development of approach to integrating evidence base with interventions • Evaluation of approaches targeting vulnerable families - opportunity to influence • Healthy schools – pre-school scheme • Annual Quality Framework & local public health strategic frameworks • Maternity Services Strategy for Wales • WAG review health visiting service

  27. Next steps...? Our Healthy Future?

  28. Acknowledgments • Jon Brassey • Eleri Tyler • Lynne Hockey • Shantini Paranjothy • Stella Botchway • Stephen Palmer

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