A springboard to a better future

By Sarah Beake and Debra Bick on 25 May 2018 Midwives Magazine

Three years into A Better Start, researchers are beginning to study the programme’s impact and cost-effectiveness – and local maternity services can help, write Sarah Beake and Debra Bick.

A Better Start is a National Lottery-funded initiative, set up by the Big Lottery Fund in 2015. The £215m programme, which runs until 2025, involves partnerships in Blackpool, Bradford, Lambeth, Nottingham and Southend-on-Sea that support families in giving their babies and very young children the best possible start in life. Working with local parents, the partnerships develop and test ways to improve their children’s diet and nutrition, social and emotional development, and speech, language and communication. Grounded in scientific evidence and research, A Better Start is one of five major programmes set up by the Big Lottery Fund to test and learn from new approaches to designing services that aim to make people’s lives healthier and happier.

Each local area partnership – or intervention area – was awarded funding through a competitive process that asked applicants to identify innovative ways to improve child outcomes. Each partnership is working with parents, public health, charities and local maternity and primary care services to create joined-up community services for expectant and new parents.

Ethos and aims

The key ethos of the programme is that the wider community will work together to co-produce and provide more joined-up services for children and families. The programme aims to improve the outcomes and life chances for children through shifting resources towards prevention of adverse outcomes. Access to support from a local area partnership programme intervention is available to parents living in the area from pregnancy until their child is three years old.

Evidence is emerging of the role that environment and nurturing have on child health and wellbeing. For example, there is increasing evidence that, during pregnancy, maternal anxiety can affect the functioning of the placenta, which in turn may influence fetal neurodevelopment (Glover, 2015). There is also evidence that children exposed to stress who live in more economically deprived areas are at higher risk of stress-related disease and cognitive impairment (Shonkoff, 2016).

Outcomes of interest following the programme’s roll-out will be collected at pre-specified times during the child’s life, and will include their social, emotional, communication and language development, as well as diet and nutrition.

Impact and cost-effectiveness

A Better Start’s size and complexity, involving different areas of England and the roll-out of locally tailored partnerships, requires a carefully developed strategy for evaluating it. Several approaches are currently being undertaken.

One of the evaluations, which looks at the impact and cost-effectiveness of the programme (Barlow et al, 2017), is called the You and Your Child study. It comprises a longitudinal cohort study in each A Better Start area to explore the impact on both parents – if the father is available – and the child in the shorter and longer term. Outcomes of interest will be compared with outcomes from women, their children and families living in 15 matched comparison areas across England. Each woman who agrees to participate, and her child, will be followed up from recruitment in pregnancy to when the child reaches the age of three.

The You and Your Child study part of the evaluation is being overseen by the Warwick Consortium, a team led by the University of Warwick including researchers from several UK universities and other research organisations. Ethical approval to undertake the study was obtained from Health Research Authority (15/WM/0150). All research and development leads in NHS trusts and other relevant bodies (for example, Clinical Research Network) were informed about the research.

Women recruited to the evaluation study will be asked to complete four face-to-face interviews: one during pregnancy following recruitment, and then every 12 months until three years after giving birth. Market research specialist Ipsos MORI will undertake the survey elements of the study.

Women will be asked to answer pre-set questions during their interviews, with their responses directly entered onto a tablet computer by the researcher. When their child is four months old, women will be asked to complete a few questions in a paper or online questionnaire. Questions will focus on the women’s physical and psychological health at each time of follow-up, and on their child’s health and development. The children’s height and weight will also be recorded at ages one, two and three years.

To thank the women who take part, they will be offered a £10 ‘Love2Shop’ voucher each time they complete a questionnaire. When children of recruited families are aged five, their teachers will be invited to complete teacher-report versions of measures of their social and emotional functioning.

A small subgroup of women will be asked for a sample of their hair, and permission for buccal swabs to be taken from their baby as soon as possible following birth. Additional hair and buccal swabs will be taken, again with the woman’s permission, from the child at the age of two.

The hair samples will be used to measure levels of cortisol, an indicator for maternal stress. The buccal swabs will provide a sample of the baby’s DNA to give an epigenetic profile. As well as traditional genetics based on inheritance, other external and environmental factors may also play a role in switching some genes on or off. If women/parents are invited to take part in this aspect of the study but would prefer not to provide samples as described, they will still be able to take part in the surveys.

A tailored approach

As part of the evaluation, the consortium recently completed a baseline survey of 1701 families, which involved parents with children aged one to three years. A pilot study has also been undertaken in 10 areas – five intervention areas and five comparison areas – to test the recruitment process and use of the research tools planned for use in the main study. More than 100 families were recruited to the pilot study and interviewed.

A key finding was that each area needed to tailor its approach to identify pregnant women, in line with their local service systems and processes. An important lesson for the consortium team is the need to be flexible with respect to recruitment approaches introduced into each maternity unit.

Next steps

The consortium will start recruitment to the main cohort study in January 2019. The aim is to recruit a total of 2885 pregnant women: 343 from each of the five intervention sites and 78 from each of the 15 comparison sites. This sample size has been set to ensure that, after attrition, we can complete interviews with sufficient numbers of parents of three-year-old children in our programme and comparison areas to detect differences in outcomes of interest.

To recruit women, the research team will need the support of the local maternity/midwifery services in these areas. These services can help identify women eligible to take part in the study – pregnant women who live in the study areas and not planning to move away within six months of giving birth. Women suffering from severe mental health problems and who are 16 years or under will not be eligible.

Midwives at local maternity units in the intervention and control areas will be asked to offer eligible women a participant information sheet, and briefly tell them what would be involved if they took part in the study. If the woman thinks she might take part, she will be asked for her permission for her address, phone number and email to be passed to the research team. Leaflets and information about the study will be translated into the most common languages spoken in the local areas after English.

If a woman gives her permission to be contacted by the researchers, her details will be passed to the team, who will contact the woman to answer any further questions she might have and obtain her informed consent to taking part. To recruit the number of women required, the consortium anticipates that the maternity services will need to identify and obtain permission for details to be passed on from around 650 women in each intervention area and around 170 in comparison areas. Assistance will also be required in taking the initial hair samples and buccal swabs.

Support from the maternity services will be key to the success in recruiting women to this study.

We look forward to continuing to work with maternity services and with colleagues who have agreed to support this study. 

Sarah Beake is a research associate and Debra Bick is a professor of midwifery and maternal health at King’s College London. They write on behalf of the Warwick Consortium. Illustration: Spencer Wilson.

A Better Start: The Warwick Consortium Evaluation
More on the evaluation of A Better Start can be found at abetterstart.org.uk


Barlow J, Beake S, Bick D, Bryson C, Day L, Gilby N, Glover V, Knibbs S, Leyland A, Lindsay G, Mathers S, McKenna K, Petrou S, Purdon S, Sylva K, Summerbell CD, Tudor F, Wheeler A, Woolgar V. (2017) Initial protocol for a national evaluation of an area-based intervention programme (A Better Start) on early-life outcomes: a longitudinal cohort study with comparison (control) cohort samples. BMJ Open 7(8): e015086.

Glover V. (2015) Prenatal stress and its effects on the fetus and the child: possible underlying biological mechanisms. Advances in Neurobiology 10: 269–83.

Shonkoff JP. (2016) Capitalising on advances in science to reduce the health consequences of early childhood adversity. JAMA Pediatrics 170: 1003.