Midwives and Public Health
Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society” (Acheson, 1988; WHO)
In other words, public health seeks to identify risks to health and find the best ways to minimise them, in order to give everyone the best chance of leading a healthy life. This is generally undertaken by work such as:
- Health protection - protecting people's health from a variety of issues, including disease and infection
- Health improvement - improving people's health, for example, by helping people quit smoking or reduce their weight
- Healthcare and public health - ensuring that our health services are effective, efficient and equally accessible to all
In light of this, it's apparent that public health is a core part of the work that midwives do every day. The RCM commissioned a report in 2017, with funding from the Department of Health, England, to examine how midwives are working with public health in greater detail.
The main aim of the project was to conduct a scoping and needs analysis; mapping the current public health activities of midwives and MSWs, services users and student midwives, using both qualitative exploratory work and quantitative surveys based on 35 core topic areas.
This was followed by the translation of the project findings into practical outputs to support improvements in the provision of care. These included the development of a public health model and associated resources, designed to assist practitioners in their work with women and their families. More information on the model and outputs can be seen below.
Overall there was general agreement across the four UK countries that a large proportion of midwives' work does fall under the remit of public health. Practitioners had a wide definition for the types of interventions and information topics that fell within this remit, and saw midwives' role as crucial for both the immediate care being provided and for the health of the family unit.
The project also found that midwives needed more time, confidence and training to discuss public health with women, to ensure information was given in a consistent and timely manner and that follow up was supported by continuity of care in conjunction with the multidisciplinary team. There were discussions on the difficulties experienced in getting tailored, specialist care and advice for women in areas including mental health and maternal weight, even if the vital referral pathways were established and available. Some of the accessibility issues stemmed from the waiting time for being seen after referral to the lack of expertise of a public health lead. The report concluded that the need for leadership at a consultant midwife level was a key factor in supporting successful public health work in maternity services.
What is Public Health?
Visit these sites for more information about public health:
- Health Careers, NHS Health Education England
- Public Health Services, World Health Organisation
- Public Health, Royal College of Nursing
- Knowledge and skills career framework, Public Health England
Improving Prevention and Population Health
The Maternity Transformation Programme’s Workstream 9 focuses on a range of initiatives to improve wellbeing, reduce risk and tackle inequalities from preconception to 6-8 weeks postpartum. The aim is to ensure every woman is fit for and during pregnancy, and that every family is well-supported to give children the best start in life.
The NHS Long Term Plan commits to strengthening its contribution towards prevention and tackling health inequalities, with specific action in a range of areas including smoking, obesity, infant feeding, maternal and paternal mental health.
How is the RCM involved?
- Influenza infection in pregnancy is associated with risks to:
- the fetus, including prematurity, low birth weight and stillbirth
- the mother, due to serious complications of flu, in especially late pregnancy
- the baby
- Pregnant women are offered the inactivated influenza vaccine to protect themselves and provide passive immunity to their baby in the first few months of life. Because of the changing nature of influenza viruses, they are modified according to the latest virus strains and in line with World Health Organisation (WHO) recommendations. Immunisation must be repeated with every pregnancy
- In 2011-2012 there was a marked increase in the number of cases of pertussis (whooping cough) in England. To help prevent further infant deaths, an emergency programme of maternal pertussis immunisation was introduced in October 2012. The vaccine is offered from 16 to 38 weeks gestations, although the optimal time is 16 to 32 weeks.
The RCM collaborates with the NHS and public health partners to support national campaigns aimed at maximising the uptake of vaccines during pregnancy. We also support public health initiatives encouraging NHS staff to be vaccinated.
- Smoking during pregnancy is closely associated with socioeconomic factors and is therefore a major health inequality. Supporting women to have a smoke-free pregnancy is vitally important for reducing infant mortality. It is the main modifiable risk factor for a range of poor pregnancy outcomes
- Smoking in pregnancy increases the risk of premature delivery and stillbirth. Maternal smoking postpartum is associated with a threefold increase in the risk of sudden infant death syndrome
- Smoking prevalence varies significantly between communities and social groups, with pregnant women in more disadvantaged groups being more likely to smoke than in more affluent groups, similarly those aged under 20 being more likely to smoke than those who are older
- Children who grow up with a smoking parent are also more likely to become smokers themselves, further perpetuating the cycle of inequality
- Interventions to help women to quit smoking have been shown to be cost-effective, and stopping smoking early in pregnancy can almost entirely prevent damage to the baby and help prevent additional treatment costs
- Babies born to smoking mothers who quit early in their pregnancy have the same or similar rates of stillbirth, prematurity, low birth weight and small for gestational age, when compared to babies born to non-smoking mothers
The RCM is a member of the Smoking in Pregnancy Challenge Group, working alongside the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, the voluntary sector and academia. It was established in 2012 in response to a challenge from the then Public Health Minister to reduce smoking in pregnancy rates to 6% by 2022. Further information on this ambition can be found in the Tobacco Control Plan.
For more information, read the NICE guidance on stopping smoking in pregnancy. This recommends routine carbon monoxide screening of all pregnant women to assist in identifying smokers and referral for specialist support to quit.
The RCM’s new position statement on support to quit smoking in pregnancy sets out some of the actions that are needed to help this to happen.
Breastfeeding is a public health priority. Midwives and maternity support workers have a central role in providing breastfeeding promotion and support.
The RCM recently refreshed and re-launched its position statement on infant feeding.
The NHS Long Term Plan contains a commitment to delivering evidence-based infant feeding programmes in all maternity services and the RCM is supportive of an outcomes-based approach to increase breastfeeding rates in the UK.
Baby Friendly Initiative is a scheme offered by Unicef to maternity units and other public bodies, including universities and local authorities, on a commercial basis, comprising a programme of training and accreditation of standards.
The Baby Feeding Law Group UK is a group of organisations working together to protect infant, young child and maternal health by ending marketing practices which commercialise infant feeding, mislead consumers and threaten breastfeeding. While its aim is to protect breastfeeding, it does not seek to limit the accessibility of safe and appropriate infant formulas for those who need or want them.
The RCM is represented on the committee of Becoming Breastfeeding Friendly (BBF) England, which has developed an evidence-based toolkit through highly structured technical and academic collaboration, led by Yale University. This aims to guide countries in assessing their breastfeeding status, and their readiness to scale up.
The RCM is also a member of the Baby Feeding Law Group, which works to strengthen UK baby feeding laws in line with UN recommendations.
The RCM recognises that many factors influence infant feeding decisions and is committed to supporting women’s choices. We will continue to campaign for high-quality services, improved employment rights and societal acceptance to encourage breastfeeding to continue for longer.
The NHS Long Term Plan has a strong focus on obesity and mapping work is underway to identify best practice in weight management services for pregnant women.
Stepping Up to Public Health describes obesity prevention as healthy eating advice that is generally part of a broad-based discussion on healthy lifestyle behaviours. Clearly there are health promotion opportunities for midwives and maternity support workers in relation to weight, physical exercise and nutrition.
The RCM and Slimming World jointly undertook research amongst midwives which showed some of the barriers and tools required for effective weight management in pregnancy.
The RCM is a member of the Obesity Health Alliance, which is a coalition of over 40 organisations who have joined together to reduce obesity.
There are currently no UK-specific guidelines on safe weight gain in pregnancy, although there is NICE guidance on weight management before, during and after pregnancy available.
Antenatal and newborn screening programmes offer tests to pregnant women and their babies at various stages of pregnancy and in the newborn period. These include:
- infectious diseases in pregnancy screening programme
- fetal anomaly screening programme (ultrasound)
- newborn bloodspot screening programme
The RCM supports members with an i-learn module on delivering unexpected news in pregnancy which covers the subject of screening.
Other RCM Public Health initiatives
The RCM has produced guidance for midwives on the Homelessness Reduction Act and the new Duty to Refer. These regulations came into effect on October 1 and apply to all public services, including maternity.
Women accessing midwifery care may be disclosing housing circumstances that put them at risk of homelessness. A referral to the local authority should be made at this early point to prevent, as far as possible, a difficult situation from becoming a crisis. Consent must always be obtained. Scenarios may include women who are ‘sofa surfing’, experiencing rent arrears or domestic abuse. The referral process is not intended to be onerous and the RCM has suggested relevant questions to ask women and a model pathway to use.
Midwives have a unique opportunity to support women and the RCM is working to support midwives.
Midwives have a duty to support each and every individual who seeks help as a result of violence, treating them with compassion, respect and dignity and referring them on to appropriate support and treatment in the areas of both health and psychological care.
Learn more about the RCM's work to stop Violence Against Women and Girls.
The RCM supports and promotes ad hoc and seasonal campaigns, including Stoptober, flu & whooping cough vaccination, World Breastfeeding Day and the fortification of flour with folic acid.
Public Health resources across the UK
NHS Health Scotland
NHS Health Scotland has a focussed remit for the reduction of health inequalities.
The range of public health resources on the Health Scotland website relating to pregnancy include information about screening, smoking and substance misuse.
Health Scotland have a number of online learning resources for midwives, designed to help develop their skills in relation to behaviour change approaches, including motivational interviewing techniques and an online hub for leadership in reducing health inequalities.
MCQIC is the maternity part of the Scottish Patient Safety Programme, which has led focussed national improvement work relating to smoking cessation support during pregnancy.
The Scottish Public Health Observatory
This organisation gathers together key information and data about public health in Scotland.
Getting it right for every child
This is the Scottish Government’s overarching programme of work designed to improve the chances of all children in Scotland, through improving the identification of babies and families that require additional support beyond universal services.
National Babybox Scheme
This Scottish Government Babybox initiative is an example of a national public health strategy with the aim of reducing inequalities at the start of life.
Public Health Wales
Public Health Wales is the national public health agency in Wales and exists to protect and improve health and wellbeing and reduce health inequalities for people in Wales.
Public Health Agency
The Public Health Agency works with partners in many different sectors, as well as directly with communities, to reduce health inequalities and ensure collective resources are used effectively.
The Northern Ireland Government publish health and well-being information and advice on their website, including guidance on a broad range of subjects, including vaccinations, screening and making healthy lifestyle choices.