Pregnancy and Population Health

• Public health - the science and art of preventing disease, prolonging life and promoting health through organised efforts of society. In the past, public health has commonly, if mistakenly, been rather narrowly interpreted and associated in particular with sanitary hygiene and epidemic disease control. We prefer a broader definition which gives as much weight to the importance of lifestyle as to environmental hygiene in the preservation and promotion of health.
• Health improvement

  • employment
  • housing
  • family and community
  • education
  • inequalities and exclusion
  • lifestyles
  • surveillance and monitoring
• health production

  • disease and injury prevention
  • communicable disease control
  • environmental health hazards
  • Emergency planning
• Health Services

  • quality
  • clinical effectiveness
  • efficiency
  • service planning
  • audit and evaluation
  • clinical governance
  • equity
• Desired outcomes of pregnancy

  • healthy mother
  • alive (absence of maternal mortality)
  • able to care for herself (absence of maternal morbidity)
  • able to care for her baby
  • healthy baby
  • alive (absence of stillbirth, perinatal, neonatal or post-neonatal mortality)
  • on time (absence of prematurity)
  • normal weight (absence of low or very low birth weight)
  • no abnormalities
• Infant mortality in England and Wales

  • 2226 infant deaths in England and Wales in 2020 (3.6 per 1000 live births)
• Causes of infant mortality

  • immaturity-related conditions
  • congenital abnormalities
  • infections
  • sudden infant death syndrome
  • asphyxia, anoxia or trauma (intrapartum)
  • external conditions
• health determinants

  • maternal age
  • parental genetic abnormalities
  • smoking, alcohol, diet and exercise
  • emotional support network
  • financial support
  • family income
  • access to housing
  • access to antenatal care
  • poverty rate
  • cultural religious views on pregnancy, contraception, abortion
  • health promotion
• causes of low birth weight

  • prematurity (multiple pregnancy, infection, diabetes, hypertension)
  • intrauterine growth restriction
  • placenta/umbilical cord (placenta praevia, placental abruption, decreased blood flow)
  • maternal health (smoking, hypertension, diabetes, anaemia, obesity)
  • fetal health (multiple pregnancy, infection, congenital defects)
• Smoking in Pregnancy

  • roughly 9% of women in England reported being smokers at the time of delivery
  • Babies of mothers that smoke during pregnancy on average 200g lighter than those who do not smoke
  • babies are twice as likely to have a low birth weight if their mother smokes during pregnancy
• Stop smoking aids

  • carbon monoxide testing at all antenatal appointments
  • opt-out referral for stop-smoking support
  • consider combination Nicotine Replacement Therapy alongside behavioural support
  • nicotine patches to wear during the day
  • short-acting preparation (gum, lozenges etc.)
  • evidence for NRT in pregnancy is mixed
  • voucher incentives
  • varenicline and bupropion are not licensed for use in pregnancy
• Obesity is a preconception risk factor:

  • impact on women
  • increased risk of miscarriage
  • gestational diabetes and perinatal complications
  • lower breastfeeding rates
  • impact on foetus
  • increased risk of stillbirth
  • metabolic abnormalities
  • developmental abnormalities
  • impact on children
  • increased risk of obesity
  • diabetes
• Smoking during pregnancy causes premature births, miscarriages and perinatal deaths. it also increases the risk of complications in pregnancy and of the child developing a number of conditions late on in life such as:

  • premature birth
  • low birth weight
  • problems of ear, nose and throat
  • respiratory conditions
  • obesity
  • diabetes
• Broader factors affecting infant mortality

  • poverty
  • policy (maternity leave, benefits)
  • social class structure
  • wages
  • social inclusion
  • political authority
  • conflict
  • infrastructure
  • social norms
• Infant mortality is determined by a range of factors, the wider determinants of health. It is estimated that 1 in 4 infant deaths in England and Wales could be prevented if deprivation levels were reduced to the lowest level of deprivation nationwide.
• The Marmot review is an independent review aiming to propose the most effective evidence-based strategies for reducing health inequalities in England. It identified 6 policy objectives:

  • give every child the best start in life
  • enable all children, young people and adults to maximise their capabilities and have control over their lives
  • create fair employment and good work for all
  • ensure healthy standard of living for all
  • create and develop healthy and sustainable places and communities
  • strengthen the role and impact of ill-health prevention
• • the more deprived the area, the shorter life expectancy. This social gradient has become steeper over the last decade, and it is women in the most deprived 10% of areas for whom life expectancy fell the most.
  • there are marked regional differences in life expectancy, particularly among people living in more deprived areas
  • mortality rates are increasing for men and women aged 45-49 perhaps related to so-called deaths of despair (suicide, drugs and alcohol abuse) as seen in the USA.
• Child poverty has increased ; children's and youth centres have closed, funding for education is down.
• There is a housing crisis and a rise in homelessness; people have insufficient money to lead a healthy life and there are more ignored communities with poor conditions and little reason for hope.