Public_Health_and_Midwifery

Introduction. Maternity services are faced with a constantly changing population and as such, the services offered to users need to be adapted regularly in order to keep up with changing demands. Since 1985, there has been a definite shift in women having their first baby’s later in life (Baxter 2009). This is a trend that today continues to grow in the UK and other developed countries such as Western Europe, the USA and Canada (Baxter 2009; Delpisheh et al. 2008; Office for National Statistics 2009; WHO 2008; Bushnik & Garner 2008; CDC 2009). As such, advancing maternal age has been identified as a growing epidemiological risk factor in which it is emerging as a growing public health concern (RCOG 2009). An increase in teenage parenthood brought about the introduction of specifically designed antenatal education to combat issues raised by parental age. I think similarly that specialised antenatal education needs to be offered to parents of an advanced age in an attempt to tackle the anxieties faced by older women and their partners throughout childbirth. I have employed the use of Ewles and Simnet’s ‘Seven Stage Plan for Improving Health’ (Ewles and Simnett 2003 see Appendix 1) in order to set out a pilot intervention to offer specialised antenatal education to parents over 35 years old. Background. The reasons for advancing maternal age are complex (RCOG 2009) but some contributing factors include pursuing successful careers, increasing numbers of women with higher education, delaying until financially stable and an increased availability of fertility treatments (Heffner 2004; RCOG 2009; Schardt 2005). Recent figures from the Office of National Statistics show that the occurrence of women having their first live baby aged forty plus has doubled over the past decade (ONS 2009). Within the Royal Borough of Kensington and Chelsea (RBKC), figures from the Department of Health of births in the area between 1999-2000 showed that 30% of births in this borough were born to women over 35 years in comparison to 20% across London and 16% in England (DOH 2001). In line with the growing UK trend it should be expected that current figures are higher still. Women are classified as high-risk from 40 years old, yet the concept of advanced maternal age has been defined as childbearing women over the age of 35 (Schardt 2005). Advanced maternal age has recently been identified as an emerging public health issue (RCOG 2009). Literature identifies increasing maternal morbidity with age (Temmerman et al. 2004) and is therefore highlighted as an emerging demographic risk factor for maternal mortality (Salanave and Bouvier-Colle 1996; DOH 2004a; Freeman-Wang and Belski 2002; Ataullaha and Freeman-Wang 2005). In addition, the Confidential Enquiry into Maternal and Child Health (CEMACE) also acknowledges the rising trend in later motherhood and states this as a significant risk factor for stillbirth, perinatal and neonatal death (CEMACE 2007). From a public health perspective one could increasingly argue that mothers 35 years and older are a disadvantaged group especially when looking at the governments measuring in health inequalities through tracking infant mortality (DOH 2004a). Women over 35 are documented in literature as being more likely to use epidural anaesthesia in spontaneous labour (Roberts & Algert 1994; Rosenthal & Patterson-Brown 1998). In addition, maternal age has also been cited as being associated with a higher incidence of maternal request for caesarean section (Herng-Ching Lin & Sudha xirasagar 2005; Lin, Sheen, Tang & Kao 2004; O’Leary, de KN, Keogh et al. 2007;Roberts, Algert, Carnegie & Peat 2002). Reasons for which have been suggested to be inclusive of fear of perineal damage, being able to schedule the birth to fit with busy schedules, refusal and reluctance to experience labour pain and social convenience (Chong & Mongelli 2003; Amu, Rajendran & Bolaji 1998; Al-Mufti, McCarthy & Fisk 1997). Many of these fears and attitudes can be addressed in antenatal education and reinforces the notion of this pilot intervention to provide a service in which older women and their partners can address these fears before the birth itself. It has been suggested that ‘high-risk labelling’ and maternal anxiety may influence the preferences of both mothers and healthcare professionals in respect of mode of delivery (Bell, Campbell, Graham et al 2001). Heightened maternal anxiety has been noted amongst older mothers in comparison to their younger counter-parts (Nicholson 1998; Windridge & Berryman 1999). It is interesting to note from some literature on increased maternal age that increased levels of intervention are not explained by obstetric complications (Carolan & Nelson 2007) and that recent evidence illustrated only a slight increase in women of an advanced maternal age compared to younger women (Joseph, Allen & Dodds et al. 2005). In light of this, increased rates of intervention may be partly attributed to medical fears spurring greater caution (Freeman-Wang & Belski 2002) and women conforming to a self-fulfilling prophecy of greater intervention leading to poorer outcomes as a direct result of their high-risk labelling (Carolan & Nelson 2007). 1. Needs and Priorities. Applying Bradshaw’s Taxonomy of Need (Bradshaw 1972) to mothers over the age of 35 a demanded need can first be identified. Studies have found that mothers of advanced maternal age are resource intensive with high demand for information (Gagnon & Sandall 2007). Additionally, many older mothers also have an early need for additional professional and social support (Carolan & Nelson 2007) more so than their younger counter parts. This early need can be provided for through the provision of antenatal classes starting earlier in pregnancy. It could be argued that a comparative need also exists in that although older mothers share many of the same concerns as younger women, they may experience additional stress believing they have placed their baby at risk as a result of their age (Kee, Jung & Lee 2000). The notion of normative need is widely debated in literature with some healthcare professionals believing that antenatal education has no evidence of effectiveness due to a lack of evaluating studies (Jaddoe 2009) therefore questioning its place in antenatal care. I would argue however, that many healthcare professionals see antenatal education as a normative need in the sense that it is easier to care for a women and her partner when they have some understanding of pregnancy and birth processes. Additionally, I would argue that there is an increasing need for antenatal education to be tailored to the specific needs of mother’s over 35 in a similar sense to what is currently provided nationally for teenage parents. Simply, the need for antenatal care exists and is demanded, yet is supplied often in an old fashioned and generalised way. Antenatal classes have remained largely unchanged over the past 40 years (Escott, Spiby, Slade and Fraser 2004) and in line with changes in the current reproductive trend, antenatal education needs to be adapted accordingly and made specific for different women’s needs. One must bear in mind that while women want to be as informed as possible it is important to ensure that information does not cause more anxiety rather than alleviate concerns (Carolan & Nelson 2007). Recent research has found that effective antenatal education has had beneficial results in terms of women needing fewer interventions at birth (Gringnaffini, Soncini, Ricco & Vadora 2000), a reduced need for anaesthesia (Hetherington 1990), greater satisfaction (Slade, MacPhearson, Hune and Maresh 1993) and lessening maternal anxiety (Brewin and Bradley 1982). 2. Aims and Objectives. 2.1 Aim. * To provide specialised antenatal classes to women of advanced maternal age (35 years plus) in order to reduce anxiety levels caused by high-risk labelling. * To improve the birth experience and healthy choices made by women regarding their care by increasing the range of knowledge and skills learnt in the antenatal period. 2.2 Objectives. * Increase knowledge of pregnancy, labour and postnatal period through regular advisory and educational classes in order to help women and partners prepare for the reality of the childbirth process enabling them to make informed healthy choices relating to their care. * Teach a wider selection of pain coping strategies to offer an alternative to epidural analgesia often preferred by this age group. * Provide regular classes and meetings in order to build support and social networks where anxieties of childbirth can be lessened through discussion and experience sharing. * To monitor and evaluate on a continuous basis, the effect of each class on the empowerment and satisfaction of women and partners and the relation of this to healthy informed birth choices. * 3. Best Way of Achieving the Aims. To date, there has been a lack of research into the learning processes used and preferred during pregnancy and early parenthood (Renkert & Nutbeam 2001). The principles of health promotion are today seen as critical in the continuing development of antenatal education (Svensson, Barclay & Cooke 2008). There is now a common view that the transfer of information alone should not be the focus of antenatal education instead preferring the provision of opportunities in which people can learn skills in order to practice desired behaviours (Nutbeam 2000). Growing in favour is the notion of self-responsibility for health. Adult learners such as mothers of advanced maternal age have valuable life experiences and prior knowledge from which further knowledge can be built. They also tend to benefit from being actively involved in their learning (Svensson, Barclay & Cooke 2008). In terms of the educators themselves, it has been suggested that they need to become facilitators in which they adopt an outcomes-based approach, shifting the emphasis from the educator to the learner (Brookfield 1996; Knowles, Holton & Swanson 1998). In a recent study, it was found that the educational structure needs to be broadened to include a combination of lectures, learning and discussion relating to skills and the opportunity to share experiences and support one another (Svensson, Barclay & Cooke 2008). Variation is vitally important in putting together a well rounded antenatal education course (Nolan 1998). In order to cater to the different learning styles that individuals will have, it is necessary to incorporate classes that comprise a balance of listening, discussing, looking and doing. In doing so, an informal learning environment will be achieved in which attendees will be more relaxed and therefore forthcoming, than they would in a formal lecture situation. An example of such would be in a pain management class where general brainstorming of methods known can start a general discussion which can form the basis from which the educator can determine the existing knowledge of the attendees. From here additional information can be given about the familiar methods but also alternatives can be introduced such as spiritualism and aromatherapy. These alternatives can then be supported with written literature which can point interested parties in the direction of finding further information on methods that are not necessarily considered mainstream. Offering a wider selection of pain coping strategies during classes may give women a greater array of options in relation to her pain relief that may delay or even provide an alternative to the use of epidural analgesia. Also appropriate in this session would be the handling of entonox equipment or the practicing of back massage. This class example demonstrates the inclusion of discussion, listening and practical experience in which incorporates a variety of learning styles in which to suit the varying needs of attendees. Audiovisuals would also be effective in increasing the knowledge of women and partners whilst providing an alternative learning style providing appropriate video content is selected. In order create a situation in which the antenatal classes act as a support and social network in addition to an educational resource, it is important to arrange an education schedule in which contact is frequent. In order to combat the anxieties held by older parents, it is important to start the antenatal education programme early in pregnancy so as to avoid a build up of anxiety. Small, informal ‘early bird’ classes should be available for women and partners up until 26 weeks gestation. During these classes, topics should be open and led by parents needs. Example topics could include pregnancy discomforts, where to have their baby and anxieties surrounding scans. These early sessions should not overload attendees with information irrelevant for their stage of pregnancy. Discussing concerns and sharing anxieties from earlier on rather than in the last few weeks of pregnancy will enable women and partners to discuss problems as they arise whilst also sharing their experiences with one another. The combination of group work, classes and discussion will improve both health awareness and knowledge. In order to improve self-esteem and decision making, scenarios can be discussed in groups in order to encourage decision making from women and partners. Scenarios could include the next step should entonox no longer be effective, what to do when faced with breast feeding troubles or what to do when contractions start. By thinking of scenarios and possible responses, confidence can be generated within the group so that when faced by a new situation in reality, they will be able to make a clear decision as potential fears or anxieties are minimised. It is important for the lessons to focus on the notion of normal childbirth and its possibility at any age whilst at the same time not ‘cherry-coating’ the reality that sometimes intervention is needed. By focusing on the normal but preparing women for all outcomes, attitudes and behaviours may change from conforming to the high-risk label whether unconsciously or voluntarily. In using the methods above to fulfil the aims and objectives of this intervention, classes should span over a number of weeks throughout the trimesters of pregnancy; the first class occurring before 26 weeks with the remainder continuing from 27 weeks onwards. It is also important to include at least one session that is entirely male and one that is entirely female so that attendees can express personal anxieties freely without the audience of their partners or the opposite sex. In view of Ewles and Simnet’s ‘Mapping of 5 Approaches to Health Promotion’ (Ewles and Simnet 1985), several approaches can be identified as being used in this intervention. In approaching the aims and objectives using the methods above, a modern educational approach will be used in that the education is two directional with parents and educator working together to ascertain needs and to teach one another. Additionally, an empowerment approach to health promotion will be employed in that the health promoter is acting as a facilitator, empowering older parents to make informed decisions relating to their pregnancy and birth experience. In relation to the health promotion definition provided by the World Health Organisation, both education and empowerment are vital components (WHO 2005). 4. Resources. 5.1 People. The client group is an important resource in that they will possess important enthusiasm, knowledge and experiences which can be a useful resource to both the educator and peers. In terms of this intervention, the specific client group is pregnant women aged 35+ and their partners. Friends, partners and women’s families may also prove to be a valuable resource in developing support systems. It is important to develop a small team in which will run the antenatal classes, of which at least one person should be a qualified and practicing midwife as it has been suggested that midwifery-led care leads to better outcomes (Hatem et al. 2008). It may also prove to be a valuable resource to have one of the lead educators trained in an alternative therapy such as aromatherapy or acupuncture. A team of two qualified professionals would be needed to start up this new service. 5.2 Existing Policies or Plans. As a pilot intervention, these specialised antenatal classes will be run alongside pre-existing antenatal classes in particular maternity teams. Existing policies such as the NICE Guideline on Antenatal care (NICE 2008) should be considered a valuable resource when implementing antenatal education strategies. 5.3 Existing Facilities and Services. In securing a maternity team to work alongside, it may be possible to share existing parent craft resources such as rooms, chairs, audiovisual equipment and dolls, although this will need to be finalised in discussions with collaborating people. 5.4 Material Resources. The number of material resources required will be dependent on the availability of existing resources. However, some degree of funding will need to be discussed and arranged. There is the potential for the following resources to also be required: * Room/Space * Chairs * Teaching / Learning Material/Handouts * Audiovisual Equipment * Pens/Paper * Dolls/Knitted breasts/nappies/entonox equipment etc. * Refreshments * Posters and Leaflets for advertising * Evaluation material Where possible it is necessary to have room space large enough to accommodate women as well as their partners in order to enable the education programme to meet the needs of both parents. The chosen location should be in a convenient, easily accessible location that is preferably available at evenings or weekends so that classes can be scheduled to fit with the busy lifestyles of the older parents-to-be. Seating should also be as comfortable as possible to enable pregnant women to be as comfortable as possible throughout the duration of the class. Practical equipment such as dolls, nappies and entonox equipment will be a valuable resource in teaching practical skills such as breastfeeding and nappy changing. Available refreshments will also aid the comfort of attendees. The inclusion of posters and leaflets will enable midwives to advertise the introduction of the specialised classes to women over 35 and could be a valuable resource in raising awareness of the programme and aid the progression from a pilot scheme to one that is well established across maternity care. 5. Plan Evaluation Methods. The evaluation component of this public health intervention will be a significant feature. Currently, few studies evaluate the effectiveness of antenatal education and so there is a space in the literature for extensive evaluation (Jaddoe 2009). Critical assessment of both the processes and outcomes of the new antenatal classes needs to be undertaken in order to identify what works and what needs to be adapted in order to improve practice. Successful evaluation will also enable the justification of resources and show whether the programme is successful in achieving its aims and objectives. It is also important as it will allow identification of any unplanned or unexpected outcomes that may result due to the new specialised education plan. As a pilot intervention, evaluation may also form the basis from which the programme can be expanded to a wider community, potentially nationally. Evaluation could also provide an important foundation to other healthcare professionals with interests in the same field. In order to evaluate the outcome of the intervention in relation to my objectives numerous elements need to be assessed. Firstly in relation to health awareness, the interest of attendees can be recorded at each class, for example how many people took up offers of additional information regarding alternative methods to cope with labour pain or how many people enquired about the use of water pools for their birth. Interest can also be measured through documenting attendance records. Changes in knowledge will be assessed through questionnaires and question and answer sessions in which the educator will observe any marked changes. It would also be beneficial to assess women postnatally in regards to their level of anxiety during labour, how they felt about making decisions and what their birth outcomes were. By doing so, it may enable a comparison to be made between the mothers of advanced maternal age attending the specialised classes and those of an increased age who attend regular classes. Questionnaires will also include open ended questions relating to how satisfied women and partners were with their childbirth experience, how supported they felt and also whether they felt the classes aided the release of any anxieties they had. In addition to evaluating the outcome, it is also vital to assess the process. Continual evaluation of the process is needed in order to adapt to the needs of women. It is important that the input is measured in terms of time, money and resources so as to be able to make an informed judgement whether the outcome was worth the cost (Ewles and Simnett 2003). It is also important to assess what the professionals involved thought worked well or what needs improving. It will be important to gain evaluative feedback from the women and their partners too so as to be able to react to their needs, to develop a programme truly tailored to the needs of women of advanced maternal age. This feedback can be gained through the use of feedback sheets and questionnaires to be completed after each class with the aim of identifying features that women and partners are satisfied with and where they would like improvement. These will assess the inclusion criteria in each lesson and also how they found the delivery of the material. Both women and partners will be offered the opportunity to partake in evaluation as it is important for the classes to be tailored to both their needs. 6. Action Plan. 7.5 Key Events Plan. i. Discuss plan with managers – January 2011 ii. Identify support from colleagues – by end of February iii. Identify initial community/hospital team to pilot the plan – end of March iv. Approach teams and agree location, times, course content and structure, availability of shared resources – by end of April v. Assemble a small team of healthcare professionals to form a planning team –April vi. Convene planning group meetings to organise who’ll do what and when, evaluation plans and identify required resources – by end of April vii. Advertise for antenatal educator role – May to June viii. Interview and appointment of educator(s), inductions and any training required – May to June ix. New plan discussed with women at booking appointment with chosen pilot team, women booked onto early bird class if they consent – July x. Begin first course of classes – end of July to beginning of August xi. Begin continuous evaluation and make necessary adaptations to course structure – from the first class xii. Summative evaluation post first course completion – March 2012 onwards. 7. Do It! Put plan into action with view to extend the plan to more women post successful evaluation as this would hopefully enable women of advanced maternal age to take some control over their care and potentially avoid the succumbing to the high-risk self fulfilling prophecy. Conclusion. In summary, I believe that women of advanced maternal age and their partners would benefit from being able to attend specialised antenatal care that is designed according to their needs. I believe by starting antenatal education early a rapport will built between the educator, the women and their partners and between peers. Literary research demonstrates that antenatal education has been found to have many benefits including reducing levels of anxiety, increasing satisfaction, reducing the need for anaesthesia and helps to result in fewer interventions. If effective, these benefits would greatly improve the health and satisfaction outcomes of women and their partners. There is a high demand for antenatal education and it is the role of healthcare professionals to provide excellent care tailored to the needs of women and their partners. By implementing the Ewles and Simnett model a clear plan has been set out which will be advantageous when coming to evaluate. 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