Improving maternal and infant outcomes and reducing inequalities: why preconception health should have parity with maternity care

Reviews of maternity services have repeatedly exposed poor-quality care and unacceptable failures during pregnancy and childbirth. Improving maternity services and ensuring that timely, high quality, compassionate and safe care is the norm must become an urgent NHS priority. However, much more needs to be done if the UK is to improve maternal and infant outcomes and tackle the persistent inequalities that contribute to its poor international ranking on maternal and infant outcomes.

The Nuffield Trust’s analysis of 1.6 million deliveries in England shows that one in five women attended A&E or required an emergency hospital admission in the year after giving birth. Two-thirds of mothers had at least one diagnosed health condition. Emergency care use after birth was significantly higher among women with potentially preventable conditions such as obesity, diabetes, hypertension and mental health problems – conditions that often existed before pregnancy. Rates were highest among women of all ethnicities – including white – living in more deprived areas, and among women from Black, Pakistani and Bangladeshi groups.

There is overwhelming evidence that deprivation and wider social disadvantage increase the risk of poor maternal and infant outcomes. These risks are amplified when deprivation intersects with pre-existing health conditions that are risk factors in maternity. Obesity, diabetes, hypertension and mental ill health, for example, are more common among deprived communities and some ethnic minority groups, driving deep inequalities in population health overall and contributing to serious complications during pregnancy and childbirth.

The examples below illustrate some common, preventable pre-pregnancy risks to maternal health. 

Obesity

Obesity significantly increases the risk of infertility and complications for pregnant women including miscarriage, gestational diabetes, preeclampsia, heart conditions, complications in delivery and the need for a Caesarean section. For babies it increases the risk of fetal growth restriction, stillbirth, preterm birth, birth defects and long-term health problems such as childhood obesity.

Obesity is one of the most common conditions in women of childbearing age, and starts young. One-third of children aged 10–11 are overweight or obese, with rates in the most deprived areas more than double those in the least deprived. Obesity prevalence is highest among Black, Pakistani and Bangladeshi children. These children include the mothers of tomorrow.

Almost two-thirds (62%) of women are overweight or obese. Prevalence is 71% among women in the most deprived areas, and remains high at 55% even in the least deprived areas, making obesity a widespread risk to maternal and infant outcomes.

A recent study shows obesity prevalence is increasing fastest at childbearing ages, and in women, Black and most deprived groups. Prevalence is highest among women from Black groups (46% overall but rising in childbearing ages to 60% by ages 50-59) and ethnic disparities in obesity persist even after adjusting for socio-economic status. In all ethnic groups, obesity shows a clear gradient with deprivation: by ages 50-59, about half or more of women of all ethnicities in the most deprived communities are obese. The authors of the study note that increasing rates of obesity at childbearing age risk perpetuating intergenerational cycles of health inequality.

Obesity is now twice as common as smoking, affects 1 in 4 pregnancies, and has been identified by the Royal College of Physicians as a major, preventable risk to maternal health.

Diabetes

The prevalence of type 2 diabetes in England (7.9%) is rising and the age of onset is falling. Inequalities in diabetes prevalence reflect obesity patterns. Among adults under 40, prevalence in the most deprived areas (35%) is over four times higher than in the least deprived areas (8%). Compared with White groups, prevalence is more than twice as high among South Asian and Black groups, who also develop diabetes around a decade earlier; prevalence of pre-diabetes in Black and Asian ethnic groups (22%) is more than double the prevalence in White groups (10%).

These inequalities are increasingly visible in maternity services. More than half of pregnant women with early-onset type 2 diabetes are from ethnic minority groups, and the prevalence of diabetes-complicated pregnancies is rising. This is associated with adverse outcomes for both mother and baby.

Mental health

Mental ill health is another major contributor to poor maternal outcomes, and is among the leading causes of maternal deaths in the UK. The Nuffield Trust reported that women with a mental health condition were almost 80% more likely than those without to use emergency services after childbirth.

Perinatal mental health conditions affect more than 1 in 4 women, with prevalence rising from 20% in least deprived to 32% in most deprived areas. Women from ethnic minority groups often face barriers to accessing perinatal mental health services, including stigma, lack of awareness, fear of child removal and services that are not culturally responsive.

Mental health conditions contribute to 70% of pre-existing multimorbidity (having two or more long-term health conditions) in pregnant women, often present alongside a physical condition. The prevalence of common mental health conditions is highest and rising in younger women; it is 26% in the most deprived compared with 16% in the least deprived areas. The prevalence of serious mental illness is highest in people from the Black ethnic group.

Improving preconception health should have parity with improving maternity services

The causes of poor maternal outcomes and inequalities are often traceable back to childhood, adolescence and early adulthood. For example, obesity is a key driver of cardiometabolic multiple long-term conditions such as diabetes, cardiovascular disease and chronic kidney disease. These conditions often begin in early life and progress quickly once conditions cluster. Socio-economically disadvantaged and ethnic minority communities have a higher prevalence, earlier onset, faster progression, and earlier mortality.

Pregnant women in the UK are becoming older, increasingly overweight and have more complex medical problems – all risk factors for adverse outcomes. A significant proportion of women enter pregnancy with pre-existing multimorbidity, especially with mental health conditions. The prevalence of pre-existing multimorbidity in pregnant women in England is estimated at 44.2%, and of ‘active’ multimorbidity in the year before pregnancy at 24%. Too many women, especially those from deprived and some ethnic minority communities, start and go through pregnancy in sub-optimal health.

The encouraging reality is that these risks are neither inevitable nor immutable. Better preconception health, earlier engagement with antenatal care, stronger support for women with complex health needs, and action on poverty and deprivation must be part of the action to reduce avoidable poor outcomes. Prevention policies must also recognise the significant differences in socio-economic status and health patterns between women from different ethnic groups.

Improving maternal outcomes should routinely become a core aim of public health strategies for improving the health of girls and women and reducing preventable morbidity, especially among high-risk communities. For example, urgent, bold action to reduce obesity prevalence, including in children and young people, should include improved maternal health among its goals and be a core element of strategies for improving maternal outcomes. Likewise, increasing uptake of flu, whooping cough and RSV vaccination in pregnancy – particularly among women from deprived and ethnic minority communities with lower uptake – should form part of targeted strategies for improving vaccination uptake.

Current policies don’t reflect the scale of the challenge. The Women’s Health Strategy’s ambitious goal of improving healthy life expectancy in the poorest parts of England by 10.5 years looks unrealistic given that current trends are going in the wrong direction, and its consideration of preconception health in maternal outcomes and inequalities is scant. Local authority preconception health scorecards are available, but the data is old and it’s unclear how consistently they are used for planning, commissioning and performance monitoring.

One of the three ‘radical shifts’ in the government’s 10 Year Health Plan is from ‘sickness to prevention’. Yet, one year on, the health of working age adults continues to deteriorate, and progress on prevention remains slow. Improving maternal and infant outcomes demands far more than better maternity services. It requires bold, coordinated action across government to tackle the risk factors for preventable morbidity in girls and women, for example, obesity, deprivation and the wider social determinants of health that put many women and their babies at risk of avoidable poor outcomes before pregnancy even begins.