menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors.
Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Sep. 33 p. (Clinical guideline; no. 110). 
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Pregnancy with complex social factors including domestic abuse, substance misuse, recent migration, or young age at pregnancy

Guideline Category
Counseling
Management
Prevention
Clinical Specialty
Family Practice
Nursing
Obstetrics and Gynecology
Preventive Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Patients
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Substance Use Disorders Treatment Providers
Guideline Objective(s)
  • To identify and describe best practice for service organisation and delivery that will improve access, acceptability, and use of services
  • To identify and describe services that encourage, overcome barriers to, and facilitate the maintenance of contact throughout pregnancy
  • To describe additional consultations with and/or support and information for women with complex social factors, and their partners and families, that should be provided during pregnancy, over and above that described in the National Guideline Clearinghouse (NGC) summary of the National Institute for Health and Clinical Excellence (NICE) guideline Antenatal care: routine care for the healthy pregnant woman (2008) (Clinical guideline 62)
  • To identify when additional midwifery care or referral to other members of the maternity team (obstetricians and other specialists) would be appropriate, and what that additional care should be
Target Population

Pregnant women with complex social factors who do not access, or do not maintain regular contact with, antenatal maternity services including the following groups:

  • Pregnant women who have a substance misuse problem (including abuse of alcohol)
  • Pregnant women who are migrants to the UK, including refugees or asylum seekers, particularly women who do not speak English
  • Pregnant women who are aged under 20 years
  • Pregnant women who experience domestic abuse

Note: Women who book before 20 weeks and maintain contact with maternity services will not be covered in this guideline.

Interventions and Practices Considered

Management

  1. General interventions
    • Improving service organisation/operations
      • Tailoring services to meet the needs of the local population
      • Involving women in their antenatal care
    • Providing training for healthcare staff on multi-agency needs assessment and information sharing
    • Enhancing care delivery
      • Providing information and offering referral at the first contact
      • Reinforcing contact at the booking appointment
    • Coordinating care among agencies
      • Multi-agency needs assessment, including safeguarding issues
    • Communicating sensitively
    • Keeping the hand-held maternity notes up to date
  2. Specialised interventions for the following groups
    • Pregnant women who misuse substances (alcohol and/or drugs)
    • Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English
    • Young pregnant women aged under 20
    • Pregnant women who experience domestic abuse
Major Outcomes Considered

Pregnancy outcomes (maternal and neonatal)

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Forming Clinical Questions and Search Strategies

Five clinical questions were developed based on the scope of the guideline. The questions focussed on access to care, barriers to care, maintaining contact with care, additional consultations, support and information needed over and above that set out in the NICE clinical guideline 62, 'Antenatal care: routine care for the healthy pregnant woman' (2008). These questions were asked for each of the guideline populations:

  • Women who misuse substances
  • Women who are recent migrants, refugees, asylum seekers, or who speak little or no English
  • Young women aged under 20
  • Women who experience domestic abuse

Four search strategies were developed to capture studies examining antenatal service provision for each of the guideline's target populations. For each population, searches were run in Medline (1950 onwards), Embase (1980 onwards), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 onwards) and three Cochrane databases (Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects) as well as PsycInfo. In addition, for three out of the four populations the Applied Social Sciences Index and Abstracts (ASSIA), Sociological Abstracts and Social Services Abstracts databases were searched. These databases were not searched for the population of women experiencing domestic abuse (or for the re-run searches) as the subscription to the databases was discontinued prior to this being carried out. However, the decision to stop the subscription was taken only after the contribution made by the social science databases had been investigated. It was found that the three social science databases contributed less than 5% of the total number of hits obtained across all three populations searched (young women aged under 20, 1.7%; recent migrants, 5.9%; substance misusers, 4.9%).

Searches to identify economic studies were undertaken using the above databases and the National Health Service (NHS) Economic Evaluation Database (NHS EED). None of the searches was limited by study type, date or language of publication (although publications in languages other than English were not reviewed). There was no attempt to search grey literature (conferences, abstracts, theses and unpublished trials) and hand-searching of journals not indexed on the databases was not undertaken.

Towards the end of the guideline development process, the searches were updated and reexecuted to include evidence published and indexed in the databases by 2 September 2009.

Full details of the systematic searches, including the sources searched and the search strategies for each review question, are presented in Appendix G of the full version of the original guideline document.

Criteria for Deciding Inclusion/Exclusion of Studies

Studies from all countries and all dates were considered for inclusion. Studies were considered for inclusion if they involved the specific target population as defined in the PICO (population, intervention, comparison, outcome) tables; see Appendix H in the full version of the original guideline document.

Many papers were considered for inclusion in more than one question due to the large degree of overlap between question content. This means that an individual paper may have been excluded from one question but included in another depending on reported outcomes. Decisions about inclusion/exclusion of studies were further supported by input from an experienced methodologist based at NICE.

All excluded studies were checked and queries raised where it was not clear whether inclusion/exclusion criteria had been applied correctly. Suggested changes were discussed and agreement reached on where changes needed to be made, and studies added to the reviews as appropriate. The total numbers of 'hits' for each population, the number of hard copies assessed for inclusion and final numbers of papers included and excluded are summarised in tables presented in Appendix H of the full version of the original guideline document. Details of excluded studies are presented in Appendix F of the full version of the original guideline document.

Refer to section 2.7 of the full version of the original guideline document for additional information regarding the inclusion/exclusion criteria.

Number of Source Documents

167 papers were included.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Intervention Studies

1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies; high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal

3 Non-analytical studies (for example, case reports, case series)

4 Expert opinion, formal consensus

Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Reviewing and Grading the Evidence

Evidence relating to effectiveness was reviewed and graded using the hierarchical system presented in the "Rating Scheme for the Strength of the Evidence" field. This system reflects the susceptibility to bias inherent in particular study designs.

The type of clinical question dictates the highest level of evidence that may be sought. In assessing the quality of the evidence, each study receives a quality rating coded as '++', '+' or '–'. For issues of intervention effectiveness, the highest possible evidence level (EL) is a well-conducted systematic review or meta-analysis of randomised controlled trials (RCTs) with a very low risk of bias (EL = 1++) or an individual RCT with low risk of bias (EL = 1+). Studies of poor quality (high risk of bias) are rated as '–'. Usually, studies rated as '–' should not be used as a basis for making a recommendation, but they can be used to inform recommendations.

For each clinical question, the highest available level of evidence was sought. However, due to the nature of the interventions under investigation it was anticipated that most of the evidence would be from retrospective observational studies. Where a number of low quality comparative studies were considered, those with small sample sizes (five or less in each group for comparative studies and one or two cases for case reports/series) were excluded along with those with two or more serious flaws (other than small sample size) which would contribute to significant bias.

Summary results and data from each study are presented in the text of the full guideline document. More detailed results and data are presented in the evidence tables provided in Appendix E of the full version of the original guideline document. Where possible, dichotomous outcomes are presented as relative risks (RRs) with 95% confidence intervals (CIs), and continuous outcomes are presented as mean differences with 95% CIs or standard deviations (SDs). It should be noted, however, that the findings reported in the included evidence rarely allow this level of analysis.

The body of evidence identified for each clinical question was synthesised narratively in clinical evidence statements.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health (NCC-WCH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Who Has Developed the Guidance?

The guidance was developed by a multi-professional and lay working group (the Guideline Development Group or [GDG] convened by NCC-WCH). Membership included:

  • Three obstetricians
  • A commissioner
  • A social worker
  • One specialist in perinatal mental health
  • One specialist in parental mental health
  • Two midwives
  • A substance misuse lead
  • Three service users

Staff from the NCC-WCH provided methodological support for the guidance development process, undertook systematic searches, retrieved and appraised the evidence and wrote successive drafts of the guidance.

Formal Consensus within the Guideline

Formal consensus was used for three purposes within the guideline: for deciding the most important barriers to antenatal care (question 1b); for choosing key priorities for implementation; and for choosing key research recommendations.

Anonymous formal consensus voting was conducted among GDG members to identify the most important barriers to care. This was carried out during GDG meetings following presentation of the evidence relating to the barriers question. A form containing all barriers identified from the evidence was distributed to each GDG member, and they were then each asked to place a tick by the five barriers they saw as being most important. When this had been done, all forms were given to a member of the technical team and the number of votes for each barrier was totaled. The number of barriers identified as priorities was four or five, depending upon how the votes were cast. The results from the voting were fed back to the GDG at the same meeting and the barriers with the most votes were then used to form the basis of the recommendations relating to overcoming barriers to care. Key priorities for implementation were voted for using formal consensus anonymous voting in a similar way. GDG members were asked at a meeting to vote for their top 10 priority recommendations using pencil and paper voting forms. Forms were examined by a technical team member and votes summed. After the first round of voting, eight top priorities were identified. A second round of anonymous voting was then undertaken with all remaining recommendations that had received at least one vote on the first round of voting. The two recommendations with the most votes on the second round of voting were added to the previous eight to give the top 10 key priorities for implementation. Following stakeholder consultation, four of these recommendations were divided into two to aid clarity. Each of the new recommendations made this way were retained as key priorities for implementation, making a total of 14 key priorities in the final guideline.

Key research recommendations were chosen using anonymous voting conducted via e-mail. Again, two rounds of voting were undertaken in a way similar to that described for key recommendations in order to identify five key research recommendations.

Evidence to Recommendations

For each guideline question, recommendations for service provision and care were derived using, and linked explicitly to, the evidence that supported them. In the first instance, informal consensus methods were used by the GDG to agree service delivery and clinical effectiveness evidence statements. Evidence summaries derived from qualitative studies describing reported barriers to accessing care were presented in tabular form. Statements summarising the GDG's interpretation of the evidence and any extrapolation from the evidence used to form recommendations were also prepared to ensure transparency in the decision-making process.

In areas where no substantial good quality evidence was identified, the GDG made consensus statements and used their collective experience and expertise to identify good practice. Health economic modelling was used to support recommendations and this is also explained in the GDG interpretations of evidence. The GDG also identified areas where evidence to answer the guideline questions was lacking and used this information to formulate and prioritise recommendations for future research.

Formal consensus voting was carried out among GDG members to identify the five barriers they considered most important for UK National Health Service (NHS) services to address in order to promote access to care. This was carried out independently for each population subgroup and the key barriers identified used to inform the recommendations for that population.

Towards the end of the guideline development process, formal consensus methods were used to consider all the guideline recommendations and research recommendations that had been drafted previously. The GDG identified 10 "key priorities for implementation" (key recommendations) and five high-priority research recommendations. The key priorities for implementation were those recommendations likely to have the biggest impact on provision of antenatal care and pregnancy outcomes for at-risk population subgroups in the NHS; they were selected through two rounds of formal voting using pencil and paper during a GDG meeting. The priority research recommendations were selected using two rounds of formal voting carried out electronically via e-mail.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Health Economics

The purpose of including economic evidence in a clinical guideline is to allow recommendations to be made based on the cost-effectiveness of different forms of care as well as the clinical effectiveness. The aim is to produce guidance that uses scarce health service resources efficiently; that is, providing the best possible care within resource constraints.

The aim of the health economic input to the guideline was to inform the Guideline Development Group (GDG) of potential economic issues relating to providing additional specialist services and consultations to improve access and uptake of antenatal care for vulnerable women, and to ensure that recommendations represented a cost-effective use of healthcare resources.

Systematic searches for published economic evidence were undertaken for all the populations included in the guideline, but no relevant economic evaluations were identified. One area was identified by the GDG as having significant resources implications and uncertainty surrounding the effectiveness. Therefore, for this guideline an economic evaluation was conducted to support the following area:

  • Additional specialist services for young women aged under 20 and substance misusers to encourage early booking and continued contact with antenatal care.

A simple economic model was developed in order to present the GDG with the potential consequences of providing various specialist services with differing costs. The service descriptions were based on programs currently running across the UK. No audit data were available and no good quality analysis work had been carried out to evaluate the efficacy of providing additional services to these vulnerable groups. As there was no good quality evidence on effectiveness of specialist services, the economic model was used to illustrate what level of effectiveness would be required from different services in order for those services to be considered cost-effective using the National Institute for Health and Clinical Excellence (NICE) willingness-to-pay threshold. The economic model in its current form does not result in an incremental cost-effectiveness ratio.

The relevance of the evidence provided by this analysis depends on the assumptions included in the model and how they apply to real-world settings. As the analyses are not based on good quality clinical evidence they can only be used to illustrate the problem as it is not known how effective specialist services will be in improving health outcomes. Where new specialist services are set up, auditing and evaluation will provide useful inputs to update this analysis in the future.

Refer to section 8 of the full version of the original guideline document for details of the economic analysis.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (The full guideline, National Institute for Health and Clinical Excellence [NICE] guideline, and Quick Reference Guide) were consulted with stakeholders and comments were considered by the Guideline Development Group (GDG).
  2. The final consultation draft of the full guideline, the NICE guideline, and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

In this guideline the following definitions are used.

  • Domestic abuse: an incident of threatening behavior, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality. It can also include forced marriage, female genital mutilation and 'honor violence'.
  • Recent migrants: women who moved to the UK within the previous 12 months.
  • Substance misuse (alcohol and/or drugs): regular use of recreational drugs, misuse of over-the-counter medications, misuse of prescription medications, misuse of alcohol or misuse of volatile substances (such as solvents or inhalants) to an extent whereby physical dependence or harm is a risk to the woman and/or her unborn baby.

General Recommendations

The recommendations in this section apply to all pregnant women covered in this guideline.

Service Organisation

In order to inform mapping of their local population to guide service provision, commissioners should ensure that the following are recorded:

  • The number of women presenting for antenatal care with any complex social factor (Examples of complex social factors in pregnancy include: poverty; homelessness; substance misuse; recent arrival as a migrant; asylum seeker or refugee status; difficulty speaking or understanding English; age under 20; domestic abuse. Complex social factors may vary, both in type and prevalence, across different local populations.)
  • The number of women within each complex social factor grouping identified locally.

Commissioners should ensure that the following are recorded separately for each complex social factor grouping:

  • The number of women who:
    • Attend for booking by 10, 12+6 and 20 weeks.
    • Attend for the recommended number of antenatal appointments, in line with national guidance. See the NGC summary of the NICE guideline Antenatal care. Routine care for the healthy pregnant woman (NICE clinical guideline 62).
    • Experience, or have babies who experience, mortality or significant morbidity. (Significant morbidity is morbidity that has a lasting impact on either the woman or the child.)
  • The number of appointments each woman attends.
  • The number of scheduled appointments each woman does not attend.

Commissioners should ensure that women with complex social factors presenting for antenatal care are asked about their satisfaction with the services provided; and the women's responses are:

  • Recorded and monitored
  • Used to guide service development

Commissioners should involve women and their families in determining local needs and how these might be met.

Those responsible for the organisation of local maternity services should enable women to take a copy of their hand-held maternity notes when moving from one area or hospital to another.

Training for Healthcare Staff

Healthcare professionals should be given training on multi-agency needs assessment (for example, using the Common Assessment Framework. See www.cwdcouncil.org.uk External Web Site Policy) and national guidelines on information sharing.*

*Department for Children, Schools and Families, and Communities and Local Government 2008. Information sharing: guidance for practitioners and managers. London: Department for Children, Schools and Families, and Communities and Local Government. Available from www.education.gov.uk External Web Site Policy.

Care Provision

Consider initiating a multi-agency needs assessment, including safeguarding issues, so that the woman has a coordinated care plan. (for example, using the Common Assessment Framework. See www.cwdcouncil.org.uk External Web Site Policy)

Respect the woman's right to confidentiality and sensitively discusses her fears in a non-judgemental manner.

Tell the woman why and when information about her pregnancy may need to be shared with other agencies.

Ensure that the hand-held maternity notes contain a full record of care received and the results of all antenatal tests.

Information and Support for Women

For women who do not have a booking appointment at the first contact with any healthcare professional:

  • Discuss the need for antenatal care
  • Offer the woman a booking appointment in the first trimester, ideally before 10 weeks if she wishes to continue the pregnancy, or offer referral to sexual health services if she is considering termination of the pregnancy.

At the first contact and at the booking appointment, ask the woman to tell her healthcare professional if her address changes, and ensure that she has a telephone number for this purpose.

At the booking appointment, give the woman a telephone number to enable her to contact a healthcare professional outside of normal working hours, for example the telephone number of the hospital triage contact, the labor ward or the birth centre.

In order to facilitate discussion of sensitive issues, provide each woman with a one-to-one consultation, without her partner, a family member or a legal guardian present, on at least one occasion.

Pregnant Women Who Misuse Substances (Alcohol and/or Drugs)

Pregnant women who misuse substances may be anxious about the attitudes of healthcare staff and the potential role of social services. They may also be overwhelmed by the involvement of multiple agencies. These women need supportive and coordinated care during pregnancy.

Work with social care professionals to overcome barriers to care for women who misuse substances. Particular attention should be paid to:

  • Integrating care from different services
  • Ensuring that the attitudes of staff do not prevent women from using services
  • Addressing women's fears about the involvement of children's services and potential removal of their child, by providing information tailored to their needs
  • Addressing women's feelings of guilt about their misuse of substances and the potential effects on their baby

Service Organisation

Healthcare commissioners and those responsible for providing local antenatal services should work with local agencies, including social care and third-sector agencies that provide substance misuse services, to coordinate antenatal care by, for example:

  • Jointly developing care plans across agencies
  • Including information about opiate replacement therapy in care plans
  • Co-locating services
  • Offering women information about the services provided by other agencies

Consider ways of ensuring that, for each woman who misuses substances:

  • Progress is tracked through the relevant agencies involved in her care
  • Notes from the different agencies involved in her care are combined into a single document
  • There is a coordinated care plan

Offer the woman a named midwife or doctor who has specialized knowledge of, and experience in, the care of women who misuse substances, and provide a direct-line telephone number for the named midwife or doctor.

Training for Healthcare Staff

Healthcare professionals should be given training on the social and psychological needs of women who misuse substances.

Healthcare staff and non-clinical staff such as receptionists should be given training on how to communicate sensitively with women who misuse substances.

Information and Support for Women

The first time a woman who misuses substances discloses that she is pregnant, offer her referral to an appropriate substance misuse program.

Use a variety of methods, for example text messages, to remind women of upcoming and missed appointments.

The named midwife or doctor should tell the woman about relevant additional services (such as drug and alcohol misuse support services) and encourage her to use them according to her individual needs.

Offer the woman information about the potential effects of substance misuse on her unborn baby, and what to expect when the baby is born, for example what medical care the baby may need, where he or she will be cared for and any potential involvement of social services.

Offer information about help with transportation to appointments if needed to support the woman's attendance.

Pregnant Women Who Are Recent Migrants, Asylum Seekers or Refugees, or Who Have Difficulty Reading or Speaking English

Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English, may not make full use of antenatal care services. This may be because of unfamiliarity with the health service or because they find it hard to communicate with healthcare staff.

Healthcare professionals should help support these women's uptake of antenatal care services by:

  • Using a variety of means to communicate with women
  • Telling women about antenatal care services and how to use them
  • Undertaking training in the specific needs of women in these groups

Service Organisation

Commissioners should monitor emergent local needs and plan and adjust services accordingly.

Healthcare professionals should ensure they have accurate information about a woman's current address and contact details during her pregnancy by working with local agencies that provide housing and other services for recent migrants, asylum seekers and refugees, such as asylum centres.

To allow sufficient time for interpretation, commissioners and those responsible for the organisation of local antenatal services should offer flexibility in the number and length of antenatal appointments when interpreting services are used, over and above the appointments outlined in national guidance (see the NGC summary of the NICE guideline Antenatal care. Routine care for the healthy pregnant woman [NICE clinical guideline 62]).

Those responsible for the organisation of local antenatal services should provide information about pregnancy and antenatal services, including how to find and use antenatal services, in a variety of:

  • Formats, such as posters, notices, leaflets, photographs, drawings/diagrams, online video clips, audio clips and DVDs
  • Settings, including pharmacies, community centres, faith groups and centres, General Practice (GP) surgeries, family planning clinics, children's centres, reception centres and hostels
  • Languages

Training for Healthcare Staff

Healthcare professionals should be given training on:

  • The specific health needs of women who are recent migrants, asylum seekers or refugees, such as needs arising from female genital mutilation or human immunodeficiency virus (HIV)
  • The specific social, religious and psychological needs of women in these groups
  • The most recent government policies on access and entitlement to care for recent migrants, asylum seekers and refugees (see www.dh.gov.uk External Web Site Policy and www.maternityaction.org.uk External Web Site Policy).

Information and Support for Women

Offer the woman information on access and entitlement to healthcare.

At the booking appointment discuss with the woman the importance of keeping her hand-held maternity record with her at all times.

Avoid making assumptions based on a woman's culture, ethnic origin or religious beliefs.

Communication with Women Who Have Difficulty Reading or Speaking English

Provide the woman with an interpreter (who may be a link worker or advocate and should not be a member of the woman's family, her legal guardian or her partner) who can communicate with her in her preferred language.

When giving spoken information, ask the woman about her understanding of what she has been told to ensure she has understood it correctly.

Young Pregnant Women Aged under 20

Young pregnant women aged under 20 may feel uncomfortable using antenatal care services in which the majority of service users are in older age groups. They may be reluctant to recognise their pregnancy or inhibited by embarrassment and fear of parental reaction. They may also have practical problems such as difficulty getting to and from antenatal appointments.

Healthcare professionals should encourage young women aged under 20 to use antenatal care services by:

  • Offering age-appropriate services
  • Being aware that the young woman may be dealing with other social problems
  • Offering information about help with transportation to and from appointments
  • Offering antenatal care for young women in the community
  • Providing opportunities for the partner/father of the baby to be involved in the young woman’s antenatal care, with her agreement

Service Organisation

Commissioners should work in partnership with local education authorities and third-sector agencies to improve access to, and continuing contact with, antenatal care services for young women aged under 20.

Commissioners should consider commissioning a specialist antenatal service for young women aged under 20, using a flexible model of care tailored to the needs of the local population. Components may include:

  • Antenatal care and education in peer groups in a variety of settings, such as GP surgeries, children's centres and schools
  • Antenatal education in peer groups offered at the same time as antenatal appointments and at the same location, such as a 'one-stop shop' (where a range of services can be accessed at the same time).

Offer the young woman aged under 20 a named midwife, who should take responsibility for and provide the majority of her antenatal care, and provide a direct-line telephone number for the named midwife.

Training for Healthcare Staff

Healthcare professionals should be given training to ensure they are knowledgeable about safeguarding responsibilities for both the young woman and her unborn baby, and the most recent government guidance on consent for examination or treatment (Available from www.dh.gov.uk External Web Site Policy)

Information and Support for Women

Offer young women aged under 20 information that is suitable for their age – including information about care services, antenatal peer group education or drop-in sessions, housing benefit and other benefits – in a variety of formats.

Pregnant Women Who Experience Domestic Abuse

A woman who is experiencing domestic abuse may have particular difficulties using antenatal care services: for example, the perpetrator of the abuse may try to prevent her from attending appointments. The woman may be afraid that disclosure of the abuse to a healthcare professional will worsen her situation, or anxious about the reaction of the healthcare professional.

Women who experience domestic abuse should be supported in their use of antenatal care services by:

  • Training healthcare professionals in the identification and care of women who experience domestic abuse
  • Making available information and support tailored to women who experience or are suspected to be experiencing domestic abuse
  • Providing a more flexible series of appointments if needed
  • Addressing women's fears about the involvement of children's services by providing information tailored to their needs

Service Organisation

Commissioners and those responsible for the organisation of local antenatal services should ensure that local voluntary and statutory organisations that provide domestic abuse support services recognise the need to provide coordinated care and support for service users during pregnancy.

Commissioners and those responsible for the organisation of local antenatal services should ensure that a local protocol is written, which:

  • Is developed jointly with social care providers, the police and third-sector agencies by a healthcare professional with expertise in the care of women experiencing domestic abuse
  • Includes:
    • Clear referral pathways that set out the information and care that should be offered to women
    • The latest government guidance on responding to domestic abuse (See Responding to domestic abuse: A handbook for healthcare professionals [Department of Health, 2005]; available from www.dh.gov.uk External Web Site Policy)
    • Sources of support for women, including addresses and telephone numbers, such as social services, the police, support groups and women's refuges
    • Safety information for women
    • Plans for follow-up care, such as additional appointments or referral to a domestic abuse support worker
    • Obtaining a telephone number that is agreed with the woman and on which it is safe to contact her
    • Contact details of other people who should be told that the woman is experiencing domestic abuse, including her GP

Commissioners and those responsible for the organisation of local antenatal services should provide for flexibility in the length and frequency of antenatal appointments, over and above those outlined in national guidance to allow more time for women to discuss the domestic abuse they are experiencing (see the NGC summary of the NICE guideline Antenatal care. Routine care for the healthy pregnant woman [NICE clinical guideline 62]).

Offer the woman a named midwife, who should take responsibility for and provide the majority of her antenatal care to allow more time for women to discuss the domestic abuse they are experiencing.

Training for Healthcare Staff

Commissioners of healthcare services and social care services should consider commissioning joint training for health and social care professionals to facilitate greater understanding between the two agencies of each other's roles, and enable healthcare professionals to inform and reassure women who are apprehensive about the involvement of social services.

Healthcare professionals need to be alert to features suggesting domestic abuse and offer women the opportunity to disclose it in an environment in which the woman feels secure. Healthcare professionals should be given training on the care of women known or suspected to be experiencing domestic abuse that includes:

  • Local protocols
  • Local resources for both the woman and the healthcare professional
  • Features suggesting domestic abuse
  • How to discuss domestic abuse with women experiencing it
  • How to respond to disclosure of domestic abuse

Information and Support for Women

Tell the woman that the information she discloses will be kept in a confidential record and will not be included in her hand-held record.

Offer the woman information about other agencies, including third-sector agencies, which provide support for women who experience domestic abuse.

Give the woman a credit card-sized information card that includes local and national helpline numbers.

Consider offering the woman referral to a domestic abuse support worker.

Clinical Algorithm(s)

An algorithm for the reasons why some pregnant women with complex social factors are discouraged from using antenatal care services is available in Appendix C of the original guideline document.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management of pregnant women with complex social factors

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Implementation of the Guideline

Description of Implementation Strategy

The Healthcare Commission assesses the performance of National health Service (NHS) organisations in meeting core and developmental standards set by the Department of Health in 'Standards for better health' (available from www.dh.gov.uk External Web Site Policy). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance. These are available on the NICE Web site (http://guidance.nice.org.uk/CG110 External Web Site Policy; see also the "Availability of Companion Documents" field).

Key Priorities for Implementation

General Recommendations

The recommendations in this section apply to all pregnant women covered in this guideline.

Service Organisation

  • In order to inform mapping of their local population to guide service provision, commissioners should ensure that the following are recorded:
    • The number of women presenting for antenatal care with any complex social factor. (Examples of complex social factors in pregnancy include: poverty; homelessness; substance misuse; recent arrival as a migrant; asylum seeker or refugee status; difficulty speaking or understanding English; age under 20; domestic abuse. Complex social factors may vary, in both type and prevalence, across different local populations.)
    • The number of women within each complex social factor grouping identified locally.
  • Commissioners should ensure that the following are recorded separately for each complex social factor grouping:
    • The number of women who:
      • Attend for booking by 10, 12+6 and 20 weeks.
      • Attend for the recommended number of antenatal appointments, in line with national guidance. See the NGC summary of the NICE guideline Antenatal care. Routine care for the healthy pregnant woman (NICE clinical guideline 62).
      • Experience, or have babies who experience, mortality or significant morbidity. (Significant morbidity is morbidity that has a lasting impact on either the woman or the child.)
    • The number of appointments each woman attends.
    • The number of scheduled appointments each woman does not attend.
  • Commissioners should ensure that women with complex social factors presenting for antenatal care are asked about their satisfaction with the services provided; and the women's responses are:
    • Recorded and monitored
    • Used to guide service development

Care Provision

  • Consider initiating a multi-agency needs assessment, including safeguarding issues, so that the woman has a coordinated care plan. (For example, using the Common Assessment Framework. See www.cwdcouncil.org.uk External Web Site Policy)
  • Respect the woman's right to confidentiality and sensitively discusses her fears in a non-judgemental manner.
  • Tell the woman why and when information about her pregnancy may need to be shared with other agencies.

Information and Support for Women

  • For women who do not have a booking appointment at the first contact with any healthcare professional:
    • Discuss the need for antenatal care
    • Offer the woman a booking appointment in the first trimester, ideally before 10 weeks if she wishes to continue the pregnancy, or offer referral to sexual health services if she is considering termination of the pregnancy
  • In order to facilitate discussion of sensitive issues, provide each woman with a one-to-one consultation, without her partner, a family member or a legal guardian present, on at least one occasion.

Pregnant Women Who Misuse Substances (Alcohol and/or Drugs)

Service Organisation

Healthcare commissioners and those responsible for the organisation of local antenatal services should work with local agencies, including social care and third-sector agencies that provide substance misuse services, to coordinate antenatal care by, for example:

  • Jointly developing care plans across agencies
  • Including information about opiate replacement therapy in care plans
  • Co-locating services
  • Offering women information about the services provided by other agencies

Training for Healthcare Staff

  • Healthcare professionals should be given training on the social and psychological needs of women who misuse substances.
  • Healthcare staff and non-clinical staff such as receptionists should be given training on how to communicate sensitively with women who misuse substances.

Pregnant Women Who Are Recent Migrants, Asylum Seekers or Refugees, or Who Have Difficulty Reading or Speaking English

Service Organisation

Those responsible for the organisation of local antenatal services should provide information about pregnancy and antenatal services, including how to find and use antenatal services, in a variety of:

  • Formats, such as posters, notices, leaflets, photographs, drawings/diagrams, online video clips, audio clips and DVDs
  • Settings, including pharmacies, community centres, faith groups and centres, general practitioner (GP) surgeries, family planning clinics, children's centres, reception centres and hostels
  • Languages

Young Pregnant Women Aged under 20

Service Organisation

Commissioners should consider commissioning a specialist antenatal service for young women aged under 20, using a flexible model of care tailored to the needs of the local population. Components may include:

  • Antenatal care and education in peer groups in a variety of settings, such as GP surgeries, children's centres and schools
  • Antenatal education in peer groups offered at the same time as antenatal appointments and at the same location, such as a 'one-stop shop' (where a range of services can be accessed at the same time).

Pregnant Women Who Experience Domestic Abuse

Service Organisation

Commissioners and those responsible for the organisation of local antenatal services should ensure that a local protocol is written, which:

  • Is developed jointly with social care providers, the police and third-sector agencies by a healthcare professional with expertise in the care of women experiencing domestic abuse.
  • Includes:
    • Clear referral pathways that set out the information and care that should be offered to women
    • The latest government guidance on responding to domestic abuse (See Responding to domestic abuse. A handbook for healthcare professionals [Department of Health, 2005]; Available from www.dh.gov.uk External Web Site Policy)
    • Sources of support for women, including addresses and telephone numbers, such as social services, the police, support groups and women's refuges
    • Safety information for women
    • Plans for follow-up care, such as additional appointments or referral to a domestic abuse support worker
    • Obtaining a telephone number that is agreed with the woman and on which it is safe to contact her
    • Contact details of other people who should be told that the woman is experiencing domestic abuse, including her GP
Implementation Tools
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Sep. 33 p. (Clinical guideline; no. 110). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Sep
Guideline Developer(s)
National Collaborating Centre for Women's and Children's Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members: Rhona Hughes (Chair), Lead Obstetrician, Royal Infirmary, Edinburgh; Helen Adams, Strategic Lead Parental Mental Health, Changing Minds, NHS Northamptonshire; Jan Cubison, Clinical Service Manager, Sheffield Perinatal Mental Health Service NHS Foundation Trust; Sarah Fishburn, Service user member; Poonam Jain, Service user member; Helen Kelly, Maternity and Children's Commissioning Manager, Solihull Care Trust; Faye Macrory, Consultant Midwife, Manchester Specialist Midwifery Service; Dilys Noble, General Practitioner; Jan Palmer, Clinical Substance Misuse Lead, Offender Health; Eva Perales, Service user member; Daghni Rajasingam, Consultant Obstetrician, St Thomas' Hospital, London; Yana Richens, Consultant Midwife, University College London Hospital; Mary Sainsbury, Practice Development Manager, Social Care Institute for Excellence, London; Melissa Kate Whitworth, Consultant Obstetrician, Liverpool Women's NHS Foundation Trust; Annette Williamson, Programme Lead for Infant Mortality, Birmingham

Expert Adviser: Donna Kinnair, Director of Nursing/Commissioning, NHS Southwark, London

Financial Disclosures/Conflicts of Interest

All Guideline Development Group (GDG) members' interests were recorded on declaration forms provided by the National Institute for Health and Clinical Excellence (NICE). The form covered consultancies, fee-paid work, shareholdings, fellowships and support from the healthcare industry. No material conflicts of interest were identified. The GDG members' declarations of interests are listed in Appendix B of the full version of the original guideline document (see "Availability of Companion Documents").

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors. Quick reference guide. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 20 p. (Clinical guideline; no. CG110). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Pregnancy and complex social factors. A model for service provision for pregnant women with complex social factors. Full guideline. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 321 p. (Clinical guideline; no. CG110). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Pregnancy and complex social factors. Costing statement. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 11 p. (Clinical guideline; no. CG110). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Pregnancy and complex social factors. Data collection tool and spreadsheet. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Pregnancy and complex social factors. Slide set. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 18 p. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Pregnancy and complex social factors. Baseline assessment tool. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Descriptions of services for pregnant women with complex social factors. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 39 p. (Clinical guideline; no. CG110). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Pregnancy and complex social factors. Guide to resources. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 19 p. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Raising sensitive issues. A training package for maternity settings. London (UK): National Institute for Health and Clinical Excellence; 2011. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Complications in pregnancy in primary care. Online education tool. London (UK): National Institute for Health and Clinical Excellence; 2011. (Clinical guideline; no. CG110). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • The guidelines manual 2009. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009. Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

  • Helping pregnant women make the best use of antenatal care services. Understanding NICE guidance. Information for people who use NHS services. London (UK): National Institute for Health and Clinical Excellence; 2010 Sep. 8 p. (Clinical guideline; no. CG110). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy. Also available in Welsh from the NICE Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on May 12, 2011.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...