
9. Prevention and pre-conception care
Maternity and perinatal services have an important role to play in the shift to prevention. The Royal College of Midwives notes that, ‘as the most trusted healthcare professional for women during pregnancy, midwives can have a positive influence on the health of the whole family’ (Royal College of Midwives, 2024). However, trust leaders noted that this shift is made difficult due to the lack of effective prevention and pre-conception care within maternity pathways, identifying it as a significant gap in current provision. Trusts would welcome a greater focus on shifting care upstream, in line with the government’s agenda, to reduce the acuity and complexity of women presenting in secondary care maternity services.
We also heard that there is a lack of clarity for where in the system responsibility for prevention should sit, which has hampered the extent to which early intervention approaches have been embedded. There is a need to work collaboratively with primary care and wider system partners to be effective. Vulnerable groups of women (such as homeless women and migrants) are statistically overrepresented in analyses of those making emergency calls during the perinatal period. Critically, 999 and 111 emergency call referral pathways are not sufficiently linked up, meaning there is no opportunity for clinicians to follow up on whether the advice given in these calls has been acted upon. This can cause safety issues in that it can lead to delays to accessing healthcare for these groups that face additional barriers and are at higher risk.
Some trust leaders highlighted that prevention isn’t in the traditional remit of maternity services but identified that there is appetite among the workforce to do more here. For secondary care providers to implement preventative initiatives, increased funding and resource is needed, otherwise interventions are often only short-term. One trust highlighted the unique role that ambulance providers could play in providing public health messages to women of childbearing age, especially as they are interacting with patients that may not access healthcare via traditional routes. However, existing urgent care pathways do not enable this approach.
We have turned into firefighting in healthcare, rather than prevention and starting from the beginning… Taking it to the basics would be beneficial.
Head of perinatal governance, acute trust
Trying to do preventative stuff is really difficult.
Head of EDI for women’s and maternity services, acute trust
Even so, there are a number of approaches trusts have taken to prioritise prevention and pre-conception care within their services. These have ranged from patient education, to smoking cessation and community-based care. One trust has piloted an opt-out referral system for all women with a history of gestational diabetes onto a diabetes prevention programme, which has involved data sharing with primary care partners to enable referrals. Another trust is working with its local authority on obesity initiatives, recognising the links with stillbirth rates. Perinatal mental health services also offer one-off preconception appointments to discuss medication and mental health in pregnancy so that women are provided with space to ask questions and get advice, which has been very helpful to patients. However, more funding is required to extend and strengthen this service.
Some trusts have prioritised their efforts on patient education to enhance awareness and self-management throughout pregnancy. For example, one trust has introduced antenatal education, support and networking sessions for black and mixed heritage women within midwifery clinics. This targeted approach aims to improve engagement and ensure that maternity services meet the needs of diverse communities. Another trust has prioritised its efforts on making connections within education settings to raise awareness among children and young people.
A small number of trusts have sought to integrate their maternity offer within Family Hubs as an existing community-based early intervention opportunity. However, one trust encountered difficulties embedding its services in these settings, in part due to the limited resource of the Family Hub and lack of existing working relationships with the local authority, highlighting a missed opportunity to provide holistic support alongside other services. Another trust, that is embedded in its local Family Hubs, isn’t able to access primary care records or systems, and so isn’t able to provide holistic care for all women staff see at these sites.
It’s been really difficult to get maternity really embedded into Family Hubs. We’ve worked hard to get midwives there, but wouldn’t say they’re embedded. If you have a Family Hub with all services there then women can access maternity support so much earlier in their journey.
Head of midwifery, acute trust
Trust leaders also highlighted a lack of accessible pre-conception and contraception information within communities, which can act as a barrier to early health interventions when pregnancies are unplanned. Some trusts have focused on improving access to contraceptive services, ensuring that women can better plan their pregnancies with the right information and support.
Additionally, smoking cessation services have been a priority within maternity services, recognising both the risk of poorer outcomes for women who smoke during pregnancy and their babies, and the links between smoking and deprivation. Most trusts provide a smoking cessation service, and one has a dedicated public health midwife leading on cessation. A small number of trusts have implemented incentive schemes to encourage women to quit smoking before and during pregnancy. It was noted that a whole-family approach is required in relation to smoking cessation and other preventative initiatives, rather than solely focusing on the woman’s health and wellbeing.
Call to action: ICBs should bring system and local partners (primary care, secondary care, ambulance, VCSE sector and local authorities) together to agree and set out responsibilities and outcomes for all aspects of maternity services, from prevention to perinatal pathways. ICBs should commission these services based on local need, tackling inequalities, and improving outcomes across all maternity services.
Call to action: All Family Hubs and Women’s Health Hubs should embed maternity services within their local offer.