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Early access to antenatal care


What happens during the early years, starting in the womb, has lifelong effects on a range of health and wellbeing outcomes including obesity, heart disease, mental health, educational attainment and economic status (Marmot, 2010).


A healthy pregnancy and the first three years of life are vital to a child’s development, life chances and achievement.  Healthy mothers tend to have healthy babies and a mother who receives high quality maternity care throughout pregnancy is well placed to provide the best possible start for her baby.  Therefore the care and support provided for mothers and babies during pregnancy, childbirth and the postnatal period has a significant effect on children’s healthy development and their resilience to problems encountered later in life (DH, 2004).


NICE guidance on antenatal care (2008) recommends that women should have access to maternity services for a full health and social care assessment of needs, risks and choices ideally by 10 weeks of pregnancy.  This ensures women are given up to date advice and are able to participate in antenatal screening programmes and an appropriate care plan can be developed.  Late booking and poor attendance for antenatal care are associated with poor outcomes.


The Healthy Child Programme (DH, 2009) was developed to set out a universal preventive service to support a healthy pregnancy and the foundations for future health and wellbeing.  The assessment in early pregnancy is the starting point for the Healthy Child Programme.


Bedford Hospital data for 2014-15 shows that Bedford Hospital sees at least 90% of women before 12 completed weeks of pregnancy and a further 8% between 13-18 weeks. There is a Late Booking Pathway in place to investigate underlying factors for late presentation.


What do we know?

 Since 2013-14, data for the 12 week maternal risk assessment is collected by NHS England directly from providers. Bedford Hospital NHS Trust provides maternity care for the majority of women living in Bedford Borough (approximately 90%) with the remaining women delivering at an alternative hospital.  Therefore Bedford Hospital data can be used as a proxy measure for the Bedford Borough population.  Graph 1 below shows the number of women accessing a midwife/health professional in Bedford Borough before 12 weeks and 6 days of pregnancy.  The local target is 90% and Bedford Hospital remains above target (following a slight dip in the first quarter of 2014-15). 

Early access

Source:   Statistical Release. Maternal 12 week risk assessment Quarter 1 2014/15.  Analytical Services, NHS England.

In each quarter the data shows that between 600-700 women are having a timely assessment.  The number of women seen after this time in Quarters 1-3 in 2014-15 was 42, 71 and 62 respectively.  

Further data from Bedford Hospital shows that most of these women are seen between 13-18 weeks. The delay can be for a number of reasons including holidays, uncertainty over dates and delays in information getting from GP to community midwife.  Additionally some women who book later have transferred from another area and have received their early antenatal care from another hospital.  Their data showed that only a very small number of women were identified as presenting later than 20 weeks.  Whilst these women would not have received early lifestyle advice, they would have all the routine blood tests, scans and screening tests (apart from the nuchal scan).


Current activity and services

The first antenatal appointment offered before 12 completed weeks of pregnancy is a full assessment of health and social care needs, risks and choices.  It is the starting point of the Healthy Child Programme which was introduced in Bedfordshire in 2009.  As part of the universal schedule it is offered to all families and identifies the need for further Universal Plus and/or Universal Plus support that may be required by families with additional needs and risks. 


In Bedford, women can access the midwife directly, in preference to a GP, as the first healthcare contact upon learning of a pregnancy.  Direct referral to the community midwife by GP practices ensures delays are avoided.  All women living in Bedford Borough are then offered a Booking Appointment through the Bedford Hospital Trust Midwifery Service, either at Bedford Hospital or a local venue such as a GP Practice or a Children’s Centre.  Early access to maternity services ensures women are given up to date diet and lifestyle advice, can participate in antenatal screening programmes and have their pregnancies accurately dated by ultrasound scan.  Health professionals develop an appropriate care plan that takes into account medical and social history and information and support is offered including maternity benefits (e.g. Health in Pregnancy Grant and Healthy Start scheme); lifestyle issues such as smoking, nutrition and diet advice including vitamin D supplementation, sexual awareness; risks and benefits of screening tests; planning place of birth and antenatal classes.


Bedford Hospital has a Late Booking Pathway in place to explore any underlying issues or concerns that may have contributed to the late booking.  Following an audit into late booking this was strengthened and implemented in January 2015.


National and local strategies

Local views

Service users sit on the Maternity Services Liaison Committee for Bedfordshire and provide direct service user input and represent the views of the wider public concerning issues relating to maternity services delivered at Bedford Hospital.


·         Early access to maternity care contributes to delivering the NHS Outcomes Framework indicator (2012/13) to reduce infant mortality and a number of outcomes in the Public Health Outcomes Framework (2013-16) including increased breastfeeding rates, reduced incidence of low birth weight of term babies and reduced maternal smoking.


  • Healthy Lives, Healthy People: Our strategy for public health in England (2010)
  • The Marmot Review: Fair Society, Healthy Lives (2010)
  • The Healthy Child Programme (2009)
  • Maternity Matters: Choice, access and continuity of care in a safe service (2007)
  •  Department of Health, National Service Framework for Children, Young People and Maternity Services – Maternity Services (2004)


Nice Guidelines

  • NICE Clinical Guidance 62, Antenatal care – Routine care for the healthy pregnant woman, (June 2008)



  • Bedford Borough Health and Wellbeing Strategy (2014)
  • Bedford Borough Public Health Strategy 2013/14
  • Bedford Borough Partnership Framework for Bedford Borough’s Children, Young People and Families 2014-2017.
  • Bedford Borough Early Help Strategy 2014
  • Bedford Borough Early Years Strategy 2014 (Draft)


What is this telling us?

What are the key inequalities?


In Bedford Borough, Bedford Hospital Trust sees the majority of women before 13 weeks of pregnancy. An audit in 2014-15 identified that a very small number are seen after 20 weeks and they would all receive blood tests, a scan and screens (except the nuchal scan).


Evidence suggests that disadvantaged women with multiple social problems and minority groups are significantly less likely to use maternity services early in pregnancy or maintain contact. This results in worse outcomes for both the mother’s and baby’s health and wellbeing than for the population as a whole (DH, 2004). 


A Health Equity Audit of access to maternity care in Bedford Borough, undertaken by the Public Health Team, looked at rates in 2009/10 and identified higher rates of women failing to book by 12 weeks 6 days in the most deprived wards in Bedford.  The data also showed some correlation at ward level between ethnicity and the percentage of mothers not booked before 12 weeks 6 days in Queens Park, Kingsbrook and Goldington Wards.


A survey carried out by the National Perinatal Epidemiology Unit found that four out of five women (80%) realised they were pregnant within the first 6 weeks, with smaller proportions taking longer to become aware of their pregnancy.  16% of all pregnant women, including many of those aged under 18, delay seeking maternity care until they are five or more months pregnant, thus missing the crucial early days of maternity care.


A report commissioned by NICE (NCCWCH, 2010) highlighted the issues faced by pregnant women with social complex factors. The guideline was commissioned in response to findings from reports which found that women from non-white ethnic groups and women in the deprived population quintile had stillbirth and neonatal death rates that were twice those of white women and those resident in the least deprived areas.


In addition socially excluded women are at higher risk of death during or after pregnancy than other women and are far less likely to seek antenatal care in early pregnancy.  The Saving Mothers Lives Report (2007) found that compared to women who had booked prior to 20 weeks, women who booked late or missed more than four routine appointments were more likely to be: Black African or Caribbean; experiencing domestic abuse; substance misusers; known to social services or child protection services; or unemployed.


The guidance identified four populations who represented socially excluded women:

  • Women who are substance misusers (including drugs and/or alcohol)
  •  Recent migrants, refugees, asylum seekers, and women with little or no English
  • Young women aged under 20
  • Women experiencing domestic abuse


Unmet needs/gaps

Whilst only a small number of women do not receive antenatal care in early pregnancy in Bedford Borough, national evidence suggests that the women presenting later are those most likely to have worse outcomes for both them and their baby.



  • GP practices should guide women directly to the community midwife as soon as possible.
  • As a result of their audit into late booking mothers, Bedford Hospital strengthened their Late Booking Pathway.  The pathway assists maternity staff to explore issues that may have contributed to the late booking to ensure that additional support needs are identified and women can be referred. This process will enable maternity services to monitor late booking and the reasons behind it.


This chapter links to the following chapters in the JSNA:

Teenage pregnancy

Drug misuse


Department of Health (2009) Healthy Child Programme – Pregnancy and the first five years of life

Department of Health (2010) Healthy Lives, Healthy People: Our strategy for public health in England

Department of Health (2012) Improving outcomes and supporting transparency Part 1A: A public health outcomes framework for England, 2013-2016

Department of Health (2007) Maternity Matters: Choice, access and continuity of care in a safe service

Department of Health (2004) National Service Framework for Children, Young People and Maternity Services

Department of Health (2012/13) The NHS Outcomes Framework

Marmot M. et al. (2010) Fair Society, Healthy Lives, The Marmot Review

National Collaborating Centre for Women’s and Child’s Health (2010) Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors

National Perinatal Epidemiology Unit (2006) Recorded Delivery: A national survey of women’s experience of maternity care

NICE (2008) Clinical Guideline 62 Antenatal care: routine care for the healthy pregnant woman

The Confidential Enquiry into Maternal and Child Health (CEMACH) (2007) Saving Mothers Lives: reviewing maternal deaths to make motherhood safer (2003 – 2005).


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