by Kerri-Anne Gifford

Every year UK community midwives develop hundreds of individual professional relationships with their clients. Mostly, happy-to-be-pregnant women are seen at their homes or in the health centre antenatal clinic. The midwife will not be able to predict for the woman exactly what date her baby will be born. What she tells her is that it is very likely her baby will be born at full term. This is recognised as greater than 37 weeks of pregnancy. Any sooner than this and the baby is classed as premature. Women like to know a date to work with and very few are thinking that their baby will be born much earlier than this unless they've had a previous experience of it or know someone close to whom this has happened. Midwives may usually touch on the subject but don’t emphasise it, as part of their job is help women worry less and enjoy their pregnancy.

Yet the midwife knows that if she works in an area where she meets pregnant women living in cramped housing conditions, no helpful support networks and very little income there may already be some things for the women to worry about. If a pregnant woman smokes, drinks a lot of alcohol and/or uses street drugs, then she and her midwife have even more to worry about and this pregnancy appears to be increasingly vulnerable. She may be in an abusive relationship. On top of this, if she has not had much education and does not know to eat a range of good nourishing foods on a daily basis then the placenta and baby will not grow well.

Add to this the possibility that she may be from a minority ethnic group where there may be language and access barriers to maternity care then the midwife will be alerted to most of the features that are associated with a possible poor outcome for mother and baby. So the woman may become ill herself and give birth prematurely. The earlier the baby is born, the lower the chances of survival and the chances of the baby having something seriously wrong with it for the rest of its life are increased. A woman with only a few of the above life aspects may already be twice as likely to have a premature baby than a woman who has a good income and few stressful events in her life. The elements which may affect different likelihood of results are in government documents called ‘health inequalities’. The World Health Organisation defines health inequalities as ‘difference in health status or in the distribution of health determinants between different population groups’.

Public health debates focus on what the statistics may reveal about social and economic deprivation. Various ways of measuring deprivation have developed over the years and some surveys illustrate more clear-cut associations with premature neo-natal deaths than others. Population statistics are often criticised as flawed for not revealing localised individual factors. However, the most reliable large scale data does show that the more deprivation factors you have the poorer you and your family’s health will be. This leads to questions being asked about what health and social interventions can be made to help reduce the neo-natal tragedy of premature baby deaths or of children having long-term physical and learning problems. For any family of any situation having a premature baby is a traumatic experience, but for a family with very few resources it can make life almost unbearable and coping skills may not exist.

Research in the public health area is inconclusive about what type of social support will help improve outcomes. And what about the contributing overall multi-factorial influences often individually related? Infection, stress, high blood pressure, previous premature labours or abortions - these also appear to be more common amongst socio-deprived groups of pregnant women. However this is not well documented on a national data set that supports the public health agenda activity. The only circumstances that run counter to this are in relation to fertility treatment and multiple pregnancies. Well-off women have been more likely to access treatment but if carrying twins or triplets they are more likely to give birth prematurely.

Some government statements refer to low birth weight babies. Their babies are not necessarily premature but more of them are born to socially deprived groups. Hard evidence is not entirely clear about why but there are some indicative features. Smoking is associated with low birth weight babies and giving up inhaling all the poisons that cigarettes contain will help women have healthier babies. Some evidence suggests that supplements of calcium may be preventative and therefore supports the nutritional intervention arguments.

Medical practitioners look to using scanning, pharmaceutical and medical techniques to try and predict and reduce low birth weight and prematurity events. Nevertheless, the UK continues to have one of the highest rates of low birth weight babies in Europe. Health practitioners would like to know what the very best things they can advise and do to reduce the risk of small and premature births, deaths and damage. Some evidence was revealed in the CESDI report (Confidential Enquiries into Stillbirth and Neo-natal Deaths), but this was mainly in terms of improving medical care and not much with public health preventative activity.

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