The editorial on maternal health in pregnancy identifies issues relevant to primary care arising from the 2014 Confidential Enquiry into Maternal Deaths and Morbidity.2 The authors recommend targeted pre-conception and antenatal interventions for women with long-term medical, mental health, and substance misuse conditions, especially for those with additional risk factors; for example, smoking and obesity, compounded by adverse socioeconomic characteristics. However, of the women who died, 61% failed to receive the recommended level of antenatal care and 10% received no antenatal care at all. The recommendations will be difficult to achieve in women who do not attend primary care appointments and/or present late or not at all for antenatal care, an issue acknowledged but not addressed within the editorial.
There is a dearth of research into why some women fail to access timely, freely and locally available antenatal care in the UK and what impact this phenomenon may have within populations of pregnant women already known to be at higher risk of adverse materno-fetal outcomes. Stereotypical, professionally derived perspectives prevail: the ‘concealed’ pregnancy; ambivalence/lack of self-care; denial; therapeutic nihilism relating to socioeconomic and cultural factors. In our qualitative study, undertaken with a socioculturally and age-diverse group of women, we identified a novel taxonomy of reasons for late or non-booking for antenatal care. These included NHS system and professional failures that ‘delayed’ access to timely care and maternal factors: ‘not knowing’; ‘knowing’ with postponement and perceived optimisation of self-care.3 A lack of reproductive health knowledge was a cross-cutting theme, which compounded other barriers to timely access to care; our sample included women who had presented late or not at all for antenatal care in previous pregnancies. Policy-makers should ‘join up’ and optimise all facets of maternal health care within public, primary, and secondary healthcare settings and improve reproductive health knowledge for all women, including opportunistic interventions. The ‘take-home messages’ within this editorial may only partially address yet another NHS health inequality conundrum. Taking maternity care to hard-to-reach women is an idea whose time has come.
- © British Journal of General Practice 2015