Public health is defined as ‘the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society’ (Acheson, 1988). It seeks to identify risks to health and find the best ways to minimise them, in order to give everyone the best chance of leading a healthy life (RCM 2017).
Good public health advice is a fundamental part of a midwives role. Midwives need to promote family-centred care by meaningful conversations with women around healthy lifestyle choices in pregnancy, making every contact count. The small changes that a woman makes in her lifestyle choices will increase her chance of achieving a healthy pregnancy, birth and baby. The Maternity Vision for Wales (2019) advocates that pregnancy and childbirth are a safe and positive experience, and parents are supported to give their child the best start in life.
Furthermore, key public health themes are set out in the RCM Stepping up to Public Health (2017); this paper not only highlights the key areas of public health – infant feeding, smoking, screening, perinatal mental health, obesity, contraception and sexual health, SID, immunisations, infection prevention, healthy lifestyle – but also discusses the barriers and facilitators to midwives providing this information effectively on a day-to-day basis. With topics such as FGM, bereavement, drug and substance misuse, domestic abuse, homelessness, honour-based violence and forced marriage being discussed less often.
As a consultant midwife working within the public health, my role consists of both clinical frontline practice as well as a strategic focus to improve public health for service users and their families to support them to achieve the best health they can during the Antenatal, Intrapartum and Postnatal period by supporting individual needs.
Key public health areas
Pregnancy motivates women to achieve optimal health, it is a time when they are receptive to information to improve their health. Midwives are key public health information givers, who protect and enhance the health and social being of women to make healthy lifestyle choices, this in turn promotes the health and well-being of society by reducing health inequalities, stillbirth, preterm birth and low birthweight babies. Public health messages should not be seen as additional work for midwives but as part of everyday midwifery practice.
It is well documented that smoking is detrimental to both mum and baby, increases the chance of fetal abnormalities, stillbirth and small for gestational age babies (RCOG 2018, NICE), we have worked closely with local public health teams to develop a dedicated specialist maternity support worker post to support midwives to offer women continued support to stop smoking.
The RCOG (2018) express the importance of maintaining a healthy weight and lifestyle in pregnancy to reduce the morbidities and mortalities. The named midwife is key to providing women with advice on healthy diet and exercise in pregnancy, however if further support is required we have established a specialist midwife-led healthy pregnancy clinic, which aims to provide bespoke care to women to help achieve a healthy weight and lifestyle during pregnancy. This has been developed with the support of local public health dieticians.
Perinatal mental health
Pregnancy may exacerbate pre-existing mental health issues or create new issues for women. National Collaborating Centre for Mental Health state that perinatal mental health issues affect around 1:5 women, with 15% suffering from anxiety and depression disorders in the perinatal period. Midwives may be the first point of contact for women to seek help and advice around this issue. We work closely with specialist perinatal mental health teams and specialist perinatal mental health midwife to help support women with new or existing mental health issues to ensure care is individualised to suit the needs of their condition.
Female Genital Mutilation carries with it significant health consequences, including both physical and psychological health impact. Women and young girls are particularly affected with increasing morbidity lasting several years post mutilation which can impact on childbirth. Therefore, establishing this as a public health issue within our communities.
The practice is illegal in the UK under the Female Genital Mutilation Act (2003) and Serious Crime Act (2015), which extends to any acts performed on UK residents. A statutory duty of ‘mandatory reporting’ applies to those under 18, and with a majority of mutilations occurring in childhood, this represents a major safeguarding concern.
With the changes to the legislation, the introduction of mandatory reporting, the implementation of an FGM clinical pathway and better awareness/training increases the need for access to a specialist FGM service. We worked closely to develop a specialist midwife for FGM role and a specialist service ‘Womens Wellbeing Clinic’ to support survivors of FGM in their pregnancy. This service also provides further support to pregnant women who are seeking asylum as well as supporting the violence against women, domestic abuse and sexual violence agenda.
Postpartum contraception aims to prevent unintended pregnancy and closely spaced pregnancies after childbirth (RCOG 2015). Childbirth presents an opportunity for providing contraception at a time when women are attending a service staffed by healthcare providers with the skills to offer a full range of methods and when women may be highly motivated to start using an effective method. Health professionals working within the maternity services should discuss and support women in their choice of contraception during the antenatal and postnatal period. The benefits of long-acting reversible contraception (LARC) methods in terms of efficacy should be highlighted to all pregnant women (FSRH 2017).
There is a high rate of unplanned pregnancies amongst women from ‘hard to reach’ groups, such as teenagers and vulnerable adults, within 12 months of birth. This risk of a subsequent/accidental pregnancy is significantly reduced by using LARC methods (Trussell 2011). Thus contraceptive advice is regarded as an essential component of maternity care.
Midwifery practice directly impacts the health of mum and baby, supporting midwives to deliver key public health messages is a pivotal role of the public health midwife. Targeting key public health areas will empower women not only to make healthy choices in pregnancy, but will also reduce health inequalities and support women and their families to achieve an optimum health in pregnancy, which in turn will reduce future morbidity and mortality rates in the child.
• Acheson, E. D. (1988). On the state of the public health. Public Health, 102(5), 431-437
• Faculty of Sexual & Reproductive Healthcare Clinical Guidance (2017) ‘’, Clinical Effectiveness Unit, ‘Contraception after pregnancy’ January 2017. http://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/
• Female Genital Mutilation Act (2003) http://www.legislation.gov.uk/ukpga/2003/31/pdfs/ukpga_20030031_en.pdf
• National Collaborating Centre for Mental Health. The Perinatal Mental Health Care Pathways. Full Implementation guidance. London. National Collaborating Centre for Mental health. 2018.
• National Institute of Clinical excellence (NICE) 2010. Smoking: stopping in pregnancy and after childbirth (PH26) NICE: London.
• RCOG (2015) ‘Leading Safe Choices’, Best practice in Postpartum Family Planning, https://www.rcog.org.uk/en/guidelines-research-services/guidelines/bpp1/
• Royal College Obstetrics and Gynaecology, Obesity in Pregnancy, Green top Guideline 72; 2018, London.
• Royal College of Obstetrics and gynaecology (2015) Smoking and Pregnancy, updated in October 2020, Patient Information leaflet. Available at www.rcog.org.uk
• Serious Crime Act (2015) http://www.legislation.gov.uk/ukpga/2015/9/contents/enacted
• The Royal College of Midwives (2017) Stepping up to Public Health: A new model for women and families, midwives and maternity support workers. RCM: London.
• Trussell.J (2011) ‘Contraceptive failure in the United States’ International Reproductive Health Journal, May 2011, Vol 83, Issue 5, Pages 397-404.
• Welsh Government (2019) Maternity Care in Wale. A five year vision for the future (2019-2024) Welsh Government July 2019.