19
Preterm Birth Committee
Corrected oral evidence: Preterm Birth
Monday 18 March 2024
4.25 pm
Members present: Lord Patel (The Chair); Baroness Blackstone; Viscount Colville of Culross; Baroness Cumberlege; Lord Hampton; Baroness Hughes of Stretford; Baroness Owen of Alderley Edge; Baroness Seccombe; Baroness Thornhill; Lord Winston; Baroness Wyld.
Evidence Session No. 12 Heard in Public Questions 166 - 179
Witnesses
I: Professor Andrew Shennan OBE, Professor of Obstetrics, King’s College London; Professor Judith Stephenson, Professorial Researcher and Honorary Consultant in Public Health/Sexual & Reproductive Health, University College London.
Professor Andrew Shennan OBE and Professor Judith Stephenson.
Q166 The Chair: Before we start, I would be grateful, starting on my left, if you would introduce yourselves so we get you on record with your designation, and then we will go on to questions.
Professor Andrew Shennan: I am professor of obstetrics based at King’s College. I am also the Tommy’s Chair of Maternal and Fetal Health based at St Thomas’ Hospital across the river here, with a specialist interest in preterm birth.
Professor Judith Stephenson: Good afternoon. I work at the Institute for Women’s Health at UCL as a professor of sexual and reproductive health, and my main research interest is in health before pregnancy. I co-chair the UK Preconception Partnership and I co-direct the NIHR Policy Research Unit in Reproductive Health.
The Chair: Brilliant. There are questions about that.
Q167 Baroness Hughes of Stretford: Welcome. Thank you for coming to talk to us today. We are very interested in your views about the primary risk factors for preterm birth, not just medical conditions but lifestyle issues and socioeconomic and demographic factors. If you start by giving an overview of the risk factors in those various categories, we could take it from there.
Professor Andrew Shennan: Obviously, there are many factors related to the chance of going into preterm labour or having a preterm delivery. The association is variable. Some factors are quite strong. Whether they are causal or not is sometimes challenging to know, and that is a key issue. You can divide them in many ways, and Judith may well have a different way of doing it, but I would say that there are demographic issues in the population that we know are strongly related to delivering early. It may be your weight. Being underweight is related to going into spontaneous preterm labour.
Baroness Hughes of Stretford: Are you talking about the mother?
Professor Andrew Shennan: Yes, the weight of the mother. A low BMI—under 18, for example—has a strong association, as strong as if you had had a previous preterm birth. Being overweight is also related to delivering early but more often because of a placental disease, metabolic-type syndrome, when you get high blood pressure issues, diabetes, glucose intolerance and so on. Babies may get either small or too big and because the mother is better off delivered, the clinician may deliver her early. That is a potent cause of early delivery.
These are not independent of age. We know that underage mothers can get diseases that require them to be delivered earlier—for example, pre-eclampsia is more common in teenagers—and older mothers are also prone to those other metabolic-type issues. That is age.
There are then behavioural issues. We know that smoking particularly is very strongly related to the risk of preterm birth. That is one area where there is strong evidence that changing it will alter outcomes, stopping smoking or changing to nicotine patches even in the first trimester. There is a very strong dose relationship.
Baroness Hughes of Stretford: Is there a stronger causal link?
Professor Andrew Shennan: Yes, exactly. I think everyone agrees, based on big studies, that there is causation there, and that if you change it, it will alter. One key question is what proportion of preterm birth can be ameliorated by this. When you model it against other causes of preterm birth it is a relatively small amount, but it is an important public health message not to smoke.
There are other behavioural issues that are strongly related. For example, it is very important in our clinics that we take drug history. We know that sympathomimetics, particularly things like cocaine, have a very strong relationship, and if you have someone who is losing babies because of this and you do not know about it, you will not pick them up in any other way.
There are all sorts of other things. There are environmental issues. We know there is a strong relationship between particulate matter, for example, and the risk of preterm birth. It is a relatively weak association and there are no studies proving that if people change their environment they will alter that outcome.
There are a number of other issues, often to do with background risk factors. Obviously, this is before women get pregnant. Some can be lumped together as cervical trauma, for example. We know that people who have had early terminations of pregnancy or any gynaecological procedure will, in effect, weaken the cervix. Abnormal smears and CIN being treated will result in a risk of having an early birth. More recently, we have realised that even emergency caesarean sections will increase your risk of subsequent preterm birth. The interesting thing is that the treatments of these things are very different and often clinicians do not even know about them. You have to ask.
Then there are other things like the IVF story about how many eggs to put back, and risk factors like that. In a way, if you wanted to prevent some of these things, it is multifactorial. For example, to prevent CIN you would need vaccines to prevent HPV. It is multifactorial.
Professor Judith Stephenson: I would agree with the above. Going on from there, I like the WHO report on preterm birth in 2020, which says, “Preventing deaths and complications from preterm birth starts with a healthy pregnancy”. In my book, that means a healthy life before conception. If we take that broad view, from the research that has been done it is clear that there are major categories of factors affecting the health of a woman, and of the father, before she becomes pregnant. I will not say so much about that, but it is not just the mother; it is the father’s health as well.
Most of the research is on the mother’s nutritional status: anaemia, vitamin deficiency and so on. That is very important globally and in the UK. We tend to think we are doing better here, but 96% of young women aged 18 to 25 in the UK National Diet and Nutrition Survey, which is the best data we have on nutrition, were below the recommended intake of iron as well as folate before pregnancy. There are big nutritional issues in this country. As I am sure everyone is aware, the food environment here, the food system and the state of nutrition is pretty parlous, with un-nutritious food far more affordable than nutritious food. That is a big factor.
Environmentally, you have touched on smoking, and I can talk more about the relative risk of that, but much of the data I am talking about is observational. I know you are asking about causality. When you want randomised controlled trial evidence of this, it is pretty thin on the ground before pregnancy, because for those studies you have to recruit women before they are pregnant and then wait and see. Some of them get pregnant, some of them do not. You need to have very big studies and follow them up for longer than a pregnancy. There are some. There are some very good ones that are ongoing and a few that have been reported internationally.
One I will mention because it is relevant to the nutrition field is a randomised controlled trial called NiPPeR. That looked at a nutritional supplement, myo-inositol and micronutrients in a sachet, a drink. The study was done in Singapore, New Zealand and somewhere else. There were three countries. It was a good randomised control trial; 1,700 women had nearly 600 babies and this nutritional supplement more than halved the rate of preterm birth. That was not the primary outcome—they were looking for an effect on maternal glycaemia, which they did not see—but it was a pre-specified secondary outcome. Therefore, it was not just, “Let’s look and see what’s going on”, a fishing exercise, as we call it; it was considered as a potential outcome. That was an important finding. There is no doubt that nutritional status is important, and it is far from good in this country.
Maternal morbidity you have mentioned already. There is hypertension. You have mentioned most of these already.
Just to give some figures, we looked at 600,000 women of reproductive age in the Royal College of General Practitioners dataset and we looked at some lifestyle factors: smoking, heavy alcohol use, recreational drug use, and overweight or obesity. 61% of women you could say had some lifestyle factors that could be improved before the pregnancy. These are all women who were of reproductive age but not pregnant as far as the GP knew. If you then add in hypertension, diabetes, anxiety and depression, you are up to 90%.
That nine out of 10 is an important figure. Nine out of 10 young women are not in a good nutritional state for pregnancy. Nine out of 10 women of reproductive age, generally speaking, are not in particularly good health. Only 10% of those 600,000 women, if they were going to have a pregnancy, would just need to take folic acid. Of course, that is a small bunch of conditions. Once you start putting in thyroid disease, congenital heart disease and other more specialist diseases—you can put in a whole lot more diseases—you will come up with a higher proportion who need good medical care and medication review before a pregnancy.
The point I want to make is that because there are lots of things that relate to the risk, there is no magic bullet here. It is not a case of picking one or two risk factors, although we can say smoking and, let us say, overweight/obesity are very important. In fact, some of the global studies have looked at all the things we have mentioned. If you put them all together, the population attributable fraction was 73%. No single one was much more than about 5% or 10%. That is what I mean. We want to get blood pressure down, for example, for all sorts of reasons, but just getting blood pressure down will not have a big impact on preterm birth.
The other reason why I say that is because these population attributable fractions are useful concepts. They give us a guide to public health action, if you like, but they also carry assumptions. If we reduce obesity, for example, and the population attributable fraction is 10% or 15%, it assumes that nothing else changes, but if you reduce obesity, of course, you reduce blood pressure and you may improve physical activity. It makes much more sense to take them together as a group in a more public health intervention.
Baroness Hughes of Stretford: Is this the implication of what you are saying, Professor Stephenson? In doing so, taking at least most of those factors as a bundle, you would capture most pregnant women. You do not have a suite of factors with which you could target. You could take one or two, like smoking, and they will have a beneficial effect elsewhere, but there is not much scope for targeting apart from smoking. Is that fair to say, or could we target people more accurately?
Professor Judith Stephenson: We certainly could. If you come on to things like socioeconomic status, there is a relationship between deprivation and preterm births and so on. Rather than saying, “This is all far too general”, there are some important entry points or ways in, if you like, and one of them is unplanned pregnancy. I do not wish to say that unplanned pregnancy is always a terrible thing. Apparently I was one myself. My parents seem to talk about a happy accident. I am not trying to stigmatise unplanned pregnancy, but it is associated with a lot of adverse pregnancy outcomes and we want couples to plan more for pregnancy. I think that is a key message.
I envision a society in which planning and preparing for pregnancy becomes more like a routine part of life, in the same way that taking your children for vaccination is a good thing that people do to prevent illness down the line. It is the same thing for preparing for a pregnancy. That has not really happened in the past, but I am happy to say that I think it is changing. When we published a series of papers in the Lancet on preconception health in 2018, people were amazed and the big media response was amazed: “We didn’t think you needed to do anything about your health before pregnancy. We knew you had to stop smoking and drinking once you were pregnant”. There has been very little on that for some fairly obvious reasons, I think, but it is beginning to change. That is an important way to get people to think about being aware that your health is important before you become pregnant, and then to think about how you might plan and prepare for that. Planning and preparing are slightly different things but they go together.
Baroness Hughes of Stretford: I would like to pursue this, but I know some of my other colleagues have questions about how you could translate that into action in a public health way.
Professor Judith Stephenson: I will be happy to talk to that as well.
Q168 Baroness Wyld: Professor Stephenson, on this point about preparing for pregnancy, how long realistically are we talking about? Rightly, you could say to women, “Stop drinking and stop smoking when you are pregnant”, but is it realistic to think that for a particularly long time before that a huge number of women will be able to adjust their lives to that extent?
Professor Judith Stephenson: Good point. We do not want to come out with a statement like the WHO did, which seemed to say that no woman should have a drink between menarche and menopause in case she fell pregnant. It is not about that.
The way we looked at it in the preconception health series of papers is to offer different perspectives on what preconception means. Before then, it always seemed to mean three months before a pregnancy, which is completely useless for any action. It is a retrospective definition. We came up with a biological definition that is quite close to the time of conception, weeks before conception, and that is the folic acid story. You need to take folic acid before conception. If you take it at booking visit, it is too late. You do not need to take it for very long before conception to get adequate folate levels—a few weeks beforehand. The same probably applies to some of the other micronutrients, vitamins, zinc and so on.
Then there is—I cannot remember what we called it—a conscious decision. Any time you say, “Hey, let’s make a baby”, that is it. That is the start of your preconception period. Then there is a longer-term perspective, what we might call a public health perspective. If you want a pregnancy but ideally you would lose quite a lot of weight before becoming pregnant, that will not happen in a couple of months. That is perhaps a more sensitive definition, but it is a useful one.
It came home to me when we did a pilot study where women with obesity—having a BMI over 34—were coming to a family planning clinic to have their implant or intrauterine device removed because they wanted a pregnancy, and the research nurse suggested to them they might want to lose weight first. I was curious as to whether they would say, “No thanks. I’m here to get pregnant, not to lose weight”, but two-thirds of them agreed to do that. Half of them completed a very challenging weight management intervention and dropped BMI considerably. The whole project was very sensitively handled. It demonstrates that the preconception period is one where many people are very concerned to get in better shape and health and understand that that is in the interests of the pregnancy and their baby.
Baroness Wyld: That is helpful, thank you.
Q169 Viscount Colville of Culross: Professor Stephenson, you have said that you should not look at one particular issue but should look at it in the round much more. However, the “smoking at the time of delivery” rate is something that the Government have tried very hard to reduce. They are hoping to get to a smoke-free generation of mothers by 2030. However, so far they have failed to hit targets. Is it at all feasible to stop all mothers smoking?
Also, we have heard so much about the epidemic of vaping amongst young people. Do we have any figures on whether vaping has any adverse effect during pregnancy, and therefore whether or not there should be a campaign to try to stop that among mothers and people trying to get pregnant?
Professor Judith Stephenson: Can we eliminate smoking? I somehow doubt it. We eliminated smallpox but not many other things. Will it come down? Yes, it could come down further. There are very strong data showing dose response with smoking. Studies with millions of pregnant women can show that three to four cigarettes a day is worse than one to two—that level of detail. Those studies also show that it is best not to smoke before conception, but if you stop smoking as early as possible in pregnancy, you can pretty much have the low-risk status of women who never smoked before pregnancy. The message is: the earlier you can stop, the better.
For some women, of course, that is extremely difficult. Nicotine replacement is a very effective intervention for that. Whether it is nicotine replacement gum, patches and so on or whether it is vaping is an interesting current question. ASH, the charity Action on Smoking and Health, recently produced a report that we looked at around vaping in pregnancy. It did not cite data, but it stated that it did not have an adverse effect on pregnancy outcomes and newborns. I think that needs looking at a bit more carefully before we say that vaping is completely safe in pregnancy. It is also more addictive than other forms of nicotine replacement, I gather. There are still some things to be worked out there, but, generally speaking, certainly vaping will be better than smoking.
Q170 Baroness Seccombe: I have a slight change of tack. Do you think that the public health authorities have any part to play in preventing stillbirth?
Professor Judith Stephenson: Absolutely. They have a very important part to play, from a lot of what your previous experts were saying. They have a very wide role to play, particularly on supporting healthy lifestyles, improving environments and supporting people out of deprivation. There is a huge need for that per se and it will have an effect on more healthy pregnancies.
The role they are playing at the moment is quite difficult to pin down. There are some local authorities with strategies that include mention of preterm birth, but they are usually more about infant deaths in general. As you mentioned, smoking at delivery is the only outcome in the current public health outcomes framework. We are hoping to get one on unplanned pregnancy in there as well.
Yes, they have a very wide role to play. Now that we have these integrated care systems, the opportunity becomes greater. The complexity seems pretty mind-blowing to me, but the raison d’être for the integrated care systems is to take account of whole populations, not just to be thinking about the health of people as they come through a clinic door, and to integrate all that better. There is a great opportunity there. The problem is that with the public health grant being cut by a third and contracts with lots of third sector organisations being terminated, they are in a far worse state to make improvements in all these areas. However, that is what the task should be.
Baroness Seccombe: Do you have any input into this, about the public health authorities being involved?
Professor Andrew Shennan: I am not a public health doctor. Therefore, I would have to take Judith’s view on this.
What I would say, going back to the question of whether you can get to the metric of no smoking, is that human nature being what it is, speaking as a clinician, I do not think it will happen. However, because of this dose response, because most women who do not give up smoking want to give up smoking—they try and they struggle, it is not just, “I’m just not going to listen to you”—and given the strong evidence that four is worse than three, three is worse than two and so on, we work with people. We do not lecture them. We do not read them the riot act. We say, “Look, you’ve done well. You’ve done this a bit less”. They get the positive feedback. Although we have this metric of “No smoking at delivery”, everything else is also good. Individually, you have to work on that positive feedback. Those public health messages need to come over.
Professor Judith Stephenson: Could I just throw in something about the ICBs? Having said that it is a rather complicated landscape at the moment, I know some that are making great strides.
Milton Keynes, Luton and Bedfordshire used some health inequality money to run a 12-month pilot on improving preconception health in that region, and it was very impressive. They reached a lot of hard to reach, underserved communities and different ethnic groups. There was a lot of community education. They trained primary and secondary care physicians in preconception health. They worked with Diabetes UK and Tommy’s, the charity, which has a really good tool for planning and preparing for pregnancy that it encourages people to use. I asked about any outcomes they had managed to capture from that and they said there was a 20% increase in antenatal booking by 10 weeks, and a lot of the community engagement is carrying on.
That is just one example. Portsmouth also is making strides in that. Their priority is to get preconception care in headlines in all the other relevant strategies, the strategies on smoking, alcohol and so on, to make sure that preconception is there.
The Chair: That is an important point, because one of the hardest tasks for us would be how to suggest anything that would produce implementation of preconception clinics. If the two ICBs are progressing with that, that is a good example for us to promote.
Professor Andrew Shennan: I was going to add that obviously preconception for everyone is challenging. We have, I think, an excellent primary care system in this country compared to many others. In the new digital world we have, when you see your GP for your blood pressure check and your urine, it does not highlight saying, “Are you planning a pregnancy? Are you of reproductive age?” It would not take much just to flag that, to get people to open up the conversation.
The other issue—human nature being what it is, with all the unplanned pregnancies and everything else—is targeting preconception care through the current systems. In diabetic care, it is saying, “Are you thinking about pregnancy?” In hypertension clinics, it is saying, “Are you thinking about pregnancy?” In postnatal, it is, “What about your next pregnancy? Get to the hospital preconception clinic”. That will always be an important thing not to forget about, even though the ideal is to have everyone in this preconception arena.
The Chair: You and I both know how difficult it is to persuade your colleagues who run a diabetic, hypertension or any other clinic. Epilepsy drugs are a classic example of making sure that preconception advice is given.
Professor Judith Stephenson: I would say that it is not about the clinics, it is about the conversations. The conversations can be had in all the current settings: conversations in general practice, conversations when women are coming for contraception. Of course, you are providing contraception for them today, but are they thinking about having a baby in a year or so? Many people will be.
We worked with health visitors, and I want to say more about them, because they are an extremely important part of the workforce. Again, their numbers have been rather decimated; they have been reduced by a quarter or a third. They are a unique workforce who can help with this, because they are specialist public health nurses. They go into everyone’s home. The conversation is very simple. It needs to be, “Are you thinking of having another baby in the next year or so?” That is a conversation with GPs, with nurses, with a whole range of healthcare providers.
Q171 Baroness Wyld: I was very glad you mentioned health visitors, because I want to go back to this point about health records that you have both touched on. You will be aware that the Government are pushing forward with the digitisation of the red book, which clearly focuses on the baby and the child to five years of age. To your point about a chat about contraception or if you go for an initial test, do you think there is a case to expand that health record? We are all going to carry our digital health record around. Why can a woman not therefore carry her reproductive health record around, which can then follow through into the red book and link the mother to the baby?
Professor Judith Stephenson: Absolutely, yes. I remember trying to do that about 10 or 12 years ago, I think, and it is progressing. That is really important, precisely because at the moment we do not have an indicator that there has been a discussion of preconception health. This is about the measurement of what is going on, to monitor things.
We looked at all the indicators from guidelines that could tell you about preconception health and we came up with 66. Sixty-four of them are in our current, routine national datasets. They are there to be mined. Interestingly, the only two that were not there were whether preconception care had ever been discussed—there is no marker on that—and IVF or assisted reproduction births. They are two important ones. The other 64, smoking, weight and so on, are there to be to be mined.
There were 23 of them in the maternity services dataset. When we looked at them, we were able to analyse that and produce the first annual report on preconception health in England. We are hoping that that will become an ongoing way of surveillance, so that we will have ways of measuring whether the health of the of women before pregnancy is improving.
In particular, there is a measure called the London measure of unplanned pregnancy, or LMUP, which is a beautifully researched measure from Geraldine Barrett in my team and Jennifer Hall, who has done a lot of work with it. I want to acknowledge them. It is a score from 0 to 12 for how planned a pregnancy is, and you use it in pregnancy or just after. If you imagine that an HIV test in pregnancy will give us a lot of information to estimate the prevalence of HIV in the country, the LMUP score in pregnancy on those 700,000 women will tell us about how well planned pregnancies are, or are not, and how it is moving. It is sensitive enough to detect changes over time and between different groups. You could look at whether women in different socioeconomic groups are becoming more prepared for pregnancy or not, or in different regions, people with different conditions and so on.
We have been working hard to get that into the maternity services dataset. It is in the current one. It needs a few more steps so that it will, I hope, become mandated in the returns to NHS Digital and OHID. Then we will be able to look at that as an end point—how are we doing on preparing for pregnancy and planning—and, as an exposure, to then say, “What’s happening with these unplanned pregnancies, preterm birth and other outcomes, and what can we do to support those mothers better?”
Baroness Wyld: What is your view, Professor Shennan? It seems to me that there should be a way to simplify this.
Professor Andrew Shennan: My view with the IT side of it is that good IT is brilliant; bad IT causes a lot of headaches. We have had a new system recently across the road in St Thomas’, and when it works well it is brilliant. You prescribe something and it says, “Did you know that the dose of this has changed now? Have you considered this? Have you considered that?” Now, in a primary care scenario, I can imagine that if you have a woman who is on an anti-epileptic or on whatever, it should just flag, “Is this woman planning a pregnancy?” “I had not thought of that.” “Have you considered changing the dose?” It is very iterative and potentially very good. I suspect we are just scratching the surface of the potential of that. With the right emphasis and the right input, I think it will make our lives easier.
Professor Judith Stephenson: Yes. That is very much about getting the right care pathways and the right flags, asking the question first, “Actually, I am thinking of having a baby next year”, and then having the flags and the data linked up.
Baroness Wyld: That is very helpful, thank you.
Q172 Baroness Seccombe: You mentioned Milton Keynes, but do you know if there are public health directors in other organisations who have it in their strategy to consider preterm birth?
Professor Judith Stephenson: It is not very prominent in local authority strategies. At the moment, through the Policy Research Unit on Reproductive Health that I mentioned at the beginning, we have all the women’s health hub plans that have been submitted to DHSC. About 13 of the 42 of those mention preconception health. They are asked to say whether they are doing anything about that or not. I was going to ask you: do you have someone from the Association of Public Health Directors coming to give evidence?
The Chair: Yes.
Professor Judith Stephenson: Good. They will know more about it.
The Chair: Can I just get it on record? Baroness Wyld mentioned the red book. Are you familiar with that concept, and if you are, what is it? I cannot put Baroness Wyld on the stand to clarify.
Professor Judith Stephenson: Sorry. The red book includes the key information about newborn babies. As soon as you have a baby, you get the red book. The health visitor gives it to you. It describes head circumference, length and so on, it charts the baby’s growth and progress on percentiles, and it goes up to about the age of—I cannot remember—preschool, preschool child health.
Professor Andrew Shennan: I only know it as a parent.
Professor Judith Stephenson: Me too. Linking it with the maternity electronic record and the baby’s electronic record—at UCL, where I work, there is a lot of work going on on that—would be a big advance. Otherwise, we have to rely on linking these datasets I talked about, which is very heavy going, but we do it.
Baroness Wyld: Yes. It sounds incredibly clunky.
Professor Judith Stephenson: It is.
The Chair: Do you have a rhetorical question that might clarify, Baroness Wyld?
Baroness Wyld: No, I think that is very clear. Thank you.
Q173 Lord Winston: Thank you indeed for coming and for the interesting evidence. I wonder whether I might be a bit more aggressive, and I do not mean that with any disrespect at all. I am a bit concerned that we have highlighted smoking as one example, but in fact on your admission it might make a 10% difference in some patients. Surely one of the issues is that there are so many associated factors with so many of these issues that we cannot be at all clear about it.
For most women who have a preterm birth, which is deeply distressing to them—this is important—we find no clear evidence that has made much difference to their cause. With smoking, for example, I remember that for years we had big notices in our antenatal clinics telling women not to smoke. Eventually I was persuaded to take those down, because many women who had had some problem with their baby, perhaps an abnormal baby or something else, thought it was because of their smoking, and of course there was no evidence at all that the smoking had done that.
I am a bit concerned about this whole concept of how we teach people in schools, for example, about how they might handle pregnancy. It is a bit off the original question I was going to ask, but it is relevant because we have dealt with some of the issues in your comments. Professor Shennan, you were strong on smoking when you started your evidence.
Professor Andrew Shennan: I am sitting here not as a public health doctor but as a clinician who sees a lot of high-risk women. You are right that most women who come to us with multiple problems are non-smokers. Maybe I should just take a step back. I run a high-risk clinic across the water. We will see 60 women a week who have lost babies, and if they have a factor like obesity or whatever we certainly do not go saying, “That was the cause and you need to change that”.
One of the problems with preterm birth is its multifactorial nature. When I teach my students, I equate it to a cough. You are dealing with a cough. That might be Covid, pneumonia or it might be a virus. It could also be cancer. It could be an allergen. It could be any number of things causing a cough. I say that preterm births are exactly the same. There are multiple possible reasons why you get to that end point, and yet the causes and the management are radically different. Even within the context of, say, a damaged cervix—a woman who has a preterm birth and who has had a problem with her cervix—if she has had a cone biopsy from an abnormal smear you might put a stitch in, but if she has had caesarean damage the stitch will not work. Even within the subgroups, the management is radically different.
We have to change our mindset. If you look at the cell biology and the genetics of a woman who has lost five babies because of domestic violence or because of her caesarean, she will have normal biology. One of my pleas is that if we do research and get to the bottom of this, we have to get clinicians who understand the phenotype and the clinical scenario working with the basic scientists and looking at the right questions at the right time. That is key. I am talking here as primary, but that is a big issue.
Lord Winston: I think you have made an important point. The phenotype is one of the issues that we are not dealing with, it seems to me.
The Chair: Would you define phenotypes for the rest of the committee?
Lord Winston: Do you want me to define phenotype?
The Chair: No. It is so that we get it on record.
Professor Andrew Shennan: What I mean by phenotype is how the patient presents: in other words, what her features are.
Lord Winston: Not the underlying problem.
Professor Andrew Shennan: Yes.
Professor Judith Stephenson: I would say two things. You mentioned schools—
Lord Winston: We have had evidence on that.
Professor Judith Stephenson: You have had evidence. Good. I will put my one statement, if I may, which is simply that in schools the emphasis is correctly on avoiding pregnancy—RSE is all about not getting pregnant—but that needs to be balanced with the very simple message that if in the future you ever find yourself thinking about having a pregnancy, your health is something to consider before the pregnancy rather than after it has occurred. That is it. Whether you go into the biology of it in the biology curriculum is other thing.
You mentioned smoking and the backlash against the push to stop smoking. This is not an easy solution, but one thing we have done—this is across all the different WHO regions in the world—is to start asking people, “What factors would matter most to you if you were considering a pregnancy?” That did not seem to be in the published literature. This is all about what they think about the factors that we think matter, but if someone is facing domestic violence or the threat of deportation, she may not be thinking about folic acid, let alone her blood pressure.
We asked this very open question. I was curious as to where health would feature in the things that matter to people and whether it would be top, middle or bottom of the ranking. It turned out that health is very important. Most people put health—mental health and physical health—at number one, then support from family and partners, and so on. Then there were the more medical issues and having enough money, but it was basically about mental health. Do you feel you are in the right state to have a pregnancy, a child? Do you have a roof over your head, do you have enough money, and what is your health like? Do you have a supportive family? Those things.
Q174 Lord Winston: You both raised one other condition that is clearly important and probably underrated, although cannot be very underrated, and that was the issue of metabolic changes. Diabetes in particular would be high on that list, I think. The Singapore GUSTO study, which is still ongoing, is a cohort study now in its 10th year, and it is large. Every patient was tested intensively throughout pregnancy in that study, and we know that a good proportion of the patients were clearly pre-diabetic or diabetic at levels not noticed because of the levels that we test in an NHS environment. They would not be regarded as diabetic, but the differences in outcome in pregnancy were significant indeed, particularly with obesity, as it turns out. I wonder whether you felt that we should be doing more about monitoring in general in pregnancy.
That is a long question, but I wanted to set the scene because I wanted to say where I was coming from. There is no doubt that that study is a good study. I think it has clearly been shown to be accepted widely.
Professor Andrew Shennan: I think what you are alluding to is that most clinical factors and risk factors are on a continuum. By the nature of research and the nature of management algorithms, we end up categorising people into normal and abnormal.
We still need good clinicians. We still need consultants to make decisions so that they can look at the spectrum of all diseases. When you have someone who is not diabetic but is pre-diabetic, or is not hypertensive but is higher than they should be, and whose BMI is borderline, you add these things together and change your perception and management accordingly. That is just the nature of good medicine. We have to have categorisation, we have to have definitions and diagnoses, but if that were the case we could run the health service with robots. We still need clinicians to take all these things into account.
I think you make a very good point that we are still learning, and that this issue of continuous variables is important. For me, working across the road, I see things all the time that other people do not, because of experience and putting things together that are not currently defined. I know you had a lot of discussions about the delays between evidence and guidelines and so on. It is an evolving situation, and we need to keep going. That is the bottom line.
Professor Judith Stephenson: I would not talk about monitoring in pregnancy. For me it is the bookends of pregnancy. When I talk about preconception health, health before pregnancy, it is also between pregnancies. Postnatal care can become interconception care for the next pregnancy. I call those the bookends, which have not received very much attention. If you have had diabetes diagnosed in pregnancy, you will get type 2 diabetes if you wait long enough.
Lord Winston: If you are not monitoring the pregnancy you would not know that, would you?
Professor Judith Stephenson: No. There is much more monitoring, as I understand it, for diabetes in pregnancy, and even though that gestational diabetes seems to go away, the risk has not gone away. What happens, partly because primary care GPs have become rather divorced from maternity care, is that there is a bit of a cliff edge. You have delivered the baby, the mother and baby are alive and well, and then things drop off a cliff edge, particularly the information. Not all GPs will know that a woman had GDM or gestational diabetes diagnosed. Then, even if the GP knows that, not very many women will get called in for a postnatal HBA1C check. You are down to about, as the last paper showed, 1% who get the annual review as recommended by NICE. There is a huge fall-off there.
Diabetes is one example. Hypertension is another one. This moment in pregnancy, nine months in pregnancy, is a real stress test of cardiovascular fitness and various other things. They are not going to go away after the baby is born. That is a reflection of the mother’s life course. We could be much more alert to monitoring that and intervening with effective interventions.
Lord Winston: Thank you.
Q175 Baroness Blackstone: Do you think enough priority is given to tackling the scourge of obesity? You talked quite a lot about smoking earlier, which obviously is a problem, but smoking has been coming down while obesity has been greatly increasing. It seems to me that senior representatives of the medical profession, like both of you, have an incredibly important role in trying to get both public policy and individual behaviour changed to reduce the extent of obesity, which you have rightly said is related to hypertension and to diabetes, which are big and important factors in preterm birth.
There are a lot of ways you can tackle this. Governments have to do it through food policy, which they have been very reluctant to do, or at least some Governments have. Health education needs to address this. Does it do it enough? You talked just now about the importance of talking to young people in health education programmes, not just about how to prevent pregnancy but about what conditions you need to have an ideal pregnancy. Certainly being hugely overweight and having a terrible diet can only be extremely deleterious to good outcomes in pregnancy. Should we not be making much more of this as an issue?
Professor Judith Stephenson: I could not agree more. We need to be giving young people far more support to improve their diet and achieve a healthy weight. You can start at any point in the life course. In the period that I am talking about, before pregnancy, we know that those factors are transmitted across the generations. If the mother has high blood pressure and excess weight, the offspring will be much more at risk of that from the start and through long-term follow-up as an adult. That is one place to start. It does not matter where you start, but the message, I completely agree, has to be that weight is important for your health and for your family’s health.
It is a huge issue globally as well as nationally. People talk about obesogenic environments. It is not about blaming people who are overweight; it is much more about thinking intelligently about the whole system. People now accept this. It needs a whole systems approach to how we create the right environments, which are less obesogenic. It is about activity and the occupations people do. It is huge and it will not be tackled by the medical profession alone, but there are these pinch points, if you like. I gave the example of losing weight before pregnancy, which might be a moment when you can support women to do that.
Professor Andrew Shennan: It is doable. Women who have a goal in a relatively short timeframe in their life can achieve things that they cannot achieve over a longer period. If we have the opportunity to target those public health messages, we should do it. I think a lot of my junior colleagues will feel, “It’s not their fault”, and that I am shaming. They almost collude in it and they do not get those messages over. As a senior clinician, one thing that worries me a lot is weight. Whenever I operate on people, whenever I see people in my clinic, that is much more of an alarm bell than many other things. I completely agree that we may have lost focus on what is an important public health message.
Q176 Viscount Colville of Culross: Professor Stephenson, you talked about unplanned pregnancy, research into that and how the data needs to be worked on still, but are there other areas of research that we need to prioritise in order to prevent preterm birth?
Professor Judith Stephenson: As well as the measurement of impact and so on that we have talked about, it is important to do some economic analysis. Some research into return on investment would be very valuable. The famous Heckman Curve by James Heckman, the Nobel Prize-winning economist from Chicago, showed that earlier investment in young children’s lives has a return on investment of 13%, meaning that you will save more money if you intervene early, in preschool rather than school. We need to look at that curve going further back. I emailed him and asked him whether he would have a go, but he has not replied. That is definitely an area that we could work on.
Ideally, you want a bunch of well-designed randomised trials that will give you the data to work on that, and there are not very many. However, we can make some assumptions. For instance, with good preconception care suppose you reduce a woman from a high-risk pregnancy to a medium or low-risk pregnancy. You could look at the economic consequences of that, which I think would be very favourable. There is an economic area.
There are all sorts of ways of trying to research or evaluate the effectiveness of what we do. When you have a lot of enthusiasm among GPs or some of these ICBs to start doing interventions in preconception care, how can you evaluate the impact of it? At the moment, the Maternity Disparities Taskforce, which I sit on, is producing a resource targeted at women. The idea is that it will be delivered through lots of local systems, and it has much more information in it than the NHS website has. You could imagine something like a bit of a natural experiment where some regions might have that rolled out at a particular intensity compared with other regions that are a bit more standard, and you could try to look at what impact that intervention is having.
I used to say that I was a hard-nosed epidemiologist and clinical trialist, but I have gone past the phase of wanting to do a big trial of preconception intervention to give all the answers, because I do not think that is the right approach anymore. As I mentioned, there are a handful going on across the globe and they are revealing important information, but I do not think it is the right approach for the UK at the moment, because things will move on during the trial and you will suddenly find that what you are doing is a bit out of date. Certainly, researching what we do is very important.
Viscount Colville of Culross: Professor Shennan, what research, beyond what Professor Stephenson has said, would you recommend?
Professor Andrew Shennan: I have listened to your previous witnesses and comments about funding and so on. I do think we need more research, and I still think preterm birth is treated as a poor relation. I know you have this level playing field, but I do not think the questions are commissioned and targeted. When they are on a par with the big health problems—cardiovascular, cancer and others—the make-up of the boards and so on means that they do not get the same rating. People do not say, “This is as important a problem as these other problems”, which I believe it is if you look at its impacts.
The cardiovascular world quite rightly has support from the British Hypertension Foundation and the oncology world has huge charity support from cancer. Preterm birth is a little bit taboo. We do not have the commercial input. My appeal is that we can do and should do more in this arena, because we are a bit behind on understanding mechanisms and there is a lot of potential to improve it. It is a bit of a woolly answer, but research is the way we will get out of this problem, and there is a lot to be done.
Q177 Viscount Colville of Culross: I want to ask a question that is rather off the wall, and you might not be able to help us at all. We have heard from previous witnesses about the importance of the microbiome in affecting the risk of preterm birth, and that is obviously affected by people’s lifestyles, what goes into their bodies and what they do with their bodies, I imagine. Have you done any work at all connecting lifestyles with the microbiome, or not?
Professor Andrew Shennan: The scientists in the group I work with across there have done quite a lot of work on microbiome. They have seen, as others have done—the Imperial group, MacIntyre and so on—different populations of microbiome associated with increased risk. Of course, it has the potential to be ameliorated. There are links with different ethnic groups. I think it is an area of interest and its interactions with other things are all important. There is a lot to be done before we start recommending interventions. We have to get diagnostics and other things sorted. It is of interest but still a bit upstream in terms of resulting in an impact on patient care.
Professor Judith Stephenson: I have not personally, but the NiPPeR trial I mentioned had some mechanism hypothesised around the microbiome. Keith Godfrey would be the person to ask about that.
The Chair: They are, as you say, hypotheses. As Professor Shennan quite rightly said, a lot more work needs to be done before we understand what we are talking about.
Professor Judith Stephenson: It is very in vogue. Tim Spector is pushing products for microbiome in Marks and Spencer at the moment. It is getting into the public mind.
Professor Andrew Shennan: They are not independent. The microbiome will interact with other risk factors, such as a short cervix allowing ascending infection and so on. There is a lot to be done.
Viscount Colville of Culross: Thank you.
Q178 The Chair: To hang on to those research issues, we have had several sessions about research. One question is: are there any research areas to be pursued that we need more research in for primary prevention? The summary of all the evidence we have heard so far on research related to preterm prevention and preterm births is that there is no co-ordination. Most of it, if I can put it crudely, is a fishing expedition. There are projects fishing to find a cause but not a co-ordinated programme, for instance, to better understand the molecular and cellular biology of normal labour and then what is different in preterm labour.
Professor Andrew Shennan: We have a unique opportunity in this country with our research networks, because we have this infrastructure to answer questions that I do not think anyone else would. I agree that it is not co-ordinated and it so could be. It needs to get away from the academic, individual recognition, brownie point issues. We need to do something. We have these networks and we have this infrastructure where we can do big intervention trials, whether it be scanning the cervix, giving progesterone relatively quickly or giving steroids correctly. It does not matter what it is. There are many questions we could answer as a country that I do not think anyone else could, because they do not have that joined-up NHS and networks.
I agree that going back to basic science and linking it to the clinical arena is important. Back to my original point, because it is so multifactorial and because there are so many aetiologies, people will have to work together. The nature of academic research is that somebody has an idea, the microbiome, the short cervix or whatever it is, and then they pursue it headlong for 10 years and it is hard for them to think outside the box. We have to bring together the relevant clinicians and scientists to ask the right questions and then make use of our opportunities to answer the questions. I genuinely think that in the UK we can do that. We do punch above our weight with our research and we should be looking to do that. With the right oomph, I think we can do it.
The Chair: Why are there no programme grants for reproductive biology?
Lord Winston: There are for reproductive biology.
Professor Andrew Shennan: You will always say that you need more resource in your area, but I genuinely think that, given the impact of preterm birth, it deserves more resource than it has. The co-ordination side of it will not cost much, it just needs that political will to knock heads together and get people to work together. I think we could do something great.
The Chair: We heard in the session before this one that the maternal and fetal medicine networks are not as well developed. Do you agree that there is a need to focus on three or four key priority areas for research that are co-ordinated and funded properly?
Professor Judith Stephenson: Yes. We need a national action plan for improving health before conception. Many of the things we need are in place or in planning. We have the strategy for women’s health, which has more focus on preconception health now. We have some important measures, like LMUP, which I mentioned, and the national datasets, which can tell us the impact of those things. We need a plan that is integrated with research. If primary care starts contacting people with Accurx and finding pathways to deliver better care, we can research the impact of the role of health visitors, specialists and so on at the same time.
Q179 The Chair: I am going to be more challenging now, because I am excited about what you said. You are a part of the disparities unit. Clearly you are an adviser on how they should take on inequalities related not just to preterm labour but to pregnancy generally. Why do we not have a vision to create all the things you said—preconception studies, preconception behaviours, postnatal clinics and so on—that are not happening, and create women’s health from preconception to menopause and beyond? That is where all women could go, with self-referrals to get information and even get diagnoses and treatment.
Professor Judith Stephenson: We have a national women’s health strategy.
The Chair: That is a strategy. I am talking about proper caring, not words.
Professor Judith Stephenson: Yes. It needs a plan of implementation. Because this is my area, and for the reasons I have given, I would focus it on health before and between pregnancies. We know how to do that.
The Chair: How would the disparities unit tackle these inequalities?
Professor Judith Stephenson: Through proportionate universalism, to use Michael Marmot’s phrase. You need to intervene universally, which is why workforces like health visitors are so important. You need to provide better preconception care for everyone but with an intensity and at a scale that is targeted towards where the need is greatest.
We have examples of where that worked. The teenage pregnancy strategy did just that. It was rolled out everywhere in England. Most money was given to the areas that were most deprived, which had the highest teenage pregnancy rates, and they saw the greatest fall in teenage pregnancy rates. That is a good example of how you can intervene and reduce inequalities, and I think we need to be doing the same thing with health before conception.
The Chair: Maybe for all inequalities. Thank you. You both have such a huge amount of information that we could keep on questioning you, but we will need to stop. Thank you, both of you, for coming today. It has been a most helpful session and we got a few important points. Thank you.