Written evidence submitted by The University of Oxford (FTDO102)
The National Perinatal Epidemiology Unit (NPEU) is a research unit based at the Nuffield Department of Population Health at the University of Oxford. Established in 1978, the NPEU focuses on research into the health of mothers, babies, and families, to generate evidence with implications for clinical practice, public health, and health policy development. Our multi-disciplinary work includes randomised trials conducted through our specialised perinatal Clinical Trials Unit, population-based surveillance, economic evaluations, confidential enquiries, and epidemiological investigations.
The NPEU hosts the NIHR Policy Research Unit in Maternal and Neonatal Health and Care (PRU-MNHC). The PRU-MNHC works with the DHSC and arm’s-length bodies in England to develop a programme of work to provide evidence to inform anticipated policy developments and projects commissioned by policymakers to address specific evidence needs. PRU-MNHC projects cited here involve routine data sources and a series of national maternity surveys, conducted at 2- to 4-year intervals to gather information from women who have recently given birth in England about their maternity experiences. Topics explored include infant feeding, the mothers’ mental health, and experiences of maternity care.
Maternal and infant health are interconnected and interdependent. Maternal mental health was highlighted as a key concern in the First 1000 Days report, but barriers remain to tackling this critical area. The overarching themes that emerge from our recent research that relate to the First 1000 Days call for evidence are a need for:
- Routine and repeated perinatal mental health assessments to identify women at risk, with particular efforts to ensure that women from ethnic minorities do not fall through the cracks;
- Further integration and communication between antenatal and postnatal maternity care, and infant services to ensure consistent information and support across and between services;
- Work in partnership with women who have experienced challenges in accessing healthcare to understand the barriers to access and co-produce solutions;
- Longer-term follow-up of neonatal interventions in premature and sick infants to understand the longer-term implications of treatments and to inform services that will better support this vulnerable group through the critical first two years of life and beyond.
We have outlined below the evidence underpinning these areas of need.
Mental health screening is critical but is not happening consistently
Maternal mental health is critical to infant wellbeing; poor maternal mental health has been associated with adverse outcomes in infants including low birthweight and psychological difficulties such as insecure attachment and behavioural issues.(1) We need to identify at-risk women early, which means a focus on consistent screening is needed. The importance of this cannot be understated: over a quarter of women experience one or more postnatal mental health problems (2) and in 2020–2022, mental
health-related causes accounted for over a third of maternal deaths that occurred between 6 weeks and a year after the end of pregnancy.(3)
Since 2014, the National Institute for Health and Care Excellence (NICE) has recommended that a woman be asked about her mental health antenatally and during the early postnatal period. However, data from the National Maternity Surveys revealed that although the proportion of women being asked about their mental health antenatally increased slightly between 2014 and 2020, the proportion being asked postnatally fell from 88.2% in 2014 to 78.3% in 2018 and to 73.7% in 2020 (4) (2024 data now collected and being analysed).
There are inequalities in mental health screening
National Maternity Surveys data revealed disparities in who was asked about their mental health before and after giving birth, with women from ethnic minorities less likely to be asked.(4) Variations postnatally may be related, at least in part, to inequities in the coverage of the baby health check that is provided at 6–8 weeks after birth: a PRU-MNHC study of routine electronic data found that women from ethnic minority groups were less likely than those from the White British group to receive this check.(5) NMS data also indicated that women living in socioeconomically disadvantaged areas and single mums were also less likely to be asked about their mental health, although these disparities were less consistent across surveys and between the antenatal and postnatal periods.(4)
Further evidence that the 6–8 week check is an opportunity for mental health screening comes from an analysis of National Maternity Surveys data from women with hypertensive disorders of pregnancy.
These women are also less likely to receive the 6–8 week check than those without hypertensive disorders of pregnancy. However, postpartum depression was more commonly recorded in those who had had a 6–8 week check, suggesting that the check may offer an opportunity for detection or encourage subsequent consultations for this condition.(6)
To understand and address inequitable barriers to healthcare access, it is essential to work with the women affected
NPEU researchers took a participatory action research approach to investigate barriers that women from underserved groups faced when accessing postnatal information about their health.(7) The study combined professionals’ expertise with the lived expertise of 60 service users experiencing multiple disadvantage, with challenges including mental health issues, significant financial need, refugee status, housing instability, limited English language, and experience of domestic violence or abuse.
Barriers to access identified included different literacy and language needs, digital poverty preventing access to online information, and inappropriate or unrelatable language, images and expectations in information materials.
Approaches identified for making information accessible included checking understanding and giving opportunities for women to ask questions; starting conversations early in the antenatal period that can be built on postnatally; developing adaptable resources that can be delivered through multiple channels; sharing resources with community groups working with mums; and linking NHS staff with community organisations to increase reach and trust.
Recommendations
- Identify and implement further mechanisms to integrate antenatal and postnatal care providers
- Further education on perinatal mental health assessments with a particular focus on ensuring women from ethnic minority groups, those living in less socioeconomically advantaged areas, and single mothers are not overlooked.
- Work with underserved groups to understand barriers to healthcare access and co-produce solutions.
We lack evidence on the long-term consequences of interventions used in premature and sick infants during the neonatal period
Research to date has shown that babies born late or moderately preterm were twice as likely as those born at full-term to have a neurodevelopmental disability at age 2 years. Moreover, these children were more likely to have cognitive impairment at age 2 if they were male, had a socioeconomically disadvantaged background, were born to a mother in an ethnic minority group, or if they did not receive breast milk at discharge.(8)
Neonatal clinical trials often look at outcomes only up to the point when the baby is discharged from the neonatal unit. It is often difficult to secure funding for longer follow-up because of the substantial additional expense and a lack of recognition of the importance of extended follow-up. However, follow- up of preterm babies who are enrolled in clinical trials to age 2 years at minimum is essential to get a full picture of a treatment effect and provide good quality, meaningful, evidence-based interventions. This is especially important given the ongoing impact of preterm birth on multi-morbidities into adulthood.
Recommendations
- Invest in clinical trial funding to ensure preterm infants who are enrolled in trials can be followed up to age 2 years at minimum
- Educate funders about the importance of extended follow up
Establishing breast milk feeding and breastfeeding in the neonatal unit
Breast milk provides the best possible nutrition for babies and is associated with positive infant health outcomes.(9, 10) Exclusive breastfeeding is recommended for the first six months of life.(11) For very premature babies, establishing breast milk feeding is particularly beneficial; but can also be particularly challenging, because these infants are unable to feed from the breast directly, so mothers need to initially express milk before later transitioning to direct breastfeeding.(9, 10)
A qualitative study of neonatal unit staff experiences in two Units with high breast milk feeding rates and two with low rates was conducted by the Policy Research Unit to highlight barriers and identify examples of good practice to support establishing breastmilk feeding and transitioning to direct breastfeeding.(9) Barriers included a lack of staff time; inconsistent messaging between the postnatal ward and the neonatal unit; and inadequate facilities including a shortage of pumps and limited on-site accommodation for mothers transitioning to direct feeding. A parallel study, of mothers’ experiences, identified information and support from staff as important drivers of motivation and found similar barriers in the form of limited facilities.(10)
Recommendations
- Fund a supernumerary infant feeding specialist role in neonatal units;
- Provide training for all neonatal unit staff to be able to provide sustained and consistent information and support about breast milk expression and breastfeeding;
- Ensure continuity of care and consistency of messaging between the postnatal ward and the neonatal unit;
- Invest in neonatal unit facilities that allow mothers to stay near their babies, to provide the opportunity for breast milk feeding.
Mental health of parents whose babies are admitted to the NNU
As already discussed, maternal mental health is critical to infant wellbeing. Two systematic reviews conducted through the PRU-MNHC have highlighted a high prevalence of anxiety and post-traumatic stress disorder in parents of babies admitted to a neonatal unit.(12, 13) In addition, a study using National Maternity Survey data found the prevalence of postnatal mental health problems was higher in mothers of infants admitted to the neonatal unit, compared with mothers of infants not admitted to the neonatal unit six months after giving birth in England.(2) Experiencing previous mental health problems increased the risk of postnatal depression, anxiety, and post-traumatic stress whereas social support and satisfaction with birth were protective. When designing neonatal services, there is an opportunity to identify at-risk women and support this vulnerable group by taking a holistic approach to care of the whole family. Our reviews also highlighted very limited research on the mental health of fathers and partners.
Recommendations
- Good communication with parents and universal assessment of depression, PTS and anxiety for all parents whose babies are admitted to a neonatal unit is needed to identify those parents who may benefit most from mental health interventions.
- Identifying need and preferred mechanisms of support among fathers and partners is a research priority
By studying routinely collected data in electronic health records, we identified substantial and worsening inequities in childhood vaccine uptake.(14) For example, in 2011–2012, children born to mothers in the Caribbean ethnic group were 12% less likely than those born to White British mothers to receive the full course of MMR; by 2019–2020 this absolute difference had increased to 22%, and by 2020–2021 it was 29%.
Recommendations
- Prioritise working with minority ethnic communities with low vaccine uptake to understand barriers and parental concerns around vaccination, and co-produce solutions at the local and national level
1. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. The Lancet. 2014;384(9956):1800-19.
2. Gong J, Fellmeth G, Quigley MA, Gale C, Stein A, Alderdice F, et al. Prevalence and risk factors for postnatal mental health problems in mothers of infants admitted to neonatal care: analysis of two population-based surveys in England. BMC Pregnancy and Childbirth. 2023;23(1):370.
3. Allison Felker, Roshni Patel, Rohit Kotnis, Sara Kenyon, Marian Knight (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Compiled Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2024. Available at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE- UK%20Maternal%20MAIN%20Report%202024%20V2.0%20ONLINE.pdf.
4. Harrison S, Pilkington V, Li Y, Quigley MA, Alderdice F. Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys. BMC Pregnancy and Childbirth. 2023;23(1):263.
5. Zhang CX, Quigley MA, Bankhead C, Kwok CH, Parekh N, Carson C. Ethnic inequities in 6–8 week baby check coverage in England 2006– 2021: a cohort study using the Clinical Practice Research Datalink. British Journal of General Practice. 2024;74(746):e595-e603.
6. Ramakrishnan R, Korb D, Li Y, Knight M, Carson C. Maternal postpartum six-week check and short-term health outcomes for women with hypertensive disorders in pregnancy: An observational study using the Clinical Practice Research Datalink (CPRD). Acta Obstetricia et Gynecologica Scandinavica. 2025;104(5):937-47.
7. BEAMS: BEtter outcomes postnAtally for MumS - Outputs. 2015. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.15068 [
8. Johnson S, Evans TA, Draper ES, Field DJ, Manktelow BN, Marlow N, et al. Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study. Arch Dis Child Fetal Neonatal Ed. 2015;100(4):F301-8.
9. McLeish J, Aloysius A, Gale C, Quigley M, Kurinczuk JJ, Alderdice F. Differences between neonatal units with high and low rates of breast milk feeding for very preterm babies at discharge: a qualitative study of staff experiences. BMC Pregnancy and Childbirth. 2024;24(1):863.
10. McLeish J, Aloysius A, Gale C, Quigley MA, Kurinczuk JJ, Alderdice F. What supports mothers of very preterm babies to start and continue breast milk feeding neonatal units? A qualitative COM-B analysis of mothers’ experiences. BMC Pregnancy and Childbirth. 2024;24(1):725.
11. UK Office for Health Improvement & Disparities. Guidance: Early years high impact area 3: Supporting breastfeeding. Updated 19 May 2021. Available at: https://www.gov.uk/government/publications/commissioning-of-public-health-services-for- children/early-years-high-impact-area-3-supporting-breastfeeding.
12. Malouf R, Harrison S, Burton HAL, Gale C, Stein A, Franck LS, et al. Prevalence of anxiety and post-traumatic stress (PTS) among the parents of babies admitted to neonatal units: A systematic review and meta-analysis. eClinicalMedicine. 2022;43:101233.
13. Malouf R, Harrison S, Pilkington V, Opondo C, Gale C, Stein A, et al. Factors associated with posttraumatic stress and anxiety among the parents of babies admitted to neonatal care: a systematic review. BMC Pregnancy and Childbirth. 2024;24(1):352.
14. Zhang CX, Bankhead C, Quigley MA, Kwok CH, Carson C. Ethnic inequities in routine childhood vaccinations in England 2006–2021: an observational cohort study using electronic health records. eClinicalMedicine. 2023;65:102281.