183. Health inequalities can be reinforced during pregnancy and the early life of a child and it is during this period in particular that the 'intergenerational cycle' of inequality is perpetuated. However, the provision of appropriate maternity care may help to break this cycle by promoting the health of mother and baby, and by helping disadvantaged women and families to gain awareness of, and access to, available services.

184. We heard a great deal of evidence which emphasised the key importance health during the very early stages of life has on long term health outcomes. The Department told us that children born to women from disadvantaged groups are more likely to be affected by pre-term labour, intrauterine growth restriction, low birth weight, low levels of breastfeeding and higher levels of neonatal complications.[163] The Maternity Alliance asserted that exposure to poor material conditions in early life, including in utero, is detrimental to health not only in the short term, but also in adult life, regardless of adult socio-economic status.[164] The NCT told us that there was growing evidence of the effect of poor mental health during pregnancy and in the postnatal period on the relationship between mother and baby, and on the baby's future mental health and wellbeing.[165]

185. In terms of promoting the general health and wellbeing of women and babies, Jenny McLeish from the Maternity Alliance told us that "some of the most helpful things that the maternity services can do or try to do are not related to obstetric outcomes."[166]

Smoking cessation

186. In particular, Ms McLeish identified support for smoking cessation as an intervention which would promote health and wellbeing beyond pregnancy and the postnatal period. Although disadvantaged women are more likely to smoke, and less likely to stop smoking in pregnancy, Ms McLeish argued that "people do seem to be more motivated when they are pregnant than at other times and it is seen as this great opportunity."[167]

187. Diane Jones, a consultant midwife from Newham Healthcare, reported on the outcome of a smoking cessation project at Newham. In the first year of the project, 39 women were referred. Of those 39, 30 stopped smoking, and all 30 were still non-smokers four weeks after the birth of their babies. This success rate was the result of "intensive … one-to-one support" for women who wanted "the support to quit."[168]

Breastfeeding

188. Babies fed on formula milk are five times more likely to be admitted to hospital with gastro-enteritis in their first year,[169] twice as likely to develop atopic eczema, wheezing and ear infections, and five times more likely to have urinary tract infection than babies who are breastfed for at least four months. For premature babies, there is evidence that breast milk reduces the risk of the serious bowel disease, necrotising enterocolitis. The NCT argued that breastfeeding "saves lives as well as reducing hospital costs" and that it was "one of the simplest and most effective ways of improving the health of our children."[170]

189. The NCT reported that the decision to breastfeed was related to age, social class and mother's education, meaning that children most at risk of poor health (owing to poor housing, overcrowding, parental smoking and other social factors) are least likely to be breastfed. According to the Infant Feeding Survey 2000, breastfeeding rates in England are amongst the lowest in Europe, with only 28% of babies receiving any breastmilk at four months of age.[171]

190. The NCT told us that many women felt that their access to support "vanished" at the end of their care from a midwife, and called for "a better way of making the transition to health visitor care" which would involve "more integration, more overt support for breastfeeding from health visitors (many of whom may need further training in this regard) and emotional support for women themselves."[172] Jenny McLeish told us that work to provide this kind of service was under way:

a lot of money, energy and time is now going into trying to assist disadvantaged women to start sustained breastfeeding even in a culture which is quite opposed to it because that would then give their child some sort of improvement on the chances that they would otherwise have had in terms of health.[173]

191. Provision of support for smoking cessation and for breastfeeding represent two interventions which can improve a woman's experience of maternity care, and the long-term health outcomes for women and babies. Women from disadvantaged groups may need specialist support in these areas. We recommend that health visitors and midwives undertake training, and that they work closely with peer groups and volunteers, to provide this support. We further recommend that the Health Development Agency issue guidance to PCTs on best practice in smoking cessation and breast feeding support for women from disadvantaged groups. There should be a flexible approach to the transition to care provided by health visitors, to allow mothers to work with whichever health professional they feel is best placed to support them.

A wider public health role for the maternity services?

192. In April 1999 the Prime Minister launched Making a Difference: the nursing, midwifery and health contribution, which outlined the Department's proposals to expand the role of the midwife to include more involvement with women's health and with public health in general. This expanded public health role would accommodate support for breast feeding and smoking cessation, and also early identification of women affected by domestic violence or by postnatal depression.

193. Given the success of maternity services in some areas, in terms of helping women to stop smoking and to initiate and sustain breast feeding, proposals for a wider public health role for midwifery staff constitute a recognition that maternity services can act as a gateway to other services. The Centre for Nursing and Midwifery Research at the University of Brighton argued that midwives were crucial to the success of wider schemes to tackle health inequalities:

The role of the midwife puts her in a unique position since she often enjoys a greater level of acceptance by clients than do other professionals such as health visitors and social workers. Because of this, teams working directly, and holistically, with disadvantaged clients have much to gain from incorporating midwives.[174]

194. Jo Garcia from the NPEU explained how Maternity services provided "a fantastic opportunity to reach women", particularly those who might not otherwise use the health service or who might have difficulty in gaining access to it:

if you are thinking about encouraging … [a woman] to use child services, it may be … that if she has a good experience with maternity care and feels she can trust the midwives and the health visitors, then maybe for her, using child services, knowing who to ask would be made easier.[175]

195. In fulfilling the wider public health role envisaged for them, midwives need training to overcome negative attitudes and prejudice, and support as they take on the challenge of caring for women and families who are difficult to reach. The Maternity Alliance suggested that training to improve access to services for disadvantaged women and to promote their general health and wellbeing, was not yet sufficient. Jenny McLeish told us that for midwives:

The public health agenda is getting there, but it has not really penetrated; it has not permeated their [the midwives'] culture. They do not have any time for reflective practice once they are on the busy wards doing their work.[176]

196. Carolyn Roth from City University argued that the proposed expansion in the public health role of maternity services had not been recognised by service planners:

The demands on the midwifery service have increased. It has absorbed an enormous amount of new things that we have recognised that we need to do to respond appropriately to women's needs and yet the service has not expanded to the same extent and there is invariably more demand than the ability to respond to it and women do suffer because of that.[177]

197. We recognise the potential of midwives, and of maternity services, to play an expanded role in promoting public health. However, maternity care staff must have access to appropriate levels of training and support if they are to be effective in this role. We recommend that the Department should facilitate the implementation of the proposals in Making a Difference by making a detailed assessment of the training and support needs of staff who provide maternity care.