Addressing inequalities in perinatal care

Over the last 20 months the COVID-19 pandemic has thrown into stark relief the health inequalities faced by the world population as a consequence of the conditions in which we are born, grow, live, work and age. The 2021 British Association of Perinatal Medicine (BAPM) Annual Conference focused on addressing inequalities in perinatal care that can affect outcomes for the babies we look after. There was a fantastic programme with a range of speakers including parents and allied health professionals giving us some wonderful insights into the challenges of achieving perinatal outcomes equal for all.

In her words of welcome, BAPM President Dr Helen Mactier reflected on the personal and professional challenges of the last year faced by everyone in neonatal care. Motivationally, she shared her medal from her recent achievement – cycling 970 miles to raise funds for BAPM and Bliss – with the quote ‘More is in you’ on the ribbon.

Dr Christine Ekechi, Consultant Obstetrician, spoke eloquently about whether race really matters. Statistics are stark, demonstrating that BAME (black, Asian and minority ethnic) women have a significantly higher risk of dying in pregnancy and that stillbirth rates for black babies are double those of white counterparts. Dr Ekechi thoughtfully explored societal, health and individual factors contributing to these variations and challenged the listener to examine their own unconscious biases, alongside highlighting the Royal College of Obstetricians and Gynaecologists’ (RCOG) ‘call to act’ to halve maternal deaths for black women by 2023.

The Peter Dunn Lecture by Professor Marian Knight discussed correcting systemic bias in perinatal care, summarising data from maternal confidential enquiries, MBRRACE-UK, the Perinatal Mortality Review Tool (PMRT) and the UK Obstetric Surveillance System (UKOSS). Professor Knight spoke movingly of “Literally sitting here counting women dying; preventable deaths (of those) who have not been vaccinated in pregnancy,” when collating the COVID-19 UKOSS data. Discussions around vaccination have been based on risk and ignored potential benefits; pregnant women were excluded from early vaccine trials and vaccine prioritisation only looked at maternal mortality, ignoring preterm birth as a consideration.

Professor Karen Luyt discussed the impact of social deprivation on infant mortality in England using the May 2021 thematic report of the National Child Mortality Database. This shockingly demonstrated an 11% increase in risk of death with each increasing decile of deprivation. The population attributable risk fraction for deprivation shows that if those children in the most deprived decile had the same death rates as those in the least deprived, we could prevent 22% of childhood deaths.

Sandra Igwe, founder of the Motherhood Group and co-chair of the National Inquiry into Racial Injustice spoke passionately about supporting the black maternity experience. Sandra highlighted “The strong black woman identity” as a seductive stereotype that can actually be damaging. Discussions centred around barriers to accessing mental health services and the recent campaign that ‘Black mothers are not hard to reach’. Emphasis was placed on using the blank canvas approach to build a more complex picture facilitating care tailored to individual needs.

Professor Tim Draycott, Vice President of the RCOG, reinforced this message and was cautiously optimistic that we can reduce avoidable harm through safe, personalised maternity care. Alongside immeasurable emotional costs, poor birth outcomes account for 59% of NHS claims and it is key we recognise that better care costs less ​in the long term. In the words of Elvis, it’s time for: “A little less conversation, a little more action, please,” using multidisciplinary training, personalised care and technological innovations.

On day one of the conference, we were treated to three fantastic oral presentations. Jennifer Jardine presented a national cohort study illustrating adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities, ​for which she was subsequently awarded a prize for the best oral presentation. Gitika Joshi showed how collaborative working can improve peri-natal diagnosis of critical congenital heart disease and Alice Beardmore-Gray gave a summary of the PHOENIX study com-paring maternal and infant outcomes after planned early delivery or expectant management for late preterm pre-eclampsia.

The BAPM Founders’ Lecture by Professor Mikael Norman highlighted variation in neonatal practice and outcomes. Worldwide variations in preterm birth rates, unit capacity, professional priorities, centralised delivery, and outcome measurements create challenges for true comparison of perinatal research.

Dawn Clements and Nicola Hunt discussed the new role of care co-ordinators in improving perinatal outcomes, as supported by the NHS Longterm Plan. Practical challenges in establishing this role and innovative solutions were discussed and it will be exciting to see evolution over time.

Rounding up day one was a talk about allied health professionals in neonatology led by Heather Norris, Charlotte Xanthidis, Michelle Sweeting and Laura Melim. It was a real treat to get a detailed insight into the key roles that dietitians, physiotherapists, speech and language therapists and occupational therapists can take in deliv-ering safe family-centred neonatal care.

Commencing the second day of the conference, we heard from Gayle Hewitt, mum of Georgia born at 27 weeks’ and Amie Turner, mum to Lillie-Rose, born at 28 weeks’ gestation. Gayle described her neonatal intensive care unit (NICU) journey and recommended practising the four Cs: care, consistency, communication and clarity to promote parental confidence and empowerment. Both Amie and Gayle highlighted the importance of supporting the transition from a NICU to a special care baby unit (SCBU) or local neonatal unit (LNU). Reflecting on her time in neonatal care, Amie stated: “The only thing I found hard was the transition from NICU to SCBU.” Amie and Gayle affirmed that: “It feels like your baby is not as important as they were in the NICU,” and that the perception may be that the quality of care has dropped.

Dr Ela Chakkarapani gave a thought-provoking analysis of the evidence around mild encephalopathy, examining the variability between diagnostic methods and outcome measures. He described uncertainties both in defining hypoxic ischaemic encephalopathy (HIE) and assessing outcomes, noting that cognitive and language impairments are better evaluated at school-age rather than two years of age, as is current practice.

Dr Chakkarapani concluded that, as outcomes for mild HIE appear to be improved by cooling, there is potential for significant benefit to those patients and their families.

Following the theme of diagnosis and treatment, consultant ophthalmologist Dr Susmito Biswas discussed current treatments for retinopathy of prematurity (ROP), such as anti-vascular endothelial growth factor (anti-VEGF). Intra-vitreal anti-VEGF treatments like bevacizumab are effective treatments with significantly greater benefit when treating zone I disease than laser treatment, however laser therapy is still recommended for zone II disease.

Dr Biswas concluded that anti-VEGF treatment is a safe treatment option, particularly for posterior and aggressive ROP, but it will not completely replace laser.

Professor Edward Bell presented evidence for the optimal time to transfuse the preterm baby, highlighting the ‘sweet spot’ for deciding when to transfuse. Results of the ETTNO and TOP trials suggest haemoglobin transfusion thresholds should be 11-13g/dL for infants in the first week who are critically ill, and 7-10g/dL for stable, older infants. This information, along with other strategies to avoid transfusion including optimal cord clamping and reducing phlebotomy, could significantly reduce transfusions for preterm infants.

On the second day of the conference, we heard three more oral research/audit presentations. Dr Manju Chandiramani emphasised the importance of babies being born in the right place, presenting a pan-London in utero transfer service quality improvement programme demonstrating how collaborative working, prioritisation and recognition can influence ‘moving mothers, not babies’.

Dr Lydia Di Stefano presented research on professionals’ views and interpretation of the BAPM revised framework for practice, Perinatal Management of Extremely Preterm Infants. Results showed trainees found the guidance useful, however there are concerns it may be misinterpreted thus highlighting the importance of education and training for effective use. Dr Claire Granger described the results of a single centre retrospective cohort review of the impact of probiotics, concluding a need for further research as introduction of probiotics did not reduce overall mortality or rates of necrotising enterocolitis or late onset sepsis.

Dr Melanie Griffin shared the ongoing multicentre prospective audit TRANSFER, looking at the incidence and outcomes of women presenting with threatened preterm birth between 22 and 23⁺⁶ weeks’ gestation.

Professor Mikael Norman continued the topic of management of extreme preterms, describing the excellent outcomes of extremely preterm infants throughout Sweden and the national recommendations that contribute to this.

The final session of the conference, led by Professor Tilly Pillay and Dr Sarah Seaton, discussed the preliminary results of the OPTIPREM study, which suggest no difference in mortality for babies born between 27 and 31 weeks’ gestation in England when comparing place of birth (NICU vs LNU). Further work will examine the clinical care, economics and social aspects of the care of this group of babies, before making recommendations to optimise service provision. Dr Eleri Adams concluded the conference sessions by presenting the GIRFT data around the transfer of preterm infants born between 27 and 30 weeks’ gestation, including the recommendation to change the in utero transfer threshold for low volume LNUs to 29 weeks’ gestation.

The BAPM Gopi Menon Awards perfectly rounded off an inspirational and enlightening conference, which was further enhanced with a wide selection of poster presentations and exhibitors. The delegates of the 2021 BAPM conference will be taking away an enormity of evidence and expertise to improve practice and minimise inequalities in perinatal care until the conference next year.

BAPM is a multidisciplinary professional association for all those working in perinatal care. For further info: www.bapm.org