Early Years Pathfinder Project This project has been set up as a pathfinder for Public Health Wales to explore how it can add value to public health activity in Wales by bringing focus and leadership to an important area of health gain, drawing upon and helping coordinate existing expertise and functions across Wales including PHW itself academia, and other health partners and agencies. This presentation gives an overview of why the early years are important, and the approach this project will take. Early Years Pathfinder Project Insert name of presentation on Master Slide 1

“giving every child a healthy start” Pathfinder project: Reproductive and child health Mission: To improve the health and social outcomes across the life-course by providing the best possible start in life for babies in Wales. Goal: To bring together health policy and health service managers, public health leaders, academic experts and practitioners to work together to design and implement the programme. What is the moving picture of the health of early years? What is the evidence that we can improve health? How well are we implementing the evidence? “giving every child a healthy start”

Overview Pathfinder phase 1 Evidence synthesis Current practice Surveillance Proposal for developing an Early Years programme

Intrauterine exposures PRIMARY OUTCOMES Birth outcomes: Birth weight, gestational age, congenital malformations, stillbirth, perinatal mortality Child health outcomes: Deaths, nutrition, growth, hospital admissions, healthcare utilisation, infection, respiratory health, injuries Women’s health Preconception physical and mental health, lifestyle choices – smoking, alcohol, nutrition, drug use Intrauterine exposures Health services (access, standards and quality of care) Maternal care (breast feeding, safety) Family care (social support) Fertility- time to pregnancy Environmental exposures: Housing, neighbourhood and workplace Life course outcomes

Teenage pregnancy Pre-term birth OR 1.2 – 1.9 Low birth weight Baby at increased risk of Pre-term birth OR 1.2 – 1.9 Low birth weight OR 1.2 – 1.8 Neonatal mortality OR 1.3 – 2.7 Harm, illness, injuries Behavioural and emotional complications 2 X more likely to have a teen birth We looked at the evidence on the impact of teenage pregnancy a couple of years ago in a review that was published in the achives of Diseases in Childhood. We found that compared to older mothers, babies born to teenage mothers were up to two times more likely to be born pre-term, or low birth weight, nearly three times more likely to be dead within the first 28 days of life, have increased risk of harm, illness, injuries, behavioural and emotional complications; and they are also twice as likely to go on to have a teenage pregnancy themselves, compared to children that are born to older mothers. However these increased risks are not because of young maternal age - the increased risk is attributable to the socio-economic circumstances leading to and following pregnancy in this group. Source: Paranjothy et al Arch Dis Child 2009 94: 239-245

Obesity Source: CEMACE The recent report from CEMACE shows that Wales has the highest prevalence of obesity in pregnancy in the UK, 6.5% of pregnant women in Wales have a BMI OF 35 or higher. So every year, that’s 2,100 babies that are exposed to the risks associated with obesity. Source: CEMACE

Obesity Pre-eclampsia RR 3 Gest diabetes RR 3 Thromboembolism OR 2.6 Baby Mother Pre-eclampsia RR 3 Gest diabetes RR 3 Thromboembolism OR 2.6 Post partum haemorhage RR 4 Stillbirth RR 2 Preterm birth RR 1.2 Intensive care RR 1.5 Large for gestational age RR 2 Compared to normal weight women, obese women who are pregnant are up to three times more likely to have pre-eclampsia, gestational diabetes, thromboembolism, and four times more likely to have severe bleeding after birth. For the baby, there is twice the risk of a stillbirth, 20% increase in risk of a preterm birth, 50% increase in risk of admission to neonatal intensive care unit, and babies are twice as likely to be big, which then predisposes them to obesity and metabolic disorders in childhood. Source: CEMACE

Workshop Consultation about the concept and way forward Directors of Public Health Local public health teams Midwives Neonatologist/Paediatrician Policy Lead for maternity services Health Economist Academics

Key indicators Exposures Outcomes Maternal obesity Smoking Alcohol intake Infection Mental health Teenage pregnancy Vulnerable groups Preterm birth Low birth weight Injuries Infant mortality Childhood morbidity – infections Breastfeeding Child development

PHW Health Boards HIRU – SAIL NWIS Wales electronic child cohort Stop Smoking Wales Maternity Information systems (various) Data flow established Data exchange established Newborn hearing screening Biochemistry Cytogenetics HIRU – SAIL Wales electronic child cohort Microbiology RADIS obstetric module – scan data (and BMI) CARIS Health visitor data All Wales Perinatal Survey NWIS National Community Child Health Database Patient Episode Database Wales Child Health System Child Death Review

Evidence for interventions Clear evidence base Less clear Folic acid supplementation Smoking cessation Breastfeeding Newborn hearing and bloodspot screening Immunisations Parenting programmes (e.g. Incredible Years) Family Nurse Partnerships Obesity prevention Reducing inequalities

WP1: Outputs An Early Years Surveillance System underpinned by a centralised database with an agreed analysis process Quarterly surveillance reports for Directors of Public Health, Clinical Directors of Neonatal and Paediatric Units, Heads of Midwifery, Local Authorities Website that will be updated on a quarterly basis within 14 days of the end of each quarter

WP2: Outputs Report of evidence synthesis to inform future direction of the programme  Implementation of a suite of evidence based programmes (links with health care quality WP3)  Evaluation of programmes in place linking with surveillance indicators

WP 3-4 WP3: Healthcare Quality WP4: Sustainable communities and environmental health

WP5: Communication and engagement Supporting local Directors of PH and local public health teams Directors of Social Care, Health and Housing and Heads of Children’s Services at Local Authorities Safeguarding Children Services Heads of Midwifery Health visitors Obstetricians, Paediatricians, G.Ps

“… we strongly support the recommendation by the Rt Hon Frank Field MP that local authorities should be able to pool data and track the children most in need in their areas. The life chances of our children should not be sacrificed by the ‘computer says no’ mentality that so often hinders local data sharing” (para 51. chapter 5) “It would also be useful to keep track of actual success or failure to prepare children to be life ready and child ready. If we truly seek to break inter-generational cycles of dysfunction we must know the number of children whose life chances are being improved by Early Intervention policies. Such measures will also inform future policy making regarding the efficacy of early intervention programmes. (Para 52)”

“Recent trend data strongly suggests that children’s mental health is deteriorating with increasing prevalence of mental disorders. Early intervention is crucial to good outcomes… We address some relative newcomers to the public health agenda which are fundamental to children’s mental health and wellbeing: access to the natural environment, a built environment which is conducive to mental wellbeing and the impact of the media, in all its forms, on children’s health.”

Our Healthy Future?

Evaluating the Family Nurse Partnership in England: a randomised controlled trial South East Wales Trials Unit, Cardiff University Dr Julia Sanders Consultant Midwife / Senior Project Manager

“The careful attention to epidemiology and monitoring, which would be a first priority for cancer or heart disease, has been neglected when dealing with the safety and quality of care” Charles Vincent et al, Is health care getting safer? BMJ, 2008,337,1205-1207