1. Early Years Pathfinder Project
Insert name of presentation on Master Slide 1

2. “Giving every child a healthy start”
“Giving every child a healthy start” Fairer Health Outcomes for All WG 2011
Pre-conception
Pregnancy
Birth
0 – 5 years
There is overwhelming evidence now that an individual’s life chances, their health, social and economic outcomes, are deeply rooted in the first five years of life, including pregnancy. The Marmot review made a strong case for investment in the early years and Welsh Government are committed to giving every child in Wales a healthy start as one of the key action areas for reducing inequalities in Wales.

3. Giving every child a healthy start
Pre-conception
Pregnancy
Birth
0 – 5 years
To explore how an explicit evidence based approach and coordination could add value to the public health activity in Wales on early years health.
Recognising that there is already a lot of public health activity in this area, this pathfinder was set up in December 2010 to explore how public health wales can add value, using an explicit evidence based approach, drawing upon and helping coordinate existing expertise and functions across Wales, including Public Health Wales itself, academia and other health partners and agencies.
This is a major new initiative, it has the backing of the Chief Medical Officer and was also endorsed by the First Minister in his speech at the 1st Annual Welsh Public Health Conference a few weeks ago.
I am going to explain the approach we have taken, our progress so far and outline the next steps for taking forward a Reproductive and Early Years programme for Wales..
Pathfinder -

4. 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
We have taken a life-course approach and this diagram shows the various biological, social and environmental factors affecting birth and early years outcomes, and the complex inter-relationships between them.

5. Reproductive and Early Years Epidemiology
Pre-conception
Pregnancy
Birth
0 – 5 years
Reproductive and Early Years Epidemiology
Measuring and tracking progress on outcome indicators (surveillance)
Evidence synthesis
I will first take you through some of the data relating to Reproductive and Early Years epidemiology and then outline the work that we have done so far in terms of developing a reproductive and early years surveillance system , and mapping the evidence base.

6. Reproductive and Early Years Epidemiology
Pre-conception
Pregnancy
Birth
0 – 5 years
I am going to show you some data now focussing specifically on maternal obesity and smoking and related birth and child health and social outcomes.

7. 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

8. 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

9. Data from the Infant Feeding Survey 2010: Early Results
Smoking and Pregnancy by mother’s socio-economic classification (NS-SEC) (2010)
This is data from the 2010 infant feeding survey, about a third of pregnant women in Wales smoke either before or during pregnancy, with higher rates in lower socio-economic groups. Extrapolating this to births in Wales, that is about 12,000 babies a year exposed to the effects of cigarette smoking.
Base: All stage 1 mothers – weighted base (15,722)
Data from the Infant Feeding Survey 2010: Early Results

10. Outcomes attributable to smoking
Population attributable risks
Stillbirth 7%
Prematurity 15%
Sudden Unexpected Infant Death 26%
Low birth weight 30%
Cigarette smoking accounts for 7% stillbirths, 15% preterm births, 1 in 4 Sudden Infant deaths and nearly a third of low birth weight babies.
Source: 1. (NICE) PH26 Quitting smoking in pregnancy and following childbirth: costing template. 2. Public Health 2007;121: Lancet 2011;377:

11. Public Health Wales Observatory
This slide shows the infant mortlaity rtate for the most deprived, and least deprived, and it looks like the gap has widened between 2002 and 2008.
Public Health Wales Observatory

12. Low birth weight Public Health Wales Observatory
This slide shows low birth weight rates for Wales, and you can see there is variation between local authority areas, with highest rates in Blaenau Gwent and Merthyr Tydfil, and lowest rate in Monmouthshire.
Public Health Wales Observatory

13. Inequalities in preterm birth <36 weeks
There are also persisting inequalities in preterm birth rates, with rates in the most deprived fifth of the population at least 20% higher than in the least deprived fifth of the population.
Source: AWPS and NCCHD

14. Odds ratio of passing KS1 95% CI
Wales Electronic Cohort of Children (Lyons et al)
150,000 children, key stage 1, , pass rates adjusted for deprivation measure.
Gestational age
Odds ratio of passing KS1
95% CI
24-28
0.34
29-32
0.53
33-36
0.72
37-42 (TERM) 1
High rates of preterm birth matter because babies born preterm have lower educational attainment. This slide shows data from the Wales Electronic Children’s cohort. This is data on 150,000 children born and resident in Wales, their health data from the child health system record linked to education data for Key stage 1 results. Children born preterm were less likely to achieve a pass at Key Stage 1 compared to children born at term, and there is a dose response relationship with poorer outcomes at lower gestational ages, even after adjusting for the effects of social deprivation. This outcome is measured at age 7-8 years, so what about earlier indicators?

15. Early Years outcome indicators
Language delay
Social and emotional capability
Physical (BMI)
Child development
Maternal mental health
Positive parenting
Parent
We know from work by Marmot, Frank Field and Graham Allen that language delay, and children’s social and emotional capability are powerful markers of child development, and their readiness for school. We also know that parent factors are important, so identifying when a child is vulnerable and a family needs help because of mental health or parenting issues is important. We do not currently systematically collect data on these factors in Wales. At a population level these data can be powerful in helping Local Authorities identify areas that require more intense services to address need. This is where we can probably learn from what other countries have done.

16. Learning from Glasgow Scottish Government and Glasgow City Council
assessment of children’s emotional wellbeing at school entry
Maps of distribution of emotional problems
In Glasgow following a successful pilot project by the University, they now assess children’s emotional and behavioural wellbeing at school entry using the Strengths and Difficulties Questionnaire. The data has allowed them to describe the emotional and behavioural wellbeing of children entering school in Glasgow. They have maps of conduct and hyperactivity problems and can show that the prevalence of these problems is about 50% higher in the most deprived parts of the city compared with the most affluent. It allows for analysis of individual and local predictive factors and also provides a baseline for future comparisons.

17. Figure 1: Proportion of children classified as vulnerable by the Early Development Instrument, Vancouver, 2007.
I havent got a map from Glasgow but I can show you one from Vancouver, Canada. They started doing this four years ago. This map shows the proportion of children classified as vulnerable by the Early Development Instrument. They have published four maps now and these have been a huge stimulus to local service development and reductions in social inequalilty.
Hertzman C , Williams R CMAJ 2009;180:68-71
©2009 by Canadian Medical Association

18. Key points from Canada
Measurement systems are key for improved childhood development outcomes because “what gets counted, counts.”
A high-quality measurement system is critical to determining what support systems are needed for children.
... coordination, refinement and a national implementation and dissemination strategy are needed.
And these are the key points from the Canadian experience:
1. Measurement systems are key and critical to determining what support systems are needed for children
2. What gets counted, counts – What gets measured gets done
3. The need for a national coordinated approach for implementation and dissemination.
CMAJ. 180:68-71

19. Measuring and tracking progress on outcome indicators
Pre-conception
Pregnancy
Birth
0 – 5 years
So coming back to the pathfinder, I am going to tell you now about the work package dedicated to developing a surveillance system to measure and track progress on outcome indicators for each stage of the early life course. Rosalind Reilly, Nathan Lester and Ray Henry have been instrumental in developing and taking this forward.
Rosalind Reilly, Nathan Lester, Ray Henry

20. Outcome indicators
Pregnancy
Smoking
Obesity
Alcohol
Mental health
Vulnerable groups
Birth
Pre-term birth
Low birth weight
Breast feeding
Infant mortality
0 – 5 years
Hospital admissions
Injuries
Language delay
Social and emotional capability
School readiness
Parenting
Maternal mental health
We have compiled a list of indicators which will need refinement and prioritisation. The indicators for pregnancy and birth will be linked to the recently published Maternity Strategy for Wales as this pathfinder is supporting the work of the Maternity Strategy Implementation Group. We will also want to capture interventions at an individual level so that we can track outcomes related to these.
We have explored the availability and quality of data items required. Some data items such as smoking, obesity, alcohol intake are all captured on the antenatal hand-held record and entered to varying extents on to maternity information systems. In some Health Boards these data are not entered onto a database but are available as paper records. However some data items such as low birth weight are collated centrally in the National Community Child Health Database (NCCHD) with good completeness, but others such as smoking during pregnancy have varying completeness between Health Boards.
Need to also capture interventions at an individual level

21. Smoking data in Wales Cwm Taf 3,982 96% 21% BCU 6,858 89% 17%
Health Board
Total births
Data completeness (%)
Smoking prevalence (%)
Cwm Taf
3,982
96%
21%
BCU
6,858
89%
17%
Hywel Dda
3,254
86%
11%
ABMU
6,050
27% 2%
CVU
6,031 5%
98% AB
5,928
0.5%
13%
Source: NCCHD 2009
This slide shows data completeness for smoking by hospital. Completeness ranges from 0.5% to 96%. Further, data on smoking is only captured once, and there is no data available on smoking prevalence in the second and third trimester.

22. 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

23. Processing Server (SAIL) Reporting Server (NWIS)
Analysis Services
(OLAP)
Data Mart
Processing Server (SAIL)
Conformed
Dimensions
Reporting Server (NWIS)
Web Server
Storage Area
Reporting Services
User Interface
Staging Area
Transform
Extract Data
Loading
Data Source
Can we do it?
Central Information Warehouse
Ray Henry has looked at the feasibility of extracting the relevant data from maternity information systems, Stop Smoking Wales and other relevant datasets and it is feasible. The next step is for us to set up a pilot project for a reproductive and early years surveillance system.

25. Evidence of effectiveness and cost of interventions
Pre-conception
Pregnancy
Birth
0 – 5 years
We have a work package on evidence synthesis, this is about mapping the evidence of effectiveness of interventions to each stage of the early life course. Siobhan Jones Jon Brassey and the Attract team have been taking this forward.
Siobhan Jones, Jon Brassey, ATTRACT Team, Rosalind Reilly, Stella Botchway

26. EVIDENCE SYNTHESIS 1. What should we be doing. 2
EVIDENCE SYNTHESIS 1. What should we be doing? 2. What will the impact be? 3. What programmes are in place?
Essentially we were asking two questions – what does the evidence say we should be doing, and if we did this, what would the impact be?

27. 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
The approach taken has been focussed on identifying recommendations from NICE guidance and the underpinning evidence (e.g. effect sizes for extrapolation to Welsh data). The column on your left shows the interventions where there is clear evidence for good early years outcomes, and the majority, as Siobhan’s mapping has shown are implemented to varying extents in Wales.
With smoking cessation we need to do some more work to address specific questions such as What are the most effective models for providing smoking cessation services to pregnant women in local settings?
I have highlighted Family Nurse partnerships in red, as we have not implemented this in Wales. This is a programme of at least 30 hours input by a health visitor or midwife, for teenage girls who are pregnant, starting from mid pregnancy untill the child is 2 years of age. Long term follow up in the US has shown improvements in health and social outcomes for both the mother and the child. The programme has been adapted for use in England and is currently being evaluated in a randomised controlled trial.
The evidence is less clear for what to do about obesity or reducing inequalities.

28. What interventions are in place?
Variation between Health Boards
Pathways for obesity, smoking cessation and perinatal mental health
Flying start – variation in parenting programmes used
The mapping of current activities has been more difficult than expected as there is not currently a straightforward way of ascertaining all the interventions in place across Wales. The information captured has highlighted that there is considerable variation across Wales in relation to the programmes and interventions in place and in how these are being delivered. . Keeping pace with the activity that is taking place is a challenge and we will be linking with Directors of Public Health to establish local co-ordinators in the health boards to provide local knowledge.

29. What will the impact be?
Need modelling of potential impact of risk factors and interventions to inform effective targeting of action

30. Reducing inequality gap in infant mortality by 10% in England
IN ROUTINE & MANUAL GROUP
Reducing teenage pregnancies by 44% (↓1%)
Prevent 10% SUDI (↓ 1.4%)
Reducing smoking in pregnancy by 2% (↓ 2%)
Reduce obesity to 23% (↓ 2.8%)
Pre-conception care, reducing infections, improve nutrition, reduce poverty, improve housing (↓ 2.8%)
DOH Review of Health Inequalities Infant Mortality PSA Target

31. Summary of next steps
Finalise outcome indicators, aligned with the Welsh Government Maternity Strategy.
Pilot a Reproductive and Early Years Surveillance System.
Review literature focussing on specific questions that address effectiveness of interventions and models of service provision.
Model potential impact of risk factors and interventions to inform effective targeting of action

32. Acknowledgements Siobhan Jones Rosalind Reilly Stella Botchway
Nathan Lester
Ray Henry
Susan Belfourd
Ruth Coomber

33. Is my future bright?