Lump sum needed

The positive messages taken from Sure Start Plus pilots for pregnant teenagers need to be rolled out nationally to improve unborn babies’ well-being, says Tim Root, but that will entail more investment

In April the pilot phase of the Sure Start Plus programme for pregnant teenagers ended. Last year’s official evaluation bestowed exceptional praise, finding that clients “were almost entirely positive” about the scheme. It boosted their emotional well-being, helped them preserve fragile family ties, obtain housing and benefits, and continue in education.

At a time when many clients felt overwhelmed, the scheme’s warm and empathic advisers were invaluable. One client said: “I don’t know what I’d have done without her.”(1) The government’s Independent Advisory Group on Teenage Pregnancy considered it “crucial that the many valuable elements of Sure Start Plus are retained and mainstreamed” throughout England. The government responded that this is a matter for local decision-making.

I asked national organisations whether they thought equivalent services for all pregnant teenagers would be provided throughout the country. All thought it would be worthwhile, but unlikely. Our antenatal services are seriously underresourced, partly because acute health services attract more interest. The national evaluation of maternity provision in Sure Start (for women of all ages) described how staff shortages in maternity services hamper their ability to help Sure Start antenatal programmes.(2)

Through children’s centres, the government plans to extend Sure Start’s coverage five-fold, but with only double the funding. Teenagers and other disadvantaged women, particularly those from Bangladeshi and Pakistani backgrounds, have low antenatal care attendance rates. Britain has a higher rate of low birthweight babies than most western European nations. Therefore I also asked the organisations how likely Sure Start would be to provide enough support for pregnant women at risk of having a low birthweight baby,  with post-natal depression, and not accessing antenatal care sufficiently.

Most organisations thought this was only slightly likely. The Royal College of Obstetricians and Gynaecologists referred to major concerns relating to the adequate funding of maternity services. The National Childbirth Trust was concerned about the small funding allocation to roll out Sure Start.

Antenatal services can offset many unborn babies’ disadvantages and potentially reduce deprivation. A large US study found that women who received no antenatal care were nearly six times more likely than other mothers to have a very low birthweight baby, and the infant mortality rate was five times greater.

A large study of British children found that those of low birthweight ceased education earlier and had lower earnings and poorer job  prospects at age 33. Other evidence shows that low birthweight weakens children’s cognitive development, even after smoking in pregnancy and various socio-economic factors, including the mother’s education level, are considered. It also leads to an increased incidence of disease in later life. Low income, relatively poor health and smoking during pregnancy all contribute independently to low birthweight. In addition, maternal stress impairs foetal growth and immune system development.

One major advantage of early antenatal care is the detection and treatment of sexually transmitted infections (STIs), which can otherwise cause problems including prematurity and  consequent lowered birthweight. The greater prevalence of STIs among teenagers than older women is an important reason for improving teenagers’ antenatal care attendance. Many  pregnant teenagers are uncomfortable attending antenatal care, feeling that they will be judged negatively by older patients and staff. Some areas have set up separate teenage antenatal clinics, which an Australian study found significantly reduced the rate of pre-term birth.(3)

 major cause of low birthweight is inadequate nutrition during pregnancy. A US programme giving poor pregnant women $35 (£20) worth of nutritious food a month made them less likely to give birth to an underweight or premature baby than other women. This achieved health savings which easily outweighed the cost of the programme. By comparison, the government’s new Healthy Start scheme will provide vouchers for fruit, vegetables or milk worth only £2.80 a week, restricted to pregnant women on income support or income-based jobseekers allowance. As  well as improving Healthy Start, public transport should be free during pregnancy to encourage antenatal care attendance.

The other major risk factor for low birthweight is smoking. Nearly half of women under 20 do so during pregnancy. Controlled trials found that the most successful schemes to quit smoking during pregnancy use financial reward and an element of social support. The NHS should start to offer a reward element. This would motivate some women who would otherwise recoil from the challenge of stopping smoking at such a  demanding time.

More evidence is emerging that stress during pregnancy harms children’s long-term mental development. A Bristol University study found that, even when birthweight, smoking and alcohol use in pregnancy, maternal age and education and other factors were considered, antenatal anxiety doubled the likelihood of children having behavioural or emotional problems. It was the  strongest factor in relation to girls’ behavioural or emotional problems, and second strongest for boys.(4)

In view of the harm stress causes, and the particularly anxiety-provoking nature of pregnancy, it is not surprising that programmes providing emotional and social support during pregnancy have proved effective. One well-evaluated US programme for disadvantaged women, starting before 28 weeks’ gestation and continuing until the child reached two, reduced abuse and  neglect, and health or accidental injury problems among the children. It also boosted birthweight, though in one trial only among single rather than married women.(5) A similar programme found that the mothers were more responsive to their children and gave them more freedom to play than comparable mothers.

It is also important to note that depression or stress during pregnancy and little social support are risk factors for post-natal depression. The only officially prescribed response to women deemed at high risk of post-natal depression is psychiatric referral. But, due to stigma and the other demands of pregnancy, few women would welcome such a referral. Many Sure Start local programmes run groups for women at risk of post-natal depression but do not refer to them thus. They provide mutual support and relaxing activities, such as swimming and holistic therapies. This suggests that massage would be a popular therapy for such women; research shows that it reduces depression, stress hormone levels and pain while boosting serotonin, which is understood to play a role in regulating mood.

Prime minister Tony Blair has emphasised the cost-effectiveness of helping children long before their problems become entrenched. Improved antenatal services could achieve this.

Root, Tim smallTIM ROOT is a senior practitioner with Hackney social services’ children and families, and previously an assistant team manager and approved social worker. He is the author of Love, Empowerment and Social Justice: Personal Relationships and Citizen Action, Open Gate Press, 2005

The author has provided questions about this article to guide discussion in teams. These can be viewed at and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

High quality antenatal care for women of all ages can help prevent low birthweight and reduce stress during pregnancy, which has recently been shown to harm children’s long-term mental development. Yet, unless the government starts to attach more importance to this, it is unlikely that antenatal services will receive adequate funding.

(1) Meg Wiggins and colleagues, Sure Start Plus National Evaluation: Final Report, Institute of Education, 2005
(2) Maternity Services Provision in Sure Start Local Programmes, National Evaluation of Sure Start, Sure Start Report 12, 2005
(3) Julie Quinlivan and Sharon Evans, “Teenage antenatal clinics may reduce the rate of preterm birth: a prospective study”, International Journal of Obstetrics and Gynaecology, 111, pp571-578, 2004
(4) G Thomas and colleagues and the ALSPAC Study Team, “Maternal Antenatal Anxiety and Behavioural/ Emotional Problems in Children”, Journal of Child Psychology and Psychiatry 44, pp1025-1036, 2003
(5) Helene Carabin and colleagues, “Does participation in a nurse visitation program reduce the frequency of adverse perinatal outcomes in first-time mothers?”, Pediatric and Perinatal Epidemiology, 19, pp194-205, 2005



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