Maternal vulnerability and birth interval in England: a retrospective analysis of hospital episode statistics

Introduction Several studies have shown that a short birth interval is associated with increased risks of adverse perinatal outcomes (e.g.: preterm birth, stillbirth) and neonatal and maternal death. It is unclear whether this relationship is likely to be causal or to reflect confounding due to psychosocial vulnerability. Objectives and Approach To determine the association between birth interval for mothers with and without indicators of vulnerability. Using Hospital Episode Statistics for England, we included mothers with a live birth in 2011. Vulnerability indicators were codes for mental health problems, adversity related injury (ARI), material or social disadvantage (M/SD) recorded in admissions in the previous five years, or age Time (in days) to next delivery within five years was analysed using Cox proportional hazard regression models and adjusted for maternal age, parity, multiple and preterm birth. Results Of 636,876 women delivering in 2011, 93,266 (14.6\%) had indicators of vulnerability: 63,421 (10.0%) for mental health problems, 8,229 (1.2%) for an ARI, 21,616 (3.4%) for M/SD, and 32,622 (5.1%) were teenage mothers. Over a third of mothers (242,401; 38.1%) had another live birth within five years. Median time to next delivery was 957 days (5-95% centiles: 433-1694), and was longest for teenage mothers (979 days, 391-1726), and shortest for women with ARIs (904 days, 391-1697). Vulnerable mothers were more likely than women with no vulnerability indicators to have another live birth (HRadj: 1.13, 95%CI: 1.12-1.14): risks were independently increased for teenage mothers (HRadj: 1.53, 1.50-1.55), women with an ARI (HRadj: 1.15, 1.11-1.19) or mental health problems (HRadj: 1.05, 1.03-1.06). Conclusion/Implications Vulnerable mothers had a shorter subsequent birth interval and an increased risk of birth in the next five years. Maternity care may be an appropriate time to target interventions to vulnerable families to enable choice about timing of subsequent pregnancy

Maternal vulnerability and birth interval in England: a birth cohort study using hospital episode statistics from 2006 to 2016

Aim To determine the association between birth interval for mothers with and without indicators of vulnerability. Methods We included mothers who gave birth in 2011 recorded in Hospital Episode Statistics. Vulnerability indicators included diagnostic codes for mental health problems, adversity related injuries (ARI), material/social disadvantage (MSD) recorded in the previous five years, or age <20 years at index delivery. We analyses birth interval using Cox proportional hazard models and adjusted for maternal and birth characteristics. Results We included 636,876 women, of whom 93,266 (14.6%) had indicators of vulnerability: 63,421 (10.0%) for mental health problems, 8,229 (1.2%) for ARI, 21,616 (3.4%) for MSD, and 32,622 (5.1%) were aged <20y. Over a third of mothers (242,401; 38.1%) had another live birth. Median birth interval was 957 days (5-95%centiles:433- 1694), and was shortest for women with ARIs (904 days,391- 1697). Vulnerable mothers were more likely than women with no vulnerability indicators to have another live birth (HRadj:1.13, 95%CI:1.12-1.14), particularly teenage mothers (HRadj:1.53,1.50-1.55). Conclusions Vulnerable mothers had a shorter subsequent birth interval and were more likely to have another birth in the next five years. Maternity care may be an appropriate time to target interventions to vulnerable families to enable choice about timing of subsequent pregnancy

Mental health service use among mothers involved in public family law proceedings: linked data cohort study in South London 2007-2019

PURPOSE: Mental health problems and substance misuse are common among the mothers of children who experience court-mandated placement into care in England, yet there is limited research characterising these health needs to inform evidence-based policy. In this descriptive study, we aimed to generate evidence about the type, severity, and timing of mental health and substance misuse needs among women involved in public family law proceedings concerning child placement into care ('care proceedings'). METHODS: This is a retrospective, matched cohort study using linked family court and mental health service records for 2137 (66%) of the 3226 women involved in care proceedings between 2007 and 2019 in the South London and Maudsley NHS Mental Health Trust (SLaM) catchment area. We compared mental health service use and risk of dying with 17,096 female-matched controls who accessed SLaM between 2007 and 2019, aged 16-55 years, and were not involved in care proceedings. RESULTS: Most women (79%) were known to SLaM before care proceedings began. Women had higher rates of schizophrenia spectrum disorders (19% vs 11% matched controls), personality disorders (21% vs 11%), and substance misuse (33% vs 12%). They were more likely to have a SLaM inpatient admission (27% vs 14%) or to be sectioned (19% vs 8%). Women had a 2.15 (95% CI 1.68-2.74) times greater hazard of dying, compared to matched controls, adjusted for age. CONCLUSION: Women involved in care proceedings experience a particularly high burden of severe and complex mental health and substance misuse need. Women's increased risk of mortality following proceedings highlights that interventions responding to maternal mental health and substance misuse within family courts should offer continued, long-term support

Indicators of adversity recorded in hospitalisation records of children aged less than 5 years or their mothers: a record linkage study of children born in England in 2011

Background Early identification of child adversity (comprising abuse, neglect, social or material adversity) is essential to target early interventions to safeguard children, and support vulnerable families. We determined the prevalence of indicators of adversity recorded in diagnostic codes in child and/or maternal hospital admissions in England. Data Source All birth admissions recorded in the NHS in England in 2011, and subsequent admissions up to 5 years old, linked to maternal records from 1 year before to up to 5 years after delivery. Methods Prevalence of adversity indicators in child and/or maternal admission records that reflect adversity-related injury (ARI), or social or material adversity (SMA). Results Among 646,956 live born children, 2.6% (95% CI: 2.6 to 2.7) had at least one adversity indicator by <5 years (0.8% ARI, 2.6% SMA). Cumulative prevalence was 1.1% in children aged <6 months, 1.2% in children aged <1 year, 2.1% by <=2 years, and 2.6% up to 5 years old. Combined prevalence in maternal and/or child records will be presented. Conclusion To inform health policy, clinical and prognostic significance of adversity indicators requires evaluation through linkage to health and welfare outcomes

Maternal mortality of women with opioid-use during pregnancy in England: investigating bias in a cohort of linked mother-baby hospital records

Introduction Opioid-addiction is a major public health threat, with rates of drug misuse related deaths increasing in North America and England. Linkage within and between administrative data datasets is important for capturing determinants and outcomes but this vulnerable population is highly susceptible to linkage error, which can result in inaccurate estimates. Objectives and Approach We investigated neonatal abstinence syndrome (NAS) as a marker of opioid-use in pregnancy, using linked mother-baby records to identify maternal opioid-use based on NAS in the baby’s record. Maternal all-cause mortality was compared for mothers with and without a NAS-pregnancy. Bias was assessed through comparison of linked and unlinked NAS baby characteristics. De-identified national hospital inpatient data – including postcode-district and GP surgery-code – were used for deterministic and probabilistic linkage of mothers and babies born in England 2002-2013. Linked national mortality data captured maternal deaths Results Linkage between maternal and baby records was possible for 96% of all live births in England, but for only 88% of study/cohort babies with NAS (n=18,087). NAS babies with unlinked records represented a more vulnerable population with longer hospital stay (median 12 versus 7 days, p<0.001), low birthweight (44% <2500g versus 27%, p<0.001) and discharge to social services (13% versus 8%, p<0.001) than NAS babies who could be linked to maternal records. Non-linkage may plausibly be driven by mismatching or missing identifiers reflecting adoption and out-of-home care arrangements for the baby, potentially also indicating greater maternal adversity. Within the linked cohort (comparing 13,581 women with a NAS baby and 4,205,941 women without a NAS baby), the crude hazard ratio for all-cause mortality was 12.1 (11.1-13.2). Conclusion/Implications Review of unlinked records suggests evidence of linkage bias, with the implication that our results may underestimate the risk of death among women with opioid-use. Complementary linkages, drawing on other data - such as birth records where the mother is named - could help address non-linkage driven by out-of-home care

Evaluating the real-world implementation of the Family Nurse Partnership in England: protocol for a data linkage study.

INTRODUCTION: Almost 20 000 babies are born to teenage mothers each year in England, with poorer outcomes for mothers and babies than among older mothers. A nurse home visitation programme in the USA was found to improve a wide range of outcomes for young mothers and their children. However, a randomised controlled trial in England found no effect on short-term primary outcomes, although cognitive development up to age 2 showed improvement. Our study will use linked routinely collected health, education and social care data to evaluate the real-world effects of the Family Nurse Partnership (FNP) on child outcomes up to age 7, with a focus on identifying whether the FNP works better for particular groups of families, thereby informing programme targeting and resource allocation. METHODS AND ANALYSIS: We will construct a retrospective cohort of all women aged 13-24 years giving birth in English NHS hospitals between 2010 and 2017, linking information on mothers and children from FNP programme data, Hospital Episodes Statistics and the National Pupil Database. To assess the effectiveness of FNP, we will compare outcomes for eligible mothers ever and never enrolled in FNP, and their children, using two analysis strategies to adjust for measured confounding: propensity score matching and analyses adjusting for maternal characteristics up to enrolment/28 weeks gestation. Outcomes of interest include early childhood development, childhood unplanned hospital admissions for injury or maltreatment-related diagnoses and children in care. Subgroup analyses will determine whether the effect of FNP varied according to maternal characteristics (eg, age and education). ETHICS AND DISSEMINATION: The Nottingham Research Ethics Committee approved this study. Mothers participating in FNP were supportive of our planned research. Results will inform policy-makers for targeting home visiting programmes. Methodological findings on the accuracy and reliability of cross-sectoral data linkage will be of interest to researchers

Determinants of accident and emergency attendances and emergency admissions in infants: birth cohort study

BACKGROUND: There is limited understanding of the drivers of increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations. METHODS: Birth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1-April-2012 and 31-March-2019 were followed up for 1 year; from 1-April-2013 (from the discharge date of their birth admission) until their first birthday, death or 31-March-2019. Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted for individual-level factors and included a random effect for local authority (LA). RESULTS: The cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendances and emergency admissions were highest amongst: infants born < 32 weeks gestation; with presence of congenital anomaly; and to mothers < 20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority. CONCLUSIONS: Drivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. The impact of these services requires further investigation. Substantial geographical variations in rates were not explained by individual-level factors. This suggests more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority

Trends in hospital admissions during transition from paediatric to adult services for young people with learning disabilities or autism: Population-based cohort study

Summary Background Transition from paediatric to adult health care may disrupt continuity of care, and result in unmet health needs. We describe changes in planned and unplanned hospital admission rates before, during and after transition for young people with learning disability (LD), or autism spectrum disorders (ASD) indicated in hospital records, who are likely to have more complex health needs. Methods We developed two mutually exclusive cohorts of young people with LD, and with ASD without LD, born between 1990 and 2001 in England using national hospital admission data. We determined the annual rate of change in planned and unplanned hospital admission rates before (age 10–15 years), during (16–18 years) and after (19–24 years) transition to adult care using multilevel negative binomial regression models, accounting for area-level deprivation, sex, birth year and presence of comorbidities. Findings The cohorts included 51,291 young people with LD, and 46,270 autistic young people. Admission rates at ages 10–24 years old were higher for young people with LD (54 planned and 25 unplanned admissions per 100 person-years) than for autistic young people (17/100 and 16/100, respectively). For young people with LD, planned admission rates were highest and constant before transition (rate ratio [RR]: 0.99, 95% confidence interval [CI] 0.98–0.99), declined by 14% per year of age during (RR: 0.86, 95% CI: 0.85–0.88), and remained constant after transition (RR: 0.99, 95% CI: 0.99–1.00), mainly due to fewer admissions for non-surgical care, including respite care. Unplanned admission rates increased by 3% per year of age before (RR: 1.03, 95% CI: 1.02–1.03), remained constant during (RR: 1.01, 95% CI: 1.00–1.03) and increased by 3% per year after transition (RR: 1.03, 95% CI: 1.02–1.04). For autistic young people, planned admission rates increased before (RR: 1.06, 95% CI: 1.05–1.06), decreased during (RR: 0.95, 95% CI: 0.93–0.97), and increased after transition (RR: 1.05, 95%: 1.04–1.07). Unplanned admission rates increased most rapidly before (RR: 1.16, 95% CI: 1.15–1.17), remained constant during (RR: 1.01, 95% CI: 0.99–1.03), and increased moderately after transition (RR: 1.03, 95% CI: 1.02–1.04). Interpretation Decreases in planned admission rates during transition were paralleled by small but consistent increases in unplanned admission rates with age for young people with LD and autistic young people. Decreases in non-surgical planned care during transition could reflect disruptions to continuity of planned/respite care or a shift towards provision of healthcare in primary care and community settings and non-hospital arrangements for respite care. Funding National Institute for Health Research Policy Research Programme

Maternal adversity and variation in the rate of children entering local authority care during infancy in England: a longitudinal ecological study

Background In England, the rate at which infants enter care varies considerably by local authority, with little evidence on what drives these differences. Decisions instigating infant entry into care may be triggered by child protection concerns arising from parental ill-health or risky behaviour from pregnancy onwards. Main Aim We explored the extent to which adversity indicated within women’s hospitalisation history, pre-delivery, explained differences in rate of infant entry into care between local authorities. Methods/Approach Combining data from several sources (Office for National Statistics Population Estimates, Public Health England Fingertips, 2011 Census, Children Looked After Return, and Hospital Episode Statistics), we derived population-level predictors for entry into care (i.e. local case-mix) for 131 English local authorities from 2006/07 to 2013/14. Our primary outcome was rate of infant entry into care. We used linear mixed-effects models to analyse the relationship between the outcome and percentage of live births with maternal history of adversity-related hospital admissions (i.e. any admission indicating substance misuse, mental ill-health, or violence, up to 36 months pre-delivery), adjusting for other case-mix measures. Results Rate of infant entry into care (mean: 85.16 per 10,000 [min-max: 0.00-318.51]) and percentage of live births with maternal history of adversity-related hospital admissions (4.62%, [0.52-16.19%]) varied greatly by local authority. Prevalence of maternal adversity accounted for 24% of variation in rate of entry (95% CI: 14-35%). After adjustment, there was evidence that a percentage point increase in prevalence of maternal adversity - both over time and between local authorities - is associated with an extra 2.56 infants, per 10,000, entering care (1.31-3.82). Conclusion Prevalence of maternal adversity prior to birth helps to explain differing rates of infant entry into care among local authorities. Further research using individual-level linked parent-child data is required to ascertain whether interventions to reduce maternal adversity before birth would decrease rate of infant entry into care