Greater Manchester: reducing infant mortality and promoting child health.
Abstract: Targeting services in order to reduce health inequalities is a key national priority. This paper describes a project funded by the Greater Manchester Public Health Network looking at service provision to reduce infant mortality and promote child health across Greater Manchester. The aim of this was to improve standards of care by setting a standard service provision for targeting services toward the most deprived groups. It involved the production of child health indicators, a literature review, standard setting, dissemination of findings, collation of data and production of a service pathway for breastfeeding, smoking cessation, nutrition and postnatal depression.

Key words

Breastfeeding, inequalities, smoking cessation, postnatal depression

Key points

* There is a lack of UK evidence supporting interventions to reduce child health inequalities

* Inequalities work needs to be targeted to the appropriate disadvantaged populations

* All health visiting and midwifery records should contain a basic dataset to enable an effective audit trail of interventions and to improve service delivery

* Sharing of good practice is important in working with disadvantaged families
Article Type: Report
Subject: Health promotion (Methods)
Public health (Management)
Infants (Patient outcomes)
Infants (Control)
Children (Health aspects)
Children (Management)
Authors: Smith, Caroline A.
Wilmott, Danita
Baker, Deborah
Pub Date: 02/01/2009
Publication: Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Ten Alps Publishing ISSN: 1462-2815
Issue: Date: Feb, 2009 Source Volume: 82 Source Issue: 2
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs SIC Code: 8000 HEALTH SERVICES
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 192802937
Full Text: Introduction

Greater Manchester has one of the lowest life expectancies in England--seven out of 10 local authorities have scores within the top quartile of the Index of Multiple Deprivation. (1) Child poverty translates into social disadvantage, which negatively affects life chances from birth onward. Recent policy documents have acknowledged this, emphasising the crucial role of preventative action and intervention in order to ensure that children have the best possible chance to reach their full potential. (2)

A supradistrict audit of health inequalities in under-fives was completed in Greater Manchester in 2005. (3) It concluded that recommendations for reducing inequalities as outlined in the Acheson report (4) were not being implemented equally or consistently across all geographical areas, services and populations. Despite some progress in recent years, Greater Manchester as a whole is still not projected to achieve the key public service agreement (PSA) targets, (5) especially in relation to inequalities in health, though some areas will meet some aspects of them.

The Greater Manchester Public Health Framework consisted of 16 inter-related projects, all of which contribute in the short, medium or long term to the objective of improving the health of the population and reducing health inequalities. Each project was led by a director of public health and project manager, and overseen by the director of health improvement.

The Reducing Infant Mortality and Promoting Child Health Across Greater Manchester project aimed to address and improve standards of care and outcomes for children and families within the area. It involved informing existing networks and structures with clear guidance and advice in relation to service improvement, to secure progress against key national and local targets. The project was funded by the Greater Manchester Public Health Network and ran for 18 months from the end of 2006. Most of its work related to the promotion of child health, with a view to reducing infant mortality.

Project context

The project was led by the deputy director of public health of a local primary care trust (PCT), and was managed jointly by health visitors and midwives from Stockport PCT who had co-ordinated the supradistrict audit. The project comprised three parts:

* The production and dissemination of child health indicators for the Greater Manchester area

* A literature review to inform setting of standards, in order for preventative services to improve child health in Greater Manchester (6)

* Networking to disseminate the findings of parts one and two to address inequalities in child health, and the development of a health promoting pathway from the standards produced in part two.

The focus of the project was to improve standards of care and outcomes, reduce infant mortality and promote child health for the under-five population and their families within Greater Manchester. This overlapped with many other projects, in particular smoking and obesity. One key aim was to inform PCTs' commissioning decisions in order to embed required service changes into contract standards.

Initially, it was proposed that there would be a steering group consisting of stakeholders such as health visiting and midwifery leads, commissioners and smoking cessation advisors. However, it eventually comprised the project lead, director, the two co-ordinators and--for the length of their part of the project--two University of Salford researchers.

The work was reported on to the PCT Directors of Public Health Group and to the area's Public Health Programme Board.

Running the project

Part one: indicators and profiles

The North West Public Health Observatory (NWPHO) was commissioned to produce a set of child health indicators, (7) based on the five themes of Every child matters. (2)

Their report provides a profile of the health and wellbeing of 1.7 million children and young people in each area across the North West of England against 50 different indicators. (7) The profiles also display North West and England averages, and North West local authority interquartile ranges for comparison purposes. Additional charts illustrate each local authority's position in the North West for each indicator.

It is published alongside an online health profiler tool. Information will enable local authorities, NHS and other local agencies to identify and tackle local issues. An associated report to accompany the data is available for download online. The online tool was first demonstrated at the launch of the North West Framework for Achieving Healthy Weight for Children and Families part of the region's obesity strategy--in February 2008.

Part two: review and standards

Researchers at the University of Salford were commissioned to undertake an extensive literature review of interventions to address inequalities in child health, and to produce evidence-based standards for the provision of preventative services that can potentially reduce child health inequalities across Greater Manchester. (6)

From this, an evidence base summarising the known benefits of selected preventative interventions for improving child health was formulated. The researchers reviewed four subject areas that had been included in the supradistrict audit:

* Smoking cessation in pregnancy

* Initiation and continuation of breastfeeding

* Improving nutrition in pregnancy

* Identification and management of postnatal depression.

Qualitative data were obtained through focus groups in order to identify possible barriers to implementation of the proposed standards, and identify innovative practices that have been used to overcome problems within Greater Manchester. This was done by discussing the preliminary standards in structured interviews (focus groups) with key healthcare professionals, including midwives and health visitors in four contrasting sites--Trafford (postnatal depression), Heywood and Middleton (smoking cessation), Wigan (nutrition) and Salford (postnatal depression). These areas were chosen because data from the supradistrict audit showed them to be tackling the problems of health disadvantage in their communities by implementing procedures that were indicative of a high standard of care.

Standards for systematic delivery were produced for each of the four interventions (see Table 1). The vulnerable groups identified from the most recent evidence were:

* Low-income women

* Adolescent mothers

* Minority ethnic women. A dataset was also produced. (6)

Part three: influencing commissioning The third part was the least defined and evolved during the course of the project.

Two specialist community public health nurses were recruited to undertake this role as a jobshare post. As the co-ordinators of the child health inequalities audit, they were well placed to build on the established network of lead professionals, commissioners, directors of public health and North West Government Office, to disseminate the evidence-based standards produced by the University of Salford and translate them into workable practice across the area.

The broad aim of the project was to improve standards of care and outcomes within the NHS to reduce infant mortality and promote child health. The original objectives were to:

* Promote parenting in schools and colleges via healthy schools and colleges

* Reduce smoking in pregnancy and the postnatal period

* Encourage uptake of antenatal screening

* Encourage antenatal assessment of risk relating to parenting skills

* Encourage antenatal assessment of risk of postnatal depression and postnatal management of mental illness

* Encourage provision and uptake of parenting training in the antenatal and postnatal period

* Promote initiation and maintenance of breastfeeding

* Promote uptake of neonatal screening--hearing screening and blood spot screening for medium-chain acylcoenzyme A dehydrogenase deficiency (MCADD), phenylketonuria, hypothyroidism and cystic fibrosis

* Encourage intensive support for high-risk families in the postnatal period

* Encourage uptake of day care and preschool education.

The co-ordinators met initially with senior members of local PCTs and hospital trusts, including commissioners, heads of service and the lead for the Children, Young People and Families Network Supervisory Board to discuss the project aims. It was envisaged that recommendations from the project would be included in the commissioning report for Greater Manchester, and it was important to try to influence commissioners at the early stage of commissioning process.

Several interactive sessions were arranged with leads of midwifery and health visiting to discuss the aims of the project and ascertain how service leads from across Greater Manchester could contribute to it. The project was designed to take both a bottom-up and a top-down approach, with the aim of including the standards in the commissioners' report and consultation with leads of service in order to ensure they were attainable and flexible to meet the service needs of local populations.

These meetings provided a forum for sharing best practice within Greater Manchester. Topics discussed included the use of a common dataset for health visiting and midwifery records. Problems relating to adequate and equitable screening for postnatal depression in mothers from black and minority ethnic (BME) populations were discussed at length, and copies of the Unite/CPHVA How are you feeling? training and resource pack (8) were obtained for each PCT and hospital trust to help with this and with problems in recruitment and training.

The project co-ordinators sat on the operational group for the NWPHO child health indicators, and also the steering group for the North West Breastfeeding Framework for Action (9) that was launched in Blackburn in February 2008.

Commissioners were continually informed of the progress of the standards, which are now to be incorporated into the commissioners' report as hoped.

A pathway for service provision for the antenatal and early postnatal period (up to three months) was developed, utilising knowledge and information from indicators (part one), review and standards (part two) and leads of service meetings (part three). The aim of the pathway was to help trusts to target service provision, as recommended in the updated Child Health Promotion Programme. (10)

It was anticipated that this pathway would be used by all hospital trusts and PCTs in Greater Manchester to address inequalities in child health, provide uniformity of service provision and promote more robust monitoring of what interventions may be effective. It has since been amended to reflect National Institute for Health and Clinical Excellence (NICE) guidance on antenatal and postnatal mental health (11) and on routine antenatal care. (12)

The project was extended for a further six months to promote wider dissemination, in order to continue the work around the pathways and to develop a new role to extend the work further.

The committee organised a successful conference titled 'Reducing inequalities in child health' in October 2008, to disseminate the findings from the project and related topics to an even wider audience.

Future plans

There are plans to appoint a Healthy Child co-ordinator, placed within the Children, Young People and Families Network Supervisory Board for Greater Manchester. This will be a unique role, looking at health promotion and the healthy child rather than only considering the 'ill' child, to enable all children to achieve their full potential. This will be a joint appointment between the Public Health Network and the supervisory board. As part of this role, it is proposed that midwifery and health visiting leads will be supported in forming a group to promote equality of service provision, benchmarking and sharing of good practices across Greater Manchester.

It is also likely that another research project will be commissioned from the University of Salford in order to review further inequalities data.

Implications for practice

Postnatal depression

The use of the Edinburgh Postnatal Depression Scale (EPDS) or appropriate screening tool in the early postnatal period is recommended in the NICE mental health guidance. (11) This has since been amended to specify that this should be done at four to six weeks' gestation, and professionals should ask two questions to identify possible depression:

* 'During the past month, have you often been bothered by feeling down, depressed or hopeless?'

* 'During the past month, have you often been bothered by having little interest or pleasure in doing things?'

Also recommended is the use of literature on postnatal depression in languages other than English, and the setting up of antenatal classes for BME women and their families. Delivering screening for postnatal depression at an earlier stage may impact on the midwifery service, and it is envisaged that addressing postnatal depression will involve joint working between midwives and health visitors. If the pathway is followed, the most 'at-risk' women will have been identified in the antenatal period and packages of care put in place.


Breastfeeding should be promoted and supported by the provision of antenatal classes for BME mothers and their families, 'deprived' groups and teenagers, and with 24-hour support in the postnatal period, such as via the National Breastfeeding Helpline. It is expected that this would be provided by each local maternity hospital as part of their delivery suite contact.

Health visiting and midwifery services will need to look at parentcraft provision, both in terms of content as well as targeting specifically and appropriately for the most 'at-risk' groups. This may involve providing parentcraft in ethnically diverse locations, schools and other community venues in more deprived areas in order to reach these high-risk groups. There is similarly a need to offer targeted breastfeeding support, as traditionally it is the middle class who use these support groups. (6) Peer supporters also need to be recruited from within high-risk groups.

Smoking cessation

All midwives and staff who come into contact with clients who smoke should be trained to level one NHS Health Development Agency standard smoking cessation training for brief interventions. (13) A smaller group of key personnel should also be trained to level two--intensive one-to-one support and advice--in order to provide smoking support groups and home visits for poor clinic attendees. The provision of a 'specialist stop-smoking midwife' in one area has proved successful. (6)

Poor clinic attendance might result from feeling pressurised about smoking cessation, (6) and these women should be followed up at home if necessary.


A nutrition questionnaire should be offered to all women at booking, followed by midwifery-led food skills workshops--though the evidence points to other professionals delivering the workshops, such as local peer trainers (14)--and the prescribing of folate for all pregnant women up to 12 weeks' gestation. For some of these interventions to take place, work may need to focus on activities with measurable outcomes.


The literature review uncovered a dearth of evidence relating to services that work to reduce inequalities and target service provision. There is an urgent need for more good quality research in these areas. The standards report was strengthened by the collection of qualitative data, supporting the evidence from the literature review.

The pathway for recommended antenatal and postnatal care for service users within Greater Manchester, produced from the three parts of the project, is perhaps the best summary of all of the work involved in it. It has been demonstrated to commissioners and heads of maternity and children's service delivery across the area, with some success in service uptake.

Working to these standards in the long term will enable the provision of evidence-based services with the best outcomes for children and families, allowing them to reach their full potential.

The forthcoming final report on the whole project will recommend that all Greater Manchester midwifery and health visiting electronic and paper records should include a basic dataset. It will also recommend regular meetings between leads of health visiting and midwifery in order to discuss common issues, good practice and audit.

Within the modern NHS, trusts are looking to target service provision, and there is a need for a named co-ordinator who would liaise with personnel to inform on policy documents and projects in order to target and promote child health within Greater Manchester's children's services.

The final report will also recommend an on-going audit review of service provision once a baseline standard has been produced, in order to address the issues of inequalities in child health.


(1) Department for Communities and Local Government. Indices of Deprivation 2004. Oxford: Social Disadvantage Research Centre, 2004.

(2) HM Government. Every child matters: change for children. London: Stationary Office, 2004.

(3) Wilmott D, Smith C. Inequalities in child health, nough to five years: a Greater Manchester supradistrict audit. Manchester: Greater Manchester Public Health Network, 2005.

(4) Acheson D. Independent inquiry into inequalities in health: report. London: Stationery Office, 1998.

(5) Razzaq A. Greater Manchester health inequalities review: Audit Commission audit 2005 to 2006 and 2006 to 2007. Manchester: Trafford Healthcare NHS Trust, 2007.

(6) Baker D, McCluskey S. Setting standards for preventative services to reduce child health inequalities in Greater Manchester. Salford: University of Salford, 2007.

(7) North West Public Health Observatory. North West children and young people's health indicators. Liverpool: North West Public Health Observatory, 2008. Available at: (accessed 6 January 2009).

(8) Adams C, Sobowale A. How are you feeling? Resource and training pack. London: CPHVA, 2004.

(9) North West Regional Public Health Group. Addressing health inequalities: a North West Breastfeeding Framework for Action. Manchester: North West Regional Health Group, 2008.

(10) Shribman S, Billingham K. The Child Health Promotion Programme: pregnancy and the first five years of life. London: Department of Health, 2008.

(11) National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management service guidance. London: National Institute for Health and Clinical Excellence, 2007

(12) National Institute for Health and Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman. London: National Institute for Health and Clinical Excellence, 2008.

(13) National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. London: National Institute for Health and Clinical Excellence, 2008.

(14) Department of Health. Choosing a better diet: a food and health action plan. London: Stationery Office, 2005.

Caroline A Smith MSc, BSc, RHV, RM, RN

Child Health Network project co-ordinator, health visitor and health and housing officer, Stockport Primary Care Trust

Danita Wilmott BSc, RHV, RM, RN

Child Health Network project co-ordinator, health visitor and newborn screening link, Stockport Primary Care Trust

Deborah Baker PhD, BSc

Director, Centre for Public Health Research, University of Salford
Table 1. Standards (6)

                           National target
Standard                   or guidance

To reduce inequalities     To breastfeed exclusively
in initiation and          for six months
continuation of

To reduce inequalities     The National Service
in identification and      Framework for mental
management of              health suggests that
postnatal depression       trained health visitors
                           should identify postnatal
                           depression promptly

To reduce inequalities     To reduce the prevalence
in maternal smoking        of women smoking
                           throughout pregnancy
                           from 23% to 15%
                           by 2010

To reduce inequalities     Multivitamins and folic
in maternal nutrition      acid recommended before
                           conception and in early
                           pregnancy in order to
                           reduce incidence of neural
                           tube defects

                           Evidence-based interventions
                           effective among low-income
                           women, Asian women, deprived
Standard                   populations and adolescent mothers

To reduce inequalities     * Peer support
in initiation and
continuation of            * UNICEF UK Baby Friendly Initiative
                           * Professional support, breastfeeding

                           * Family support

To reduce inequalities     * Routine postpartum EPDS
in identification and        administration--low-income
management of                and adolescent mothers
postnatal depression
                           * Culturally appropriate screening
                             tool--South Asian and black
                             British women

                           * Culturally appropriate information
                             and resources on postnatal depression

                           * Antenatal assessment

                           * Postnatal assessment

                           NICE recommends managed clinical
                           networks for the delivery of
                           perinatal mental health services to
                           be established throughout the country,
                           including specialist perinatal
                           services in each locality

To reduce inequalities     * Effective referral procedures to
in maternal smoking          smoking cessation clinics

                           * Nicotine replacement therapy

                           * Home visits to offer support and
                             advice, including partner or family
                             members where appropriate

                           * Peer support groups

To reduce inequalities     * Antenatal nutrition programme
in maternal nutrition
                           * Community-based food skills

                           * Nutritional screening
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