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Nice guidance

Pregnancy and social difficulties

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A new NICE guideline advises how to care for pregnant women in difficult circumstances who may be reluctant to use services

There is overwhelming evidence that pregnant women in difficult social circumstances need better support and care. The National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence have therefore developed a new clinical guideline to improve care for these women pregnant women with complex social factors.

This is the latest in a series of NICE guidance to reduce complications in pregnancy. Other recent guidance covers: preventing, diagnosing and managing hypertension (high blood pressure) in pregnancy; quitting smoking in pregnancy and following childbirth; and weight management before, during and after pregnancy. All are available for download from the NICE website.

The social factors in question in the new guideline, which can include poverty, homelessness, unemployment, substance misuse, difficulty in reading or speaking English, teenage pregnancy and domestic abuse, are consistently linked to poor birth outcomes. For example, women living in areas of high deprivation in England are five times more likely to die during pregnancy or after childbirth than those in more affluent areas. Their babies are also around twice as likely to be stillborn or die shortly after birth.

Low take-up of antenatal care

It is widely known that this group of vulnerable women often do not attend antenatal appointments; 17% of women who died during or after childbirth had concealed their pregnancy, did not attend antenatal services, or had registered with antenatal services after their 22nd week of pregnancy.

This could be because they find services difficult to access or understand, or are concerned about being judged or becoming involved with social services once the child is born. As a consequence, warning signs for conditions like pre-eclampsia or gestational diabetes can be missed. Women may also not be informed about potentially harmful lifestyle factors, such as drinking, drugs and smoking.


This clinical guideline calls for the reorganisation of NHS services to improve access to and take-up of antenatal care for women with complex social factors, thereby helping to prevent complications and potentially save the lives of mothers and babies. It calls on antenatal services to become flexible and supportive, which includes working with social care providers and, in some cases, charities and the police, to plan care for these vulnerable women and their unborn babies.

While it offers guiding principles for care for all women whose pregnancies are complicated by difficult social circumstances, it highlights the following groups as needing particular, tailored support:

  • Those aged under 20;
  • Women who misuse substances;
  • Women who experience domestic abuse;
  • Recent migrants, asylum-seekers or refugees, or those who have difficulty reading or speaking English.

The guideline makes recommendations for commissioners to help them shape services according to their local populations. It also includes key information to help midwives engage with these women and make them feel safer, better understood and reassured.

Particular points of interest are:

  • Giving women a telephone number to contact a healthcare professional outside normal working hours;
  • Offering a at least one private one-to-one consultation to make it easier for sensitive issues to be discussed;
  • Using a variety of methods (including, for example, text messages) to remind women who misuse substances of upcoming and missed antenatal appointments;
  • Providing interpreters for women who have difficulty speaking or reading English.

There will be inevitable challenges in implementing these recommendations in practice, but it is unacceptable that mothers and babies are still dying in this country because of a lack of antenatal care. Healthcare providers must do everything we can to help and support these women to ensure that they – and their babies – survive and are safe and healthy.

  • This article is based on work undertaken by the National Collaborating Centre for Women and Children’s Health, which received funding from NICE. The views expressed are those of the author and not necessarily those of NICE.

The guideline is available for download at

Author Yana Richens is consultant midwife and supervisor of midwives at University College Hospital London, and a member of the guideline development group.


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