Improving the health outcomes for children, young people and their families; and reducing the health inequalities that exist within our communities are key priorities for BCU HB. There is clear evidence that one of the most important things we can do to improve the health of our population and reduce inequalities is to support children to have the best start in life.

Influencing the development of children to maximise their health, social and educational development is most effective when done as early as possible; the first 1000 days being critical. There is also a strong economic case, as return on investment in the early years is higher than at any other stage of the life course.

Rates of stillbirth, preterm birth, low birth weight, neonatal deaths, admissions to neonatal units, infant mortality, child mortality, injuries and teenage pregnancy have all been shown to be significantly higher in areas with high levels of deprivation. Across North Wales we have described variation in health outcome and life experience. This includes the unacceptable variation of low birth weights of babies across our communities and the fact that babies born in the most deprived areas of North Wales could expect to die approximately seven years earlier than those born in the most affluent areas. Giving every child the best start in life is the highest priority recommendation in Professor Sir Michael Marmot’s recent strategic review of health inequalities (Marmot 2010).

Maternity Services:

We know that:

· A child’s first relationship, the one with his mother acts as a template that permanently moulds the individual’s capacity to enter into all later emotional relationships;

· Confident and supported parents are better prepared to raise strong families and contribute positively to their local communities and society in general;

· Providing a safe and nurturing environment for every child is the best way to ensure healthier and happier adults.

Evidence of this can be found in the Royal College of Midwives (RCM) publication https://www.rcm.org.uk/sites/default/files/Emotional%20Wellbeing_Guide_WEB.pdf

which indentifies the best ways to support healthy parent-infant relationships in the antenatal and early postnatal period.

However, whilst the evidence is clear, putting the evidence into practice takes time and commitment and investment. Midwives are in an ideal position to contribute to this agenda. They are a profession that are trusted by women and are able to influence them.

Supporting the birth of strong confident happy parents should now be seen as an essential part of a midwife’s role and this will require investment in their education and training.

Workforce: The government policy of requiring health boards to assess midwifery staffing needs using a nationally agreed workforce planning tool ‘Birth Rate Plus’ has meant that there has not a been a shortage of midwives in Wales. However, this policy has to be continued to ensure that in a time when women have increasingly complex care needs, which take more midwifery and obstetric time, quality care is not compromised.

A realistic look at the wider maternity workforce, to ensure that maternity care assistants are available to support this work will be required.

Working collaboratively with third sector and local authorities could provide the referral pathways that midwives need if women are to maximise their opportunity for a healthy pregnancy.

Local authorities could be encouraged to provide exercise classes for pregnant and new mother and Welsh Government could consider extending exercise referral to all pregnant women so that the cost of classes does not fall on impoverished young families.

The Strategic Vision for Maternity Services in Wales (2011): This strategy focussed on the importance of pregnancy and birth in setting the scene for a child’s future emotional and physical health. In its introduction it quotes Michael Marmot - ‘from heart disease to obesity, educational attainment and economic status, the months before and the years immediately after birth are crucial to the life chances of the mother, her child and her family’[i]. It should be noted that the pace in setting up initiatives which could improve health and well-being has been slow. Some examples are given below.

· Mental health: On a positive note, midwives have made great strides in ensuring that the majority of pregnant women have direct access to them and are seen by 10 completed weeks of pregnancy. This enables midwives to identify women with serious mental health problems so that they can refer them to appropriate professionals and organisations that can offer support. However, it has taken 4 years for health boards to develop care pathways and services for women with serious mental health problems in pregnancy. To support new mothers to form loving relationships with their babies this has to be encouraged during pregnancy and immediately after the birth. A new mother with mental health challenges may not be able to get this relationship off to a good start and this could have a profound impact on the baby’s life chances.

· Smoking and obesity: Whilst midwives can identify women who may need support in managing their weight and in giving up smoking there are very limited focussed resources available to support women. This in turn means that some midwives may be reluctant to discuss health concerns if they cannot suggest interventions that may be helpful.

· Breastfeeding: Breast feeding initiation rates in Wales are low but more disappointingly continuation rates are also poor. Both require some investment and they require very different investment. This is an almost intractable challenge of culture. A generation that lives on fast food, instant results with muddled perceptions of women’s breasts all collude in making bottle feeding an easy answer. To tackle this we cannot just look to midwives and health visitors. Guidance and support from a variety of people is required i.e. social scientists and public health experts in understanding how to start to make this cultural shift.
Most new mothers leave hospital after giving birth with 2 days, long before breastfeeding is established. For those women who do start breastfeeding, health boards need to consider what support is required in the community to make sure that they continue to breast feed.

· Normal birth: We should not underestimate the importance of encouraging normal birth in a setting that, for labouring women, feels private and safe. The National Institute for Health and Care Excellence (NICE) state that women with low risk pregnancies (up to 45% of women) should be encouraged to give birth in midwife led settings[ii]. This reduces the chance of medical intervention and can mean that new mothers recover more quickly from childbirth that baby is more responsive and the immediate bonding between mother and baby is uninterrupted. Uninterrupted skin to skin contact between mother and newborn has been shown to increase maternal confidence in caring for her baby, increases breastfeeding duration and helps the baby in the transition from foetal to newborn life. This reduces crying and stress which then positively impacts on the mother and her ability to form a close and loving relationship from the start.

If we are to encourage women to choose midwife led setting for birth the environment has to be suitable. Labouring in water is an effective form of pain relief and has to be available in all midwife led units. To offer birth in a midwife led unit without this effective pain relief is unacceptable.

· High Caesarean section rates and induction rates in Wales: Intervention in labour reduces opportunity for skin to skin contact and early bonding with the baby. A real commitment to reduce rates will be required from all health boards if we want new families to get off to a good start in life.

· Preparation for labour and parenting: Pregnant women and their partners are relatively receptive to public health messages. Investment in antenatal classes and groups where couples are given information on the importance of, and how to start the development of a close and loving relationship with their unborn baby and them in pregnancy would be a wise investment. These opportunities exist for families who live in Flying Start areas but it needs to be extended to as many families as possible.

Recent government policies, whilst acknowledging the importance of the first 1000 days, have tended to focus on initiatives after birth. On the front of the all Wales hand held maternity record (introduced over 5 years ago) is a quote which reads “Birth is not only about making babies. Birth is about making mothers--strong, competent, capable mothers who trust themselves and know their inner strength.”

Childhood:

Globally there is an increasing body of evidence on how experiences during childhood have long-term impacts on our health and life chances. In January 2016, Public Health Wales published the first ever study in Wales of Adverse Childhood Experiences (ACE’s) which found that 47% of the Welsh adult population are estimated to have experienced at least one ACE and 14% have experienced four or more ACEs.

ACEs are stressful experiences occurring during childhood that directly hurt a child (e.g. maltreatment) or affect them through the environment in which they live (e.g. growing up in a house with domestic violence). A baby’s brain grows from 25% to 80% of its adult size during the first 2 years, hence the the first 1000 days are critical, although there are opportunities across childhood and adolescence, our focus to build strong foundations should be the first 1000 days

Preventing ACEs can improve health across the whole life course, enhancing individuals’ well-being and productivity while reducing pressures and costs on the National Health Service (NHS). Tackling Poverty programmes such as Flying Start and Families first promote behaviours which support positive parent child relationships resulting in secure emotional attachment and positive maternal and family emotional health and resilience.

The Public Health Wales Observatory report “Health of Children and Young People – Wales Report” (2014), identifies that health and behaviour developed during childhood and adolescence is often carried through into adulthood and can affect health later in life. Supporting children to adopt a healthier lifestyle from early years is therefore critical.

BCUHB wide summary response:

Our strategies and plans therefore focus on preventing ill health, promoting health and wellbeing and intervening early by improving access to services. These actions place the child, their family and carers at the centre of approach, ensuring that the health, wellbeing and safety of children and young people are safeguarded. Below is a summary response to the consultation which gives an overview of our current programmes, policies and areas of work in relation to the first 1000 days, and recommendations for future key areas of focus and consideration:

Items relevant to whole consultation	Relevant Legislation	Children Act 2004 (Parts 3 & 4) Mental Health Measure
	Relevant Welsh Government strategies, delivery plans and programmes	Early Years Outcomes Framework Healthy Child Wales Programme
	Relevant Public Health Wales programmes/projects	Cymru Well Wales First 1000 Days Collaborative Programme
	Evidence Base	NICE QS128 – Early Years: Promoting health and wellbeing in the under 5s Public Health Wales 2016 Making a Difference: Investing in Sustainable Health and Well-being for the People of Wales Report
	Other Relevant Interventions	United Nations Convention on the Rights of the Child All Wales Child Protection Procedures (to be reviewed following introduction of Social Services and Wellbeing (Wales) Act 2014)
Consultation sections
1. Promote and protect the health and wellbeing of children from pregnancy (for example through positive parenting, high immunisation rates and tackling smoking in pregnancy). Includes: · Maternal and childhood immunisation programs · Maternal smoking prevention in young women · Maternal smoking cessation · Antenatal and postnatal care · Vitamin supplementation · Maternal mental health screening and care · Prevention of low birth weight o Reduce teenage pregnancies o Reduce sexually transmitted infections · Provision of information for parents	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes	Healthy Child Wales Programme Tobacco Control Action Plan for Wales A Strategic Vision for maternity Services in Wales 2011 Together for Mental Health Delivery Plan 2016-2019 (p13-14) Building a Brighter Future: The Early Years and Childcare Plan Parenting in Wales: Guidance on engagement and support Parenting in Wales: Strategies for working with Fathers
	Relevant Public Health Wales programmes/projects	Routine Immunisation Schedule Wales 2016 Bump Baby and Beyond: information book for parents
	Evidence Base	NICE PH 14 Smoking: preventing uptake in children and young people NICE PH 48 Smoking cessation in secondary care (2010) NICE PH 26 Stopping smoking in pregnancy NICE PH11 – Maternal and Child Nutrition NICE QS98 – Maternal and Child Nutrition NICE QS37 - Postnatal care NICE PH27 - Weight management in pregnancy
	Other relevant interventions including BCUHB	· Strong and well established immunisation programmes · Mind Cymru ‘Two in Mind’ project (perinatal mental health) · Maternal smoking cessation service (based on findings of MAMSS research) has been funded and is being implemented across BCU HB · Dream Big social media campaign for smoking prevention in adolescent girls · Implementing NICE Guidance 26/48 · Eating for 1, Healthy and Active for 2. Training for community midwives Royal College of Midwives accredited, developed in BCUHB · Getting the Best Start , Training provided for Health Visitors accredited by CPVA developed in BCUHB · Perinatal mental health service · North Wales Condom Card scheme
	Recommendations	· All Wales specialist smoking cessation service for pregnant women embedded into midwifery team with clear referral pathways · Provision of CO monitors to all midwives · Guidance of the use of electronic cigarettes in pregnancy · Clear national pathway to support mental wellbeing for pregnant women (high risk and those with mild to moderate need) · Parenting programmes for pregnant parents to prepare them for the challenges of parenthood · Evidence based universal parenting programmes suitable for the parents of teenagers and also for preparing young people for parenthood · Support for system change projects at a local level to ensure links between Health and Local Government programmes in the first 1000 days · Strategic recognition and support for teenage pregnancy prevention and sexual health services as a contribution to improving child health and preventing ACEs; and ensuring long-acting contraception is widely and easily available · Ensure earlier and more widespread access to vitamin supplementation and fortification in pregnancy and childhood · Strengthen school nursing services to enable ongoing advances in the immunisation programme while also permitting the full range of prevention work in schools and with children, including school-based clinics · Promote and incentivise pregnancy testing in primary care to enable early pregnancy messages and screening · Continued focus on improving maternal immunisation uptake for flu and pertussis and to address known inequalities in uptake of childhood immunisations
2. Deliver improved child health outcomes across Wales (for example prevention of obesity and the promotion of health-enhancing behaviours for every child such as eating a well balanced diet, playing actively, and having an appropriate weight and height for their age and general health). Includes: · Breastfeeding promotion and support · Nutrition and cooking education · Play promotion and resources · Community planning for physical activity · Health visiting services · Programmes for healthy weight in children	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes	Healthy Child Wales Programme Start active stay active (UK-wide) Investing in a better start: Promoting breastfeeding in Wales Wales – a Play Friendly Country (2014) (also a linked sufficiency assessment toolkit available)
	Relevant Public Health Wales programmes/projects	10 Steps to a Healthy Weight
	The evidence base on interventions	NICE 11 Maternal and child nutrition NICE CG43 Obesity prevention
	Other relevant interventions including BCUHB	· Healthy Child Wales Programme · UNICEF UK Baby Friendly Initiative · BCUHB Breastfeeding web pages · Come and Cook programme · Tiny Tums/Boliau Bach teaching materials · Weaning educational resources · Local promotion of ten steps to a healthy weight action plans · Local area support to play sufficiency
	Recommendations	· Support for full roll out of Healthy Child Wales Programme · Breastfeeding data collection systems to be more accurate · Coordinated approach to Breastfeeding Peer Support across Wales · Promotion of breastfeeding friendly premises in each locality rural and urban · Support for local implementation of play sufficiency · Promote playing outside through the seasons including Winter and Summer – communication messages at a national level · National healthy weight campaign based upon the 10 steps · Encourage more staff across a range of partners skilled in delivering Come and Cook sessions · Advise that conversations regarding Infant Weaning begin early ideally pre 12 weeks to support delaying early weaning. · Promote awareness of portion sizes for children – resources developed such as portion sized plates and bowls for different age groups. · Promotion of parents establishing good bedtime routines to support children’s sleep and gain appropriate support when sleep issues arise with their child (as good sleep contributes to a healthy weight).
3. Tackle child health inequalities, with a specific focus on child poverty and disabled children. Includes: · Poverty-specific programmes · Access barriers to health improvement programs · Children with physical disabilities · Children with learning disabilities and autistic spectrum disorders	Relevant Legislation	Child and Families (Wales) Measure 2010 (associated guidance here)
	Relevant Welsh Government strategies, delivery plans and programmes	Families First Flying Start Building a Brighter Future: The Early Years and Childcare Plan Child Poverty Strategy for Wales (2015) Welsh Government (2015). Taking Forward the Tackling Poverty Action Plan.
	Relevant Public Health Wales programmes/projects
	The evidence base on interventions	An Equal Start 2012 (Institute of Health Equity report; focus on Children's Centres in England)
	Other relevant interventions including BCUHB	· Local area support for evidence based parenting programmes
	Recommendations	· Support full roll out Healthy Child Wales programme · Ensure programmes designed to meet need across all geographical areas within local authorities · Allocate resources to those with the greatest need, using principals of ‘proportionate universalism’ · Use a combination of both universal (population wide) and targeted interventions that reflect the level of disadvantage and hence, the level of need: this includes strengthening universal services, which are under pressure · Targeted support around time of diagnosis to help parents navigate and plan for future specialist service needs and co-ordinate any mainstream support
4. Reduce child deaths and injury prevention, particularly in the most deprived parts of Wales where infant mortality is much higher than the least deprived. Includes: · Road safety and urban planning · Child safeguarding: intentional and non-intentional injuries	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes	Welsh Government (2015). Taking Forward the Tackling Poverty Action Plan 2015 Safeguarding children: Working Together under the Children Act 2004
	Relevant Public Health Wales programmes/projects	Child Death Review Dr. Sarah Jones has provided response to Dr. Julie Bishop on this.
	The evidence base on interventions	Healthy Child Wales Programme Dr Chris Johnson’s paper on factors in Low Birth Weight
	Other relevant interventions including BCUHB	· Healthy Child Wales Programme · First 1000 days Collaborative Programme (Cymru Well Wales) – Wrexham Pathfinder Project (systems working) · Home safety adjustments advised by health visitors Twenty’s Plenty campaign for lower speed limits · BCUHB Safer Sleeping Guidance and risk assessment tool for parents
	Recommendations	· Roll out of Flying Start programmes to meet need across local authority areas (more than just defined area + additional 10%) · Requirement for all Local Development Plans to carry out a Health Impact Assessment to ensure consideration of child safety in planning decisions
5. Support effective child development and emotional and social well-being - specifically interventions that are delivered outside the health service which can help to detect and address developmental delays.	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes	New childcare offer (free 30 hours per week for 3-4 year olds – could it be extended to include 0-2 in future? There is a Welsh Government survey asking this – details here)
	Relevant Public Health Wales programmes/projects
	The evidence base on interventions	NICE – ADHD (72 ), ASD ( 128), Epilepsy (137 ), Challenging behaviour ( 11 ) NICE PH40 - Social and Emotional Wellbeing: Early Years NICE QS31 – Looked-after children and young people
	Other relevant interventions including BCUHB	· Healthy Child Wales Programme · Local area support for evidence based parenting programmes · First 1000 days Collaborative Programme (Cymru Well Wales) Pathfinder Project -Wrexham
	Recommendations	· Evidence based early parenting programmes focussed on attachment, cognition and behaviour · Team approach including health staff and local authority staff to support high risk families · Strengthen CAMHS programmes to enable much earlier coverage of and support for problems before they reach a crisis Further roll out of Friends and Seasons Full implementation of the Neuro-development Pathway
6. Focus on improving learning and speech and language development through the home learning environment and access to early years’ provision (including childminders, preschools and day nurseries).	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes
	Relevant Public Health Wales programmes/projects	Healthy and Sustainable Preschool Scheme
	The evidence base on interventions
	Other relevant interventions including BCUHB	· Healthy Child Wales Programme · BCUHB speech and language service · Early years learning and care settings · Local area support for evidence based parenting programmes
	Recommendations	· Universal approaches to reading promotion in small children as demonstrated in Scotland and other home learning support · Evidence based early intervention parenting programmes focussed on attachment, cognition and behaviour · Increased roll out of Healthy and Sustainable Pre School Scheme, including easier ways to support participation by smaller child-care settings
7. Reduce the adverse impact on the child of psychosocial issues such as poor parenting, disruptive family relationships, domestic violence, mental health issues and substance misuse through effective safeguarding. Includes: · Adverse childhood experiences · Alcohol and drug use in the household · Violence and abuse in the household · Parenting	Relevant Legislation
	Relevant Welsh Government strategies, delivery plans and programmes	Together for Mental Health Delivery Plan 2016-2019 (p13-14)
	Relevant Public Health Wales programmes/projects
	The evidence base on interventions	Adverse Childhood Experiences research publications Tackling the Roots of Disadvantage 2013
	Other relevant interventions including BCUHB	· Healthy Child Wales Programme · Partnership working with PSB’s to implement FGA · Partnership working to implement Social Services Well Being Act · Programmes raising awareness of ACEs · Parenting programmes, including Incredible Years · Substance misuse midwife and wider team · Police–led domestic violence forum and its member groups and projects · First 1000 days Collaborative Pathfinder Project - Wrexham
	· Recommendations	· Evidence based early intervention parenting programmes focussed on attachment, cognition and behaviour · Parenting courses for expectant parents and for parents of teenagers · Widespread training for staff and the public to raise awareness of ACEs, move all public services to working in an ACE informed way. · Team approach including health staff and local authority staff to support high risk families · Good quality Sex and Relationships Education in school which promote messages about what is a healthy relationship and supports early pregnancy prevention · Strengthen school nursing services to enable ongoing advances in safeguarding work while also permitting the full range of prevention work in schools and with children.