Headlines for child poverty in Conwy[i]
· Conwy has an above average proportion of children living in families on low income
· HM Revenue and Customs (HMRC) data on this measure shows that there
are 4,510 children living in “poverty” within the County Borough – this is
19.8%.of all children living in Conwy. While this is slightly lower than Wales
(22.2%) and England (20.6%), it is still a high proportion of children in the county.
· Almost one in five children in Conwy County Borough live in a family with both
parents out of work or working less than 16 hours per week (or one parent for
single parent families). While this is lower than the averages for Wales and
England, it is still a high proportion of children in the county.
· Babies born in disadvantaged families are more likely to be born early and be
born underweight. These babies are more at risk of suffering from health
problems in childhood and also into their adult life. The percentage of newborn babies who are underweight is slightly higher in Conwy County Borough than in Wales.
· Research has shown that there is a close relationship between teenage
conceptions and social and economic deprivation. Children of teenage
mothers are also more likely to live in poverty as adults. Conwy has higher
teenage conception rates than Wales.
· We also know that the rates of breastfeeding initiation and continuation rates within Conwy are lower than the national average, with early cessation of breastfeeding being a particular issue within BCUHB.
This response focusses on the WG funded activity which seeks to target the areas that the committee is exploring. As such this response highlights more of the positive work, recognising the risks to delivery, rather than the gaps. That said it should be noted that:
· Where a family has previously been involved in the social care system, experiencing removal of a child, there is limited preparatory work when subsequent pregnancies occur; providing a pre-birth support service as a standard to upskill the parents and family would increase the opportunity for positive outcomes.
· Parenting support is often provided informally, and outside the confines of trained family workers the quality is variable. This is particularly evident in the guidance sought by new parents regarding biologically normal infant feeding behaviour or how to manage sleep disruption. Despite evidence bases clearly indicating responsive baby-led parenting improves a child’s outcomes controlled crying/cry it out approaches continue to be advocated, rather than as safety measures (if frustrated then walk away from your safely placed child).
· Anecdotally there continues to be misunderstanding of the centiles plotted via the red book – with parents unclear that their child does not need to track the 50th centile and that the centile curves are not absolutes.
· There are no services currently available to address & support individuals who are looking to conceive, apart from a brief consultation with the GP who may prescribe folic acid. This is an apparent gap in provision not only in Conwy but that of Wales.
· Women in Flying Start areas do not have the continuity of care which might be hoped for in terms of the same midwife (where possible) attending the birth and post-delivery, as has provided ante-natal care. This is more explicit in non-Flying Start areas where midwives may vary between appointments.
· Generic midwives are constrained to a maximum of 15 minutes ante-natal care per consultation - due to austerity, lower staffing numbers, difficulties in recruitment.
· Disinvestment by Public Health Wales and Health Boards in breastfeeding support is perverse, given the impact that effective breastfeeding support is known to have on:
o Maternal mental health and wellbeing
o Enabling women to achieve their breastfeeding goals
o And as such on:
§ Childhood obesity levels
§ Attachment and development
§ Risk of sudden infant death etc.
§ Maternal cancer rates
The areas of work explored by this consultation would be directly impacted by improved breastfeeding support, leading to improved outcomes for children, women and families.
· Parents whose children are under 2 and where there are concerns regarding developmental delay, report feeling unsupported by services whilst they wait for a diagnosis. Services are available to families where children have a recognised diagnosis. Where there is co-morbidity of conditions (physical disability and possible cognitive delay) parents who are engaged with services for the physical disability remain unable to access support for cognitive development concerns until they have that diagnosis. This can further frustrate.
Conwy County Borough Council’s Family Intervention Team works with families where children and babies are at risk of being brought into the care system. Assessments include the use of virtual babies to support the process, as well as in tailored parenting sessions. Much of this work is undertaken on a one-to-one basis.
The Edinburgh Post Natal Questionnaire is now in use with Health Visitors and Midwives within the BCUHB footprint. These assessments are shared with the mental health team to establish where secondary mental health support is required or if access to other appropriate services can be facilitated.
Families First fundinghas afforded the opportunity to develop examples of working such as the Llanrwst Family Centre. Delivered from a church hall opposite the town’s primary school, the centre draws on resources which are available within the community and statutory services to deliver a bespoke programme based on local need. The Centre staff co-ordinate resources to meet the needs of population cohorts, as well as around individuals as required. The provision, which is based on effective partnership working to achieve shared goals, addresses: The lack of antenatal class provision in the rural community; Parental skills through the nurturing parenting programme; Engagement with mothers to support their mental health through baby club, baby massage, 3 Ts (Talk, Toast, Tea); Supporting breastfeeding in the community by facilitating a monthly group for the Health Visitor, supported by a Peer Supporter; Improved family relationships, reducing the potential for adverse childhood experiences through close working with relationship counselling providers and financial/debt management staff; Close working with families where there is a child with additional needs, providing communication skills (e.g. Makaton) and opportunities to share experiences.
This is underpinned by an ethos which encourages people to develop resilience to manage their circumstances or to change them where they have the agency to do so.
Meanwhile the Team Around the Family model (Families First funded) adopted in Conwy utilises timely outcome focussed interventions based on family needs, particularly along the coast and with families where children are typically school age. Ideally, of course, improved intervention and prevention work taking place in the first 1,000 days supports a reduction in need to access services at later periods of life.
Our model in Flying Start Conwy is that of providing intense and specialist support from the point of conception to our most vulnerable families in Conwy, who live in our most deprived coastal areas. The support continues until the Childs’ 4th birthday.
The Flying Start Midwife (FSM) is the first point of contact following the Notification of Pregnancy by the generic community midwife. All women within Flying Start have contact with the FSM in the early 2nd trimester, which has been identified in the research literature as a unique opportunity where women are positively motivated towards behaviour change and at their most receptive to health promotion messages. Furthermore, the FSM may be the first professional to visit the expectant mother in her own home, and is therefore in the unique position of being able to identify any concerns early on and thus ensure timely intervention. Routine Enquiry around domestic abuse has resulted in disclosures, whilst women may have felt too pressured by time limitations and the clinic environment to make disclosures to their generic community midwife.
Our ante-natal staffing quota in Flying Start consists of one full time midwife, one part time midwife and one midwife support worker. These individuals are currently confined to Flying Start postcodes, which is deemed as a weakness when considering the wider authority area and the genuine need for this support to be across the board in Conwy.
The FSM is a nurturing, warm, supportive individual who provides women with a feeling of safety, encouragement and empowerment. Trust is established quickly. Interventions can be either on a one-to-one basis (within the woman’s home) and / or through group work. Our specialist midwives provide effective, empathic, holistic and tailor made specialist ante-natal support to our expectant mothers.
Interventions during pregnancy typically commence on a one-to-one basis and once empowered, women feel comfortable and confident to attend our groups. Our conversion of women receiving one-to-one support and subsequently attending groups is high. This encourages positive peer support and the sharing of knowledge & information during pregnancy.
FSM are able to provide support to ensure positive outcomes are reached for the woman, child and the wider family through providing appointment durations based on need. They are able to provide information and guidance, quite often subtly, regarding positive parenting, smoking during pregnancy, and support with improvement to maternal mental health, healthy eating and the adverse effects of substance misuse on child development.
FSM support individuals with the following complexities – individuals who are highly likely to have been subjected to Adverse Childhood Experiences or could lead to their children, in future, being deemed as having experienced ACE’s: Women with mental health issues; Women with drug and alcohol abuse issues – this would be in partnership with the generic specialist drug & alcohol generic services midwife in Conwy (only one specialist substance misuse midwife covering the whole of North Wales); Women with eating disorders; Women with learning disabilities; Women with risk factors such as high or low BMI, smoking; Women with physical disabilities; Victims of domestic violence; Women who have previously delivered prematurely; Women with a history of children with disabilities; Women who have previously had stillbirth, multiple miscarriages, or previously traumatic births (often suffering from PTSD and / or Tocophobia); Women who have previously failed to bond with their child – our intervention is to empower and support women regarding bonding and attachment in readiness for their new arrival; Victims of child sexual exploitation or sexual abuse during adulthood; Women who may have had children removed from their care in the past; Women who may have displayed serious concerns and are at risk of their first child being removed from their care; Women who have been identified as at increased risk of early breastfeeding cessation - who lack confidence to breastfeed, or who are culturally / socially influenced by the predominance of artificial feeding; Women who need support and advocacy around their housing and financial needs; Women for whom there are significant or complex barriers to accessing maternity care; who do not attend antenatal appointments or who refuse access to care.
Statistics confirm that women feel much more comfortable with midwives in comparison to a number of other health & social care professionals, thus allowing our midwife to build rapport & trust from the very outset, allowing the woman to feel comfortable to disclose any complex matters.
Local research- A group of 12 highly vulnerable and complex women in Conwy were monitored as part of a qualitative and quantitative local piece of research regarding the effectiveness of FSM breastfeeding support. 90% of the women supported were still breastfeeding on the 28th day. This proves the highly valued support of our midwives can empower women, who may never had considered breastfeeding previously, to breastfeed and bond with their child.
This is significant because there is a low breastfeeding initiation rate in Conwy and very steep drop off rates in the first 10-14 days postnatal period. The research literature confirms that the absence of breastfeeding in Conwy has a profound impact on major indicators of public health; for example: breast/ ovarian cancers; obesity; diabetes; childhood illnesses and infections and perinatal mental health. ‘In sheer, raw, bottom line economic terms, breastfeeding may be the single best investment a country can make’ (Hanson, World Bank Global Practices Vice President, at 7th Annual Academy of Breastfeeding Medicine summit). FSM are able to offer improved continuity of care in the early postnatal period, particularly around individualised breastfeeding support. The Infant Feeding Coordinator for BCUHB has proposed that the breastfeeding support service delivered by Flying Start midwives could be developed to improve continuity of care throughout the perinatal period. This is currently being piloted in another area and is a service that could be developed in Conwy.
Indicators suggest that through women accessing our specialist midwifery support in Flying Start, reduces the risk of post-natal depression. This is through our encouragement of women to attend our ante-natal group sessions, such as ‘Welcome to the World’ ‘Bump to Baby’ ‘Breastfeeding’ plus our approach & one to one support to vulnerable and quite often complex women.
Our midwifery approach is very much multi-disciplinary and quite often being the foundation of a woman’s journey into Flying Start, thus making the transition to health visiting and other Flying Start services much more comfortable & smooth.
Perinatal mental health is high on the agenda for both BCUHB and also that of the regional local authorities. In 2016, BCUHB launched a new three year plan to improve mental health services across North Wales.
FSM are highly skilled to deal with complex mental health matters during pregnancy. Recent evidence indicates that stress and anxiety in pregnancy can have harmful effects that may continue throughout the infant’s lifespan (Mueller and Bale, 2008; Talge, 2007). Longitudinal studies show an increased risk for hyperactivity and conduct disorder. There is also evidence that increased stress hormones in-utero is linked with impaired cognitive development. Where there are concerns around perinatal mental health, FSM will often engage in Joint Pre-Birth Health Assessments with the Flying Start Health Visiting Team to assess risk and arrange a package of ongoing care and support throughout the perinatal period. This is subject to ongoing assessment and review. Due to the reciprocal and trusting relationship that the FSM is able to build with the woman, she is often empowered to engage with other services if appropriate, such as the GP or Community Mental Health Team. Undertaking one-to-one listening visits to the anxious or depressed mother requires a significant time commitment, but is important in terms of the developing foetus. FSM encourage a mindful approach and support the woman and her family to make a positive transition to parenthood. They ensure timely intervention where it is identified that the woman is experiencing negative mental representations or is reluctant to engage with her baby during pregnancy. Research highlights that negative maternal representations during the antenatal period is significantly linked with the security of the infant’s attachment to the parents at 1 year of age. Women who have experienced domestic abuse are more likely to have negative representations and to have infants who are insecurely attached. The FSM team deliver antenatal and postnatal groups which include women who are anxious or depressed. The need to provide support early for women with mental health issues during pregnancy is imperative to that of the woman’s wellbeing and the child’s development.
In October 2016 the monthly Flying Start Multi Agency Safeguarding Meeting (MASM) commenced on a monthly basis; safeguarding in any urgent cases is prioritised in between these regular meetings. Throughout the month, Flying Start staff, through supervision are able to voice their concerns in relation to expectant mothers, families and / or children. The wellbeing of our children & families is the key driver for this meeting.
Concerns can be anything from visible signs of neglect to children, all the way through to a decline in a woman’s perinatal mental health. This forum has strengthened communication regarding concerning cases within our programme. It has improved decision making and collaboration with other services. Staff have clarity on who is leading on concerning matters and are provided with quicker decisions regarding outcomes aimed for those concerned. Staff feel they have another forum to provide concerning feedback of which Management decisions are made.
The Flying Start Health Visiting (FSHV) Core Programme is developed on the following principle:
Working in a manner that promotes partnership working, mutual awareness and respect between family Health Visitor and clients. Through clear information sharing and engagement with communities, FSHV help to support and empower parents to improve the life and health outcomes for their children.
The core interventions of the FSHV Programme, which commences during the antenatal period, are available to all Flying Start families and include: Assessment of family need – commences antenatally; Assessment of health, growth and development; Childhood immunisations; key public health messages on:
· social and emotional development and impact on brain development
o smoking and substance use
o prevention of Sudden Infant Death Syndrome (SIDS)
o breastfeeding, responsive/ safe feeding and healthy weaning
o childhood nutrition
o obesity and physical activity
o child home safety and accident prevention
o healthy relationships and domestic abuse
o oral health care
o pet/dog safety
o contraception and sexual health
· promotion of positive parenting and informal and formal parenting programmes and parenting groups;
· secure infant, attachment and bonding; baby massage
· supporting and understanding childhood behaviour;
· Promotion of Speech, Language and Communication skills
· stimulation and play;
· involvement of fathers;
· perinatal mental health;
· parental emotional health and wellbeing;
· preparation and support with transition to parenthood;
· safeguarding; and
· transition to childcare and formal education and school readiness.
· to actively promote engagement with hard to reach families and ensure all non-attendees are followed up as per local policies
· To actively promote the use of other elements of the Flying Start programme.
The goal within the first 1000 days is for every baby to receive sensitive and responsive care from their main caregivers during the first years of life. Parents need to feel confident to raise their children in a loving and supportive environment. The intensive support that parents receive from their Flying Start Health Visitor before and after the birth of their child, provides a unique opportunity to work with them at a stage which is so vitally important to the development of their child.
Whilst the childcare entitlement of Flying Start is for children the term following their second birthday, the impact of other services with which the childcare team link, is essential in supporting a smooth transition into childcare and meeting the holistic needs of the child. This demonstrates the importance of linking with those involved in a child’s life in the first 1,000 days.
Our family workers are highly skilled & trained individuals who provide practical and empowering support to our families across Flying Start areas. Health and Education colleagues are able to link with family workers for ongoing wellbeing and nurturing support to families. Intervention times can range from a one-off all the way through to up to 8 weeks (or more if needs are highly complex)
Children’s Zones
We are developing the Children’s Zones model in the county of Conwy, building on the work undertaken in Llanrwst and the benefits of the co-ordinated approach seen in Flying Start and through Team Around the Family. Underpinning this work is the acknowledgement that parenting in the modern environment is not easy – families are often separated, away from the support of grandparents, aunts and uncles – regardless of social circumstance, employment status or educational attainment. Recognising the value of where agencies (statutory, public and third sector) can work together to achieve shared goals with complimentary approaches. Some of the gaps in Welsh Government targeted programmes (e.g. the postcode led provision of Flying Start or Communities First) will be mitigated by understanding a whole county approach to the core support which enables parents.
Zones will be developed around the secondary schools and their feeder primary schools, whilst recognising that schools are not always appropriate to engage parents who have had their own negative experiences within the system.
Greater flexibility in funding streams, to enable them to dovetail with intention would assist. For example, the prescribed nature of Flying Start funding means that families who would benefit from the additional resources provided may not be able to if they are not within the communities specified or eligible for the “outreach” element of the work.
To achieve the benefits described in the first 1,000 days activity and funding needs to target parents as the agents for improvement in their children’s outcomes.