Amy J Stevens is a Public Health Lead at Bevan Healthcare CIC, Bradford, UK. She is on Twitter: @AmyJStevens1
Anne Connolly is a GP with a special interest in gynaecology and RCGP Women’s Health Clinical Champion, Bevan Healthcare CIC, Bradford, UK.
Inclusion health populations, including refugee and asylum-seeking populations, sex workers, and people experiencing homelessness, are subject to inequalities in maternal, perinatal, and child health outcomes. These are linked to socioeconomic status and compounded by the marginalisation, discrimination, and healthcare access barriers experienced by inclusion health populations.1–3
At Bevan, an inclusion health social enterprise providing primary care and wellbeing services, we believe in taking an upstream approach to addressing these inequalities by focusing on improving preconception health. Preconception health is an important determinant of maternal and child health with integrated community-based preconception care and contraception recommended as a solution to addressing reproductive health needs across the life course.4
In 2020, Bevan secured funding to implement a Starting Well programme.5 Our aim was to empower women and their families to improve the outcome of future generations by optimising their physical, psychological, and social wellbeing prior to conception. As preconception health is a complex issue we adopted a multi-faceted approach targeting women, families, communities, and our workforce. Workstreams implemented over the funded period are presented in Box 1.
| Box 1. Bevan Starting Well programme workstreams |
| • Co-produced preconception messaging and resource • Community group education and awareness sessions • Community champions training and support • Workforce training on preconception health • Introduction of a Making Every Contact Count (MECC) approach in routine service provision • Introduction of a pregnancy intention question into medication reviews to enable opportunity to deliver pharmacological and contraceptive advice • Psychological formulation and therapeutic interventions for women identified to be at high risk of unplanned pregnancy or adverse pregnancy outcomes • Development of a primary care drugs formulary for prescribing in perinatal mental health • Three-week postnatal reviews for early initiation of contraception |
Evaluation feedback confirmed that an intentional focus on preconception health is needed and welcomed by inclusion health populations. Women engaged by the programme reported increased understanding of preconception health as well as feeling empowered to take personal action and access services in order to achieve this.
Positive outcomes included improved self-reported mental health and wellbeing; uptake in contraception by women not intending to get pregnant; and identification of individual needs facilitating targeted social prescribing and referral into Bevan’s clinical services.
A comprehensive summary of our programme evaluation is beyond the scope of this opinion piece, but in view of the paucity of information on the provision of health interventions for inclusion health groups we wanted to share some key lessons.
The value of asset-based approaches
Taking an asset-based approach by valuing, enhancing, and utilising the skills, insights, knowledge, and connections within our local community was key to successful programme delivery. Partnering with local stakeholders across the health system and third sector, and building on existing Bevan services — including our multidisciplinary outreach service, in-house contraception and women’s health clinic, social prescribing team, and our advocates and volunteers — had multiple benefits. It enabled pooling of expertise and resources and ensured interventions were responsive and relevant.
Training up community champions from our target populations increased the reach of and engagement with interventions and preconception health messages as it harnessed the power of existing relationships of trust. Our social prescribing team was pivotal to effectively supporting marginalised people to access community assets and services that could enable them to live healthier lives. Collaboration with multiple stakeholders initiated the development of new working relationships and enhanced existing ones, which we hope has created a sustainable system-wide joint endeavour to improving preconception health.
The value of co-production
A trauma-informed approach to engagement and culturally appropriate framing of health messaging is necessary if inclusion health communities are to be successfully engaged. Co-production with partners experienced in supporting our target populations and people with lived experience of inclusion health was vital.
The value of creating social connections and trusted support networks
Group work and events that facilitated connection with others was highly valued by the women engaged with Starting Well. Development of supportive networks was a target outcome of the group intervention and the qualitative data collected highlighted the power of this in improving mental wellbeing and empowering participants. Women described how the opportunity to share experiences and socialise with others improved their mood, motivated them, gave them self-confidence, and made them feel more positive about the future. Programmes that facilitate the creation of trusted support networks to isolated inclusion health populations may be a sustainable cost-effective addition to specialist mental health services in achieving good mental health.
While proof of success in improving maternal and child health outcomes will not be measurable in the short term, the observed impact on wellbeing, awareness, and service engagement is promising, and we hope to inspire our primary care and inclusion health colleagues to invest in preconception health.
Competing interests
Details of payments for lecturing and consultancy received by Anne Connolly can be found at https://www.whopaysthisdoctor.org. Amy J Stevens has declared no competing interests.
Acknowledgements
Sadhana Patel, Sarah Faithorn, Emma Perry, and all the Bevan Starting Well Team involved in the development, implementation, and evaluation of the Starting Well programme.
References
1. Jardine J, Walker K, Gurol-Urganci I, et al. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet 2021; 398(10314): 1905–1912.
2. St Martin BS, Spiegel AM, Sie L, et al. Homelessness in pregnancy: perinatal outcomes. J Perinatol 2021; 41(12): 2742–2748.
3. Jones L, McGranahan M, van Nispen tot Pannerden C, et al. “They don’t count us as anything” Inequalities in maternity care experienced by migrant pregnant women and babies. 2022. https://www.doctorsoftheworld.org.uk/wp-content/uploads/2022/06/Maternity-care-report.pdf (accessed 23 Jan 2024).
4. Hall J, Chawla M, Watson D, et al. Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care. Lancet Public Health 2023; 8(1): e76–e84.
5. Department of Health and Social Care, Public Health England, NHS. VCSE Health and Wellbeing Fund Starting Well 2020/21: information pack for voluntary, community and social enterprise (VCSE) sector organisations. 2020. https://assets.publishing.service.gov.uk/media/5f609d10e90e072bbfa0bc97/starting-well-information-pack.pdf (accessed 23 Jan 2024).
Featured photo by Reproductive Health Supplies Coalition on Unsplash.
