Maternal and Child Health

Health promotion in the first 1000 days of life: key findings of the ISS project

A conference was held on 20 April 2023 to present the main findings of the project entitled “A survey of the preventive and clinical care pathways offered to women, couples and parents, for the purpose of promoting the first 1000 days of life and identifying good practices, organizational models and suitable interventions”. Promoted and funded by the Ministry of Health, under the 2019 programme of the National Centre for Disease Prevention and Control (CCM), the project was coordinated by the Women’s, Children’s and Adolescents’ Health Unit of the National Centre for Disease Prevention and Health Promotion of the Istituto Superiore di Sanità (ISS).

The project (due to end in May 2023) was conducted in 9 Regions and 1 Autonomous Province among over 500 professionals from the different areas of health and social care that play a role in protecting and promoting the health of children, from conception to their second year of life.

It involved the collection of original data in three main areas:

• The quality of maternity care, as perceived by women who had given birth
• The dissemination of good practices for the promotion of mental health in pregnant and postpartum women
• Parenting support offered by health and social care services/professionals.

Survey on the perceived quality of maternity care

A survey on the perceived quality of maternity care allowed all participating women to describe their experience of the care received during pregnancy, childbirth and the first 3 months of their child’s life. Similar surveys are regularly carried out in several countries. However, updated information at supraregional level was needed in Italy to help guide policymakers and clinicians.

Overall, 16 level II maternity units and 2 alongside birth centres in 9 Regions and 1 Autonomous Province (all known for their good care practices) took part in the survey, which aimed to identify the areas of maternity care that women were satisfied with and those in need of improvement. All women at least 18 years of age who had given birth to a live baby at one of the participating birth facilities during the recruitment period (May-October 2022) were invited to the survey.

The participants were asked to complete two separate questionnaires, adapted from the validated questionnaire of Ireland’s National Maternity Experience Survey and translated into 5 languages (Arabic, Chinese, French, English and Spanish), before hospital discharge and three months after their child’s birth.

Online training was provided to both the interviewers and field-research team coordinators tasked with conducting the survey at the birth facilities.

Key findings

In total, 3642 women took part in the study, which had a response rate of 78.3%. Respondents had an average age of 34 years, 50% held a university degree and 73% had a job. Non-Italian citizens accounted for 11% of the sample. Most women described their experience of maternity care as positive: 90% described the overall care they received in pregnancy and labour, during and after childbirth and after discharge from hospital as good or excellent. On a scale from 0 to 10, the average scores were as follows: 8.4 for pregnancy care, 9.0 for childbirth care, 7.7 for postpartum care at the birth facility, and 8.3 for postnatal care received at home in the first 3 months after the birth.

The majority of women reported trusting and being treated with respect and dignity by the healthcare staff who cared for them during pregnancy, childbirth and the first 3 months of their child’s life. Publicly-funded pregnancy and childbirth care, provided respectively by family planning services and hospitals, received the highest score (8.8). Over 85% of the women who had been visited at home by a midwife after giving birth reported being given clear information as well as appropriate and useful advice.

The least positive experiences were reported with regard to postnatal care (in hospital and in the community), and 32% of the participants were not given the opportunity to choose their preferred type of pregnancy and childbirth care. In addition, the information they received on mood changes and mental health throughout the process was deemed inadequate. Some improvements are therefore needed in these areas.

The women who were struggling financially reported less positive experiences at all stages of maternity care.

Assessing perceived quality is essential to ensure that maternity care is always centred on the needs of women, and it is to be hoped that all Regions will start carrying out similar investigations on a regular basis. The tools, materials and methods used in this survey might prove useful for such future initiatives.

Surveys on perinatal mental health

In its guideline on improving early child development, the World Health Organization (WHO) includes supporting maternal mental health among the priority areas of intervention. Perinatal mental disorders, i.e. mental disorders that may affect women during pregnancy and in the first year postpartum, are common (1 in 5 women suffer from them) and are associated with (sometimes severe) adverse health outcomes in both mothers and their children. In the United Kingdom, the cost burden of perinatal depression alone is estimated to be 75,728 pounds per woman with this condition, with almost 75% of the cost resulting from long-term impact on the child’s health. As part of the project, two online surveys were carried out to identify good practices for the promotion and protection of perinatal mental health: the first was conducted among healthcare professionals from family planning services based in selected areas of the country, and the second among healthcare professionals from mental health departments nationwide. The goal was to provide information (for the first time in Italy) on the available care pathways for the management of perinatal mental disorders, with particular emphasis on the integration between specialist mental health and maternity care services.

Key findings

The first survey involved 144 family planning services from areas where good practices are known to be in place for the management of perinatal mental disorders. The majority of these services were assessing the emotional state of pregnant women on their first visit, and also provided more in-depth assessments of their mental health. In 90% of the participating family planning services, the information collected was used to assess the risk of developing perinatal depression and counselling and support were offered, if needed, in line with international guidelines. A written protocol for the integrated care of women with perinatal mental disorders was available in 55% of the family planning services (none of which were from southern regions).

The second survey targeted 127 mental health departments from all over the country, and had a response rate of 94%. Only 58% of the departments were offering preconception counselling to women diagnosed with/treated for a mental disorder who were planning a pregnancy, although NICE recommends that all women of childbearing age with a severe mental disorder should receive preconception counselling on an annual basis. About 87% of the departments did not have a guidance document for prescribing psychotropic medications to women of childbearing age. In over 60% of the departments, women with a suspected perinatal mental disorder were waiting less than 2 weeks for a mental health assessment, in line with international recommendations. However, specific care plans and diagnostic-therapeutic care pathways for the management of perinatal mental disorders were not available in over 70% and almost 80% of the departments, respectively (especially in the southern regions).

Overall, the findings confirmed the role of family planning services as the first port of call for perinatal mental health promotion as well as the diagnosis and prevention of perinatal mental disorders (in accordance with the 2017 Decree identifying essential publicly-funded healthcare services), in light of their non-stigmatizing approach, which takes into account the woman’s specific needs in this period of her life, her relationships (partner and extended family), and social networks. As for mental health departments, specialist skills and specific care pathways for the management of perinatal mental disorders should be enhanced (especially in the southern regions), also by investing in dedicated training and staff.

Studies of responsive parenting support

The protection and promotion of maternal and child health is recognized as a public health priority worldwide. WHO and UNICEF recommend policies aimed at supporting Early Child Development (ECD) through a series of interventions, based on the Nurturing Care Framework, that can ensure children’s good health and nutrition, opportunities for early learning, responsive parenting, child security and safety, also for the purpose of reducing inequalities in health. Similarly, the European Union Strategy on the Rights of the Child 2021-2024 highlights the willingness and urgency to continue implementing policies and securing funding to promote the rights of children and adolescents. Professionals should provide direct and appropriate intersectoral support to parents, to help them nurture the development of their children’s full physical, emotional, cognitive and social potential.

As part of the CCM project, two studies were carried out to explore responsive parenting support by investigating some of the aspects included in the Ministry of Health’s guidance document for the first 1000 days of life and monitored by the ISS-coordinated Surveillance system for children aged 0-2 years. These were: a workshop-based qualitative study targeted at primary/social care, education and social policy professionals with a role in protecting and promoting health in the first 1000 days of life; and a survey of primary care paediatricians to assess their knowledge, attitudes and clinical practices regarding protection and promotion of the physical and mental health of both children and their parents during the first 2 years of life.

Key findings

The workshop-based qualitative study was conducted in 4 Regions among about 120 professionals from the healthcare, education and social sectors. The goal was to look at the experiences of these professionals to identify factors facilitating or hindering the implementation of programmes/interventions in the first 1000 days of life, for the purpose of developing guidance on good practices in supporting responsive parenting. The workshops made it possible to explore interventions and programmes already implemented in the participating regions and aimed at: promoting responsive breastfeeding and feeding; protecting children from exposure to alcohol and tobacco smoke as well as from the effects of prolonged screen exposure; promoting early reading at home; reducing inequalities; increasing access to services.

The multi-professional and intersectoral debate during the workshops was highly valued by the participants. The information shared within the working groups highlighted the importance of developing processes for co-constructing interventions and programmes within a common framework, to help guide future actions. The groups also emphasized the need to: prioritize programmes that are sustainable over time; promote professional education and training opportunities that help develop a shared knowledge and language base; identify contact points in the community; use also digital resources to reach the target groups for the actions. The increased availability of cultural mediators and use of multilingual materials were deemed key to reaching out to foreign parents, who account for 20% of all births in Italy.

The survey of primary care paediatricians gathered information on their knowledge, attitudes and clinical practices regarding health protection and promotion during the first 2 years of life, with a view to identifying the training needs of all professionals involved.

The survey involved 5 health authorities and about 300 professionals, and had a response rate of 60.8%. The anonymous web-based questionnaire investigated: lifestyles, environmental factors, behavioural aspects, screening and development, mental health and relational aspects, inequalities, access to services and changes to clinical practice during the SARS-CoV-2 pandemic.

Over 90% of primary care paediatricians had a positive attitude towards the areas investigated by the survey. Most of them had good knowledge of the issues explored. There were, however, also some disappointing findings: 31% of the paediatricians thought that it is safe for pregnant women to consume a small amount of alcohol, e.g. a glass of wine; about 25% did not identify the correct recommendations on how to safely transport babies in a vehicle using a child car seat and how to place them to sleep in a cot; 11% thought that maternal depression goes away without treatment. As for clinical practices, over 40% of the paediatricians reported not always informing parents about: the risks of drinking alcohol while breastfeeding; environmental risks (45% seldom informed them of the seasons and times of the day when air pollution levels are highest); access to services (only 30% provided them with adequate information on existing services in the community that might offer non-health support, while 16% referred depressed mothers to a psychologist). 

The increased use of telemedicine and telephone consultations was reported as the main change in clinical practice as a result of the pandemic. 

Overall, the study made it possible to identify the areas in which training/further education activities would prove more beneficial to the professionals.