Addressing inequalities in maternal care and outcomes

Health inequalities peer learning forum, held on 24 June 2024.

This event brought together trust and system leaders, alongside operational and equity leads, to discuss the barriers and enablers for addressing inequalities in maternity services.

Find the presentation slides here.

About the event

Maternity care within the NHS is marked by stark race and health inequalities. Pregnant women and people from Black and Asian ethnic minority groups are more likely to experience adverse outcomes and additional risks compared to their white counterparts. Findings from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries highlight these racial inequalities, and how deprivation can further exacerbate poor outcomes.

Key areas for improvement have been identified in workforce culture and leadership, patient access and engagement, and application of quality improvement approaches. Yet improvements in maternity services has been slow. In 2021, 41% of maternity services were rated as 'inadequate' or 'requires improvement' by the CQC.

The speakers at this event reflected on the national data trends and highlighted areas where NHS trusts and maternity services can make improvements and reduce inequalities.

Key themes from the event

This peer learning forum offered an interactive discussion space for attendees to share learnings, challenges and opportunities experienced at their respective organisations. The event was not recorded, however, anonymised key themes from the event are summarised below.

Overall, the discussions surfaced high levels of commitment to addressing inequalities in maternal care, but there are notable challenges to achieving improvements.

Workforce culture and leadership

There was recognition among trusts that there are cultural challenges within parts of the workforce, with specific concerns relating to unconscious bias, lack of understanding, education and appreciation of issues facing specific groups. Separate concerns around lack of engagement from maternity staff in trust initiatives were also noted. It was understood that racism impacts upon both staff experiences and on the quality of care provided to women and pregnant people, and babies.

Trusts reflected on the value of having a diverse workforce that is representative of their wider community, but many shared that this was not currently the case. Representation provides role models and a sense of safety, respect and empowerment for women and pregnant people.

Improving culture relies on robust systems for speaking up, escalation and calling out racism and discrimination. Trusts shared that this involves building confidence and psychological safety among the workforce, alongside normalising discussions on racism.

Accountability and buy-in among senior leaders within trusts is seen as critical for driving improvements, including leading on challenging boards to become anti-racist organisations. Trusts noted that inclusion should be a cross-organisation initiative, not just a focus for maternity services, in order to be meaningful. It also involves focusing on broader inclusion topics, such as LGBTQ+ maternity services and how this interacts with race equality.

Trusts highlighted the value of dedicated equality, diversity and inclusion (EDI) leads, both in executive positions and within midwifery teams. EDI and cultural safety midwives act as a link point for midwifery and wider organisational EDI work. However, challenges were noted around resourcing and supporting the development of these roles. It was noted that despite the importance of these roles, addressing inequalities should be everyone’s responsibility.

Data was raised as a barrier to overcoming cultural challenges. Trusts pointed to poor data quality, lack of data infrastructure to interpret results, and a lack of qualitative data to explain trends. Without accurate data, the wider workforce are unable to understand the scale of the inequalities experienced.

Training and education was seen as a key tool for improving awareness and understanding of racism and inequalities among midwifery teams. Challenges were noted around having opportunities to deliver collective training for whole departments and multi-disciplinary teams. There was concern that training on this agenda can often feel like a tick-box exercise. It was felt that face-to-face training would be the most effective training format.

Some trusts shared positive experiences of fostering informal opportunities for team bonding and socialising within midwifery services, focused on making all team members feel valued and welcome. It was highlighted that there is often less staff turnover within midwifery teams, whereas medical teams rotate more regularly. Positive multi-disciplinary relationships were seen to improve team cultures, enabling people to speak up and raise concerns, alongside fostering a sense of belonging. However, many trusts pointed to the need to improve experiences for internationally educated midwives, who require more targeted pastoral support.

Patient access and engagement

Engagement with women and pregnant people, families and communities was recognised as a means to build trust between patients, carers and staff, and to ultimately improve outcomes. There was variation in experience with engagement approaches, while some trusts have engagement incorporated throughout work, others have challenges engaging with communities.

Some trusts highlighted the benefit of working with community leaders, faith leaders, volunteers and community champions to reach out to communities. It was noted that it takes time to develop community networks and relationships, so progress can be slow.

Other trusts have worked in partnership with voluntary sector organisations and local Healthwatch organisations to deliver engagement events with women and pregnant people, and communities. They have also worked in partnership with Local Maternity and Neonatal Systems (LMNS) and maternity and national voice partnerships. Other trusts reflected that there was more to do to better join up their efforts with other organisations.

Trusts highlighted challenges in ensuring that their engagement was diverse and representative of wider communities, particularly noting the race inequalities in maternity services. This involves not over-relying on the same patient views and experiences and considering what groups aren’t engaged to share their views, which might require using non-traditional engagement techniques and considering accessibility (such as providing translation services). It was understood that there is a mistrust and fear among some patients that historically do not feel listened to or valued by healthcare organisations.

Trusts shared examples of best practice relating to engagement with patients and communities. This included providing a terms of reference for engagement work, sharing information back with communities to demonstrate the impact of their input, basing engagement activities within trusted community settings, responding to patient feedback to implement service changes, and sharing engagement results across the trust. It was felt that these practices should be embedded across the trust’s approach to engagement, not just within maternity services.

Some trusts highlighted the value of working with public health and primary care colleagues on engagement activities to build awareness across the system.

Approaches to quality improvement

There is an increasing level of adoption of quality improvement (QI) approaches embedded within maternity services. Some trusts are receiving specific support from NHS England and the NHS Race and Health Observatory to support with their QI maternity work.

Trusts are using different QI approaches, including Plan, Do, Study, Act (PDSA) and Experience based co-design (EBCD). One trust described their approach as “mile deep and inch wide” as they were implementing small highly targeted actions. Another trust had identified safety priorities from the Patient Safety Incident Response Framework (PSIRF) and was applying QI approaches to each of these priority areas. Another was focusing their QI projects with specific population groups.

It was noted that health inequalities are sometimes missed within traditional QI approaches and must be actively prioritised within maternity QI projects.

Trusts highlighted a lack of QI training as a barrier to embedding QI among the workforce. It was noted that formal training is required alongside data, toolkits and metrics to monitor implementation.

One trust also highlighted the need for additional admin and project management support to successfully embed QI projects and processes.

Good practice examples in maternity services

Despite the challenges highlighted by trusts, there were numerous examples of good practice. These included:

Training - bystander and allyship training, awareness raising on the impact of racism on health outcomes, and training on cultural safety

Engagement with communities – implementing a people’s council to bridge the gap between exec team and service users, hosting community based events to hear community experiences in local settings, and appointing patient representatives to improvement boards

Increasing diversity among the workforce – hosting roadshow events to promote employment opportunities within local communities and schools

Accountability – trust-wide commitment to becoming an anti-racist organisation and having an executive lead (or ICB lead) for maternity services to ensure regular reporting on maternity services at the board

Improving cultural awareness among the workforce – reverse and reciprocal mentoring opportunities, and working with staff networks

Data – use of a health inequalities data dashboards or heat maps to understand the inequalities and identify targeted interventions (such as looking at smoking cessation trends alongside birth rates)

Strategic commitment – development of a population health strategy and an outcomes framework, prioritising focus on a small number of indicator (including infant mortality)

As a number of trusts are starting out in their maternity improvement work, many would welcome greater sharing of good practice among trusts.

Additional resources

Chair: Miriam Deakin – director of development and engagement, NHS Providers

Speakers: Kate Brintworth – chief midwifery officer, NHS England
Donald Peebles – national clinical director for maternity, NHS England
Robert Wilson – head of Joint Policy Unit, Sands and Tommy's