This long-read shares learning from our Health Inequalities, Race Equality and Improvement programmes.
Women from black and Asian minority groups, as well as those from disadvantaged areas, are more likely to experience poorer outcomes in their maternity and neonatal care. Black women are four times more likely to die in pregnancy and childbirth than white women, and Asian women two times more. There is an urgent need to address these stark inequalities and for trust boards and the wider system to drive rapid improvement.
Through a series of events, we've been working with trust leaders and their partners to share learning around improving maternity and neonatal outcomes, with a focus on addressing race and health inequalities. Three themes emerged from the discussion: workforce culture and leadership, patient access and engagement and quality improvement approaches. We explore these in turn below, along with examples of good practice and support resources.
Workforce culture and leadership
Trusts recognise that cultural challenges exist within parts of their workforce, including unconscious bias and a lack of understanding of differing patient needs, negatively impacting both staff and those they care for.
In response, we heard from attendees about the need for robust systems in place for speaking up, escalating and calling out safety issues, racism and discrimination. Normalising discussions around discrimination and giving staff opportunities to share their experiences with each other are important in enabling organisational cultural change.
The importance of board leadership here is clear, with Naomi Chambers', professor of healthcare management at Alliance Manchester Business School, research on the desirable characteristics of effective healthcare boards noted. This work can help boards to understand their role and assess their readiness to lead and embed cultural change. A recent report into the conditions for sufficient board oversight in maternity and neonatal services also offers helpful suggestions about data and intelligence, robust and candid review processes and early action to address concerns.
More broadly, attendees spoke about the value of ensuring that the workforce is representative of the local community to promote a sense of safety, respect and empowerment for those receiving care, as well as within the workforce itself. We know that staff from black and minority ethnic backgrounds have more negative experiences of working in the NHS and have increased levels of work-related stress, which can impact on ability to deliver quality care. Many trusts also fed back on the value of dedicated equality, diversity and inclusion (EDI) roles in helping embed this approach organisation-wide and underpin positive role modelling by senior leaders.
Unsurprisingly, training and education emerged as key enablers for improvement across behaviours, clinical practice and analysing and using data. Recommendations from the NHS Race and Health Observatory highlight the inherent discrimination within a number of clinical practices and include important modifying assessments, tools and resources for staff to better understand how disease can impact people of different racial backgrounds differently and to address health inequalities.
Staff from University Hospitals Birmingham shared practical examples of how they are implementing changes based on the findings of research with black African and Caribbean communities in Lewisham and Birmingham, including engaging staff on unconscious bias and adapting training materials to be inclusive. Cross-disciplinary training can also improve maternity outcomes by helping to cultivate 'collective competence', where staff have an understanding of the roles and skills of others and are able to work more effectively together.
Patient access and engagement
Engaging with patients to understand their perspectives of care is critical in improving experience and outcomes. A recent NHS Providers report details how co-production and engagement with communities plays a key role in reducing health inequalities.
At this series of events, we heard how grassroots organisations and other voluntary, community and social enterprise groups with existing trusted relationships with communities can assist in gathering insights and helping to ensure that all voices are represented. Maternity voice partnerships listen to the experiences of women and families, and bring together service users, staff and other stakeholders to plan, review and improve maternity and neonatal care.
The diversity of opinions and experiences being shared should mirror that of the population, and trusts must actively engage the voices of those who are underrepresented in quantitative and qualitative data. This includes assessing their data to make sure they have an awareness of which voices are lacking and who they need to engage.
Cultural beliefs, communication challenges and a lack of awareness of available services are all key barriers to access which need to be understood across different patient groups. Colleagues from University Hospitals of Leicester NHS Trust told us about how they are using patient evaluation surveys to understand the challenges for South Asian women and pregnant people in accessing their perinatal mental health services.
Quality Improvement approaches
Feedback from these sessions and more broadly suggests that Quality Improvement (QI) approaches are increasingly being adopted by maternity services. However, there is a risk with traditional QI methodologies that equity can be missed unless actively considered from the outset.
In an effort to counter this, we heard examples of QI programmes which have a core aim to embed anti-racism principles and consider health inequalities across maternity services. This is part of a pilot programme being delivered by the NHS Race and Health Observatory's Learning Action Network, in partnership with the Institute for Healthcare Improvement. The programme begins with an assumption that racism is one of the factors that underlies the persistence of maternal and neonatal ethnic health inequalities. It aims to develop an anti-racism focused QI model and identify, scale and spread improvement approaches that embed anti-racism into services to improve maternal outcomes.
Teams across trusts and regions are coming together in clinical areas where evidence highlights significant racial inequalities in health outcomes, such as post-partum haemorrhage, gestational diabetes, perinatal mental health and preterm birth.
Colleagues also told us how they are working respectively on reducing racial disparities in preterm optimisation, increasing referrals of South Asian women and pregnant people to antenatal and perinatal mental health services, and reducing post-partum haemorrhage experienced by black and ethnic minority women and pregnant people. They shared their initial learning as part of this pilot programme at our recent webinar on using QI to enhance maternity and neonatal outcomes.
Conclusion
Our webinar series on the interconnection between health inequalities, racism and outcomes for maternity and neonatal care revealed complex challenges. But – as this summary of initiatives, resources and learning shows – there is strong commitment and energy from trust leaders, national decision makers and wider partners to address inequalities and improve outcomes.
Complementing this work, NHS Providers continues to engage with political and national decision makers to address the challenges within maternity services and to make the case for appropriate staffing, investment and support.
Additional resources:
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Catch up on the recording from our webinar Using quality improvement to enhance maternity and neonatal outcomes.
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Read our report on the importance of co-production and engagement with communities as a solution to reducing health inequalities.