Women and birthing people from Black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey.

Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what might be done to improve local services.

This is the second in a series of blogs reflecting on the learnings and experiences from her Fellowship. Read Rosie's first blog focusing on partnering with minoritised women and birthing people and third blog focusing on the challenges of tackling structural issues during fixed-term projects.

Croydon is an ethnically and socially diverse London borough. Approximately 52 per cent of Croydon residents are from minority ethnic backgrounds and this is representative of the maternity population. As such, it felt a particularly appropriate location to spend time understanding why significant perinatal health inequalities related to ethnicity still exist.

Over the course of my time as a Darzi Fellow, I spoke with maternity service-users, staff and other stakeholders from across Croydon about the underlying causes of these health inequalities; you can read about some of methods used to involve people and communities in the project here.

This blog details five recommendations which I hope will support ongoing work in Croydon, but which may also be relevant to other maternity services or health and care services looking to tackle health inequalities.

1. Acknowledge the role of systemic racism in upholding perinatal inequity and make organisational commitments towards becoming anti-racist

This subject was raised during one of the earliest conversations I had with a voluntary sector colleague. At the time, she was also working on a project with a neighbouring mental health trust who had made an organisation-wide commitment to become anti-racist. She felt strongly that this was the minimum standard to build trust and engage with the NHS on projects such as this. During my fellowship there has been a catalogue of publications supporting this recommendation including the Black Maternity Experiences survey, the Birth rights Inquiry into Racial Injustice, the Race and Health Observatory (RHO) report on Ethnic Inequalities in Healthcare and the recent Invisible report from the Muslim Women’s Network.

Of course, it is vital that an organisational commitment to strive towards anti-racism is backed up with a suitable action plan that identifies how this will be achieved - without which, it can serve as a fig leaf to hide inaction.  

2. Work collaboratively to find solutions and invest in social capital

Both health and health inequalities are created in the community. The solution to tackling perinatal health inequalities is unlikely to lie within the four walls of a hospital, even if that is where the inequality is being played out. It is therefore crucial that the NHS knows how to work collaboratively with its communities to co-design strategies to tackle perinatal inequalities.

One of the messages that came across strongly from the conversations at the Whose Shoes event was the need for stronger networks to support birthing people and their families; an investment in local “social capital” for pregnancy and early years.

The HEARD campaign is currently working on developing a local maternity programme to meet this need. Ideas included developing maternity peer support, training hairdressers to have conversations about the importance of early referral to maternity services to increase community knowledge levels and a Maternity Champions programme.

3. Invest in effective data capture at a local level

Capturing accurate data around ethnicity in the NHS can be problematic and unreliable. Although there is enough data at a national level to identify the scale of the issue, we don’t consistently have effective data capture at a smaller scale to evaluate of the impact of local initiatives. Without baseline data, assessing the impact of any programmes is difficult because realistic targets cannot be set and funding for projects is jeopardised.

However, some localities have developed effective workarounds. For example, in maternity care, when the childbearing parent is booked in at hospital, a family origin questionnaire is completed to facilitate screening for sickle cell disease or thalassaemia. This could be used to also aid a conversation around the importance of accurate ethnicity data for population health monitoring and as such, upskilling midwives to carry this out could be effective.

Finally, it is important that data capture also considers inequality through an intersectional lens. There is a clear need to improve data capture around other protected characteristics and exclusion health factors in conjunction with ethnicity such as sexuality, religion and deprivation decile or housing insecurity.

4. Listen, hear and take action

The theme of not listening to women has been written large throughout the course of my Darzi Fellowship. Accounts of women not having their concerns listened to, or not taken seriously are an omnipresent feature of sequential maternity reports. When women express choices that go against guidelines or medical advice they are often not supported adequately. Action must be taken to better equip maternity staff to have conversations around informed decision making and personalised care.

Even in circumstances where maternity staff are supportive of women’s bodily autonomy, processes to support fully personalised informed decision-making during labour are not well established. Widespread uptake of new approaches, such as the iDecide tool, are likely to improve the safety, personalisation and experience of labour care.

5. Invest in staff

There remains a widespread misunderstanding about what racism is and how it plays out in health settings, so enabling staff to identify this and supporting them to examine their own bias is so important. Locally delivered cultural awareness training would further support increased safety of personalised maternity care.

A second training recommendation would be to support maternity staff to develop an enhanced understanding and awareness of the role of maternity services in addressing social determinants of health. In maternity services, the perception persists that health interventions such as smoking cessation, weight management and glycaemic control are only required for the duration of the pregnancy. A more long-term view is required to maximise the long term health impact and mitigate against the disparate incidence of chronic disease. Consideration should be given from a commissioning perspective to other opportunities for staff to deliver public health interventions during pregnancy aligned with the prevention agenda. For example, this could be through improving family health and mental health literacy among specific populations.

For any of these recommendations to be implemented, there is also a requirement to invest in a full-time member of staff with a responsibility focused on health inequalities related to ethnicity. Their role would include engaging with the local community and developing the social capital initiatives, embedding cultural shifts, and ensuring that choice and personalisation are protected in maternity care. They would also be there to deliver training as appropriate, set up mechanisms for routine collections of maternity experience feedback and oversee the implementation of new and improved data capture as described earlier in this blog.

With enormous thanks to Ranee Thakar, Gina Short, Olamide Odusanwo, Manjit Roseghini, Donnarie Goldson, Mobola Jaiyesimi, Antoinette Johnson, Leila Howe, Gemma Dakin, Alison White, Jay Patel, Ima Miah, Felisha Dussard, Andrew Brown, Tai Lamard, Gill Phillips, Paul Macey and all the birthing families of Croydon who were so generous in sharing their experiences with me.

Find out more about the maternity and neonatal work happening in South West London ICS.

Women and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs reflecting on the learnings and experiences from her Fellowship. Read Rosie's second blog focusing on key recommendations from the project and third blog focusing on the challenges of tackling structural issues during fixed-term projects.

Evidence points to a shocking disparity in maternal and perinatal death, preterm birth and fetal growth restriction, between people from black, Asian and mixed ethnic backgrounds and their white counterparts. This has a significant impact on health and economic outcomes, and while the causality is not fully understood there has previously never been a policy ambition designed to address this.

However, following the health inequalities highlighted by the Covid-19 pandemic and the impact of the Black Lives Matter movement, this is starting to change. In September 2021, NHS England requested each local maternity and neonatal system develop a strategy to address this by September 2022.

The Context in Croydon

In Croydon, work to improve outcomes for women from minoritised ethnic backgrounds was underway before this. The maternity unit delivers 3,200 babies per year and approximately 52 per cent of Croydon residents are from minoritised ethnic backgrounds, which is representative of the maternity population.

In Spring 2021, a passionate and dedicated midwife, Olamide Odusanwo, was determined to do what she could to tackle the issue of perinatal inequality. With colleagues Gina Short, Helen Chambers and Ranee Thakar, she set up the HEARD (Health Equity And Racial Disparity) campaign.

They carried out surveys with women (and birthing partners) and staff to better understand the local context. This led to changes including increased appointment length and frequency for people from minoritised ethnic backgrounds, and the creation of a dedicated service for people who felt their concerns were not being heard during their maternity journey. They also helped identify the scale of work needed to tackle the issue and the clear need for a dedicated midwife to work on the project.

This is where I came in – a midwife by background, with a passionate interest in health inequalities – I came to Croydon as part of the Darzi fellowship leadership programme. The Darzi fellowship includes a PGCert Leadership in Healthcare and a change project in the hosting trust. We are expected to explore the challenge in depth to develop long term, sustainable solutions.

Tackling a ‘wicked’ problem through involving people and communities

To scope the project we interviewed a number of stakeholders including women and birthing partners from minoritised ethnic backgrounds, as well as voluntary sector staff involved in related health equity projects. The most common themes were access, barriers and listening to women and birthing people.

We looked for data which could help illustrate these three themes. However, data on ethnicity is poorly recorded which made it difficult to establish a baseline. While work is ongoing at a national level to address this (NHSEI 2021), it was a significant limitation to the project. We also struggled to find data to illustrate the themes of listening to service users and barriers. However, the theme of not listening to women and birthing people was identified in the preliminary Ockenden report where recommendations were made about the need to improve this.

Due to its complexity the issue was quickly identified as a ‘wicked’ problem. Wicked problems need to be addressed using a collective approach. This is because no individual perspective is enough and so solutions must be built on collective knowledge. Accordingly, there was a clear need to develop a ‘collective’ to undertake the work by creating a network.

We hosted a Whose Shoes event to engage interested citizens and wider health and voluntary sector staff, to establish a network and start discussing solutions. Whose Shoes is an award-winning board game with a multi-perspective approach to transforming health and social care services by putting the person in the centre. It is renowned for its co-production ethos and has a strong track record in maternity care.

It was crucial for us to reach groups beyond those normally reached by our engagement work. As part of this we had to overcome mistrust of institutions, which we started to address by holding the event at a trusted voluntary sector partner organisation - Croydon BME Forum - instead of on hospital premises. We sent invitations via social media from this organisation, the Asian Resource centre Croydon, Happy Baby Community and Big Local Broad Green.

The event was well attended and resulted in us expanding the membership of the HEARD campaign to include local experts by experience (women and birthing partners) and wider health and voluntary sector members. This was key for co-design of the next steps. The picture board below recaps the informal discussions that were had during the Whose Shoes event, highlighting the topics that members felt were important to address.

As is often the case with fixed-term projects, it feels like we are really starting to gather momentum, just as my year is coming to an end. Nevertheless, the brilliant work of the HEARD campaign will continue after the completion of my Darzi fellowship and as I leave, I am acutely aware of the power of people. This project started with one idea from one midwife, who shared her idea with others, who in turn shared it with more people who then all came to coalesce around the same cause - to drive the change they wanted to see in their community.

With enormous thanks to Ranee Thakar, Gina Short, Olamide Odusanwo, Manjit Roseghini, Donnarie Goldson, Mobola Jaiyesimi, Antoinette Johnson, Leila Howe, Gemma Dakin, Alison White, Jay Patel, Ima Miah, Felisha Dussard, Andrew Brown, Tai Lamard, Gill Phillips, Paul Macey and all the birthing families of Croydon who were so generous in sharing their experiences with me.

Find out more about the maternity and neonatal work happening in South West London ICS.