The COVID Maternity Equality Project (CMEP) closed in October 2022
The Health Foundation supported the College through a grant for a one year project looking at whether and how changes to maternity care during the COVID-19 pandemic have affected existing inequalities.
Prior to the COVID-19 pandemic, there were already inequalities in maternity care and outcomes in England. Black women were four times more likely to die during pregnancy, birth and the postpartum period, and Asian women three times more likely, than white women. During the pandemic there have been substantial shifts in the way that maternity care was delivered in Britain, which have been captured in a survey led by the RCOG1. However, the effects of these changes on maternity outcomes have not been measured, and it was also unclear whether these changes had widened or narrowed the existing inequalities. This was an opportunity to learn lessons about how services may mitigate existing inequalities through service innovation.
This study aimed to identify changes to outcomes for women and babies during the pandemic and whether these were related to particular changes in maternity services offered. The study used routinely collected maternity data to identify units (positive deviant trusts) who had demonstrated a substantial reduction in maternal and perinatal outcomes, where changes in practice during the COVID-19 pandemic narrowed existing gaps in outcomes between women from different ethnic groups. The study also identified comparator trusts, which had reduced inequalities but to a lesser degree.
The study used participatory qualitative methods to explore and understand the nature of the changes made in those trusts that were more successful in reducing inequality gaps, with the aim of learning lessons that could be implemented across the maternity system. The project also gathered insights directly from women from various backgrounds, who had given birth in the UK before or during the pandemic and who formed the projects ‘women’s reference group’. This group provided continuous input to the project.
Please watch this short animation video for an overview of the findings.
The quantitative arm of the study showed that the national incidence rates of both maternal and perinatal adverse outcomes were stable in the pre-pandemic period. Rates decreased in the 1st lockdown period while in the 2nd pandemic period, rates for both mothers and babies raised to the pre-pandemic levels.
Incidence rates by ethnicity had a similar trend to the national one, and the same trend was seen in each ethnic group. However, higher rates were observed in ethnic minority groups compared to white ethnicity in the pre-pandemic period as well as in the pandemic period.
The subsequent qualitative study found that during the first wave of the pandemic there were two key differences in the positive deviant trusts, compared to the comparator trusts. These were:
- Increased staffing resources or productive re-allocation of staffing expertise: Positive deviant trusts made productive use of the drastic changing in staffing due to shielding, illness, and pausing of services. For example, for lots of the units there was more availability of senior staff who were given specific tasks to improve care or were able to provide support to teams. Comparators instead described staff ‘stepping in’ where needed, with no benefits to this.
- Increased proactivity and flexibility in delivery of care: Positive deviant trusts described proactivity at the start of the pandemic. They showed pride in how their trusts reacted quickly, and the expertise of their staff: who in some cases pre-empted and advised on national RCOG guidance. They also described improved team-working and the removal of barriers for quick decision making. Comparator trusts instead spoke of anxiety around changes in guidance and staff working separately.
Staff from positive deviant trusts admitted none of these changes would have specifically benefitted women from minority ethnic groups, but spoke of ways that these changes might have impacted women indirectly. For example, flexibility and proactivity allowed enhanced care to remain in place for women with high risk pregnancies or who are from vulnerable backgrounds, and women who needed interpreters were still seen face to face. Staff hypothesised that, in their trusts, women from ethnic minorities may be more likely to be in these particular groups, and thus their outcomes improved more than those of white women, hence reducing the inequality gap in this time.
The Covid-19 pandemic was a catalyst for the positive deviant trusts to build a culture of proactivity and team working, which, alongside a productive use of a change in staffing resources enabled a reduction in inequalities.
More work is needed to determine how this can be promoted and fostered.
Watch Bianca's story below
Recordings from the Dissemination Event
The College held a dissemination event and you can watch the clips from the event.
- Welcome from President –Dr.Ranee Thakar
- Ayesha, a member of the Women’s Reference Group Member talks about her experience of giving birth during the pandemic and her participation in the project.
- Dr Stamatina Iliodromiti, the Principle Investigator and Consultant in Obstetrics and Gynaecology, Royal London Hospital, introduces the project.
- Tina, a member of the Women’s Reference Group Member talks about her experience of giving birth during the pandemic and her participation in the project.
- Esra, a member of the Women’s Reference Group Member talks about her experience of giving birth during the pandemic and her participation in the project.
- Buthaina Ibrahim, RCOG Quantitative Researcher discusses the findings from the data.
- Dr Jemima Dooley, RCOG Qualitative Researcher discusses the findings from the interviews with staff from the positive deviant and comparator trusts.
- Dr Stamatina Iliodromiti, the Principle Investigator and Consultant in Obstetrics and Gynaecology, Royal London Hospital, draws conclusions the findings from the project.
- Q&A Session
1. Jardine et al, Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care. BJOG - An international journal of Obstetrics and Gynaecology https://doi.org/10.1111/1471-0528.16547