Over the years, maternity services have rightly placed more emphasis on an ability to serve a diverse community in its entirety. That means understanding the needs of the local community, says Sumayyah Bilal

Nationally published data, from sources such as MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK), has increased awareness that there are stark disparities of maternal outcomes for Black, south Asian and global majority women in the UK. Despite recognition of this health inequality, little has changed.

As a woman of mixed heritage, these numbers are more than statistics as they could have affected the outcomes of my own pregnancies. In 2022, while working as a consultant midwife in a north central London hospital, I established tailored parent education classes for Black women and introduced the role of an equity and equality lead midwife. This article reflects my journey, setting out the learning as a guide for others looking to support local maternity service demographics.

Learning to listen

The Trust’s data showed nearly 30% of its maternity service users were from the global majority. A review of the data on serious incidents and cases that were referred to, and met the threshold for, the Healthcare Safety Investigation Branch (now known as Maternity and Newborn Safety Investigations) showed that, even though the global majority accounted for 30% of the local demographic, it accounted for more than half of all reported serious incidents. This reinforced that the work was needed.

All service users are encouraged to share their feedback through surveys or linking in with their Maternity and Neonatal Voices Partnership (MNVP), but there were disproportionately fewer responses from global majority users. So I designed a questionnaire that was sent to those noted to be of Black heritage on their booking forms, with the hope that I could explore their reasons for low engagement and what information would be beneficial to them.

With next to no responses, I then attempted ad hoc phone calls with service users. These were more productive, though there was still hesitancy in giving feedback. Thinking creatively, I then started to approach Black women attending obstetric and diabetic clinics (where there were a high proportion of Black women and birthing people booked in). These corridor conversations were valuable in capturing what was important to them, because face-to-face communication provided greater transparency.

Service users articulated fear of judgement on cultural practice and expressed the desire for a safe space to discuss sensitive matters. They were more likely to engage if the facilitator was also Black.

After consulting the Trust’s head of midwifery, I was given the go-ahead to contact Black community midwives to discuss the proposal and incorporated their thoughts and feelings into the model. I established a working group and set up a Trust maternity social media page to promote the classes.

New classes

Based on the useful feedback received, I reviewed the Trust’s existing parent education framework and modified the content of the classes. The format was three consecutive face-to-face interactive classes over a three-week period covering antenatal, intrapartum and postnatal.

The first session covered:

• why the classes were created
• icebreaker discussion on their experiences: how do they feel Black women are represented? What challenges or positive experiences have they had? Who are their role models?
• risk factors associated with Black pregnant women
• diet and lifestyle – African and Caribbean Eatwell Guide and food composition
• foods to avoid in pregnancy
• perinatal mental health cultural taboos and local services available
• useful resources
• bonding and getting to know your baby, from pregnancy to birth.

The second session covered:

• preparing for labour
• choices for place of birth
• birth plans and preferences
• what to bring to hospital
• perineal massage and pelvic floor exercises
• signs of labour
• when to come to hospital
• three stages of labour
• what can your birth partner do? – advocating and addressing stereotypes
• pain relief
• activity: what is important to you when being cared for in labour?
• modes of delivery and interventions
• self-advocating and informed choice
• recognising infection on Black skin
• skin-to-skin contact
• activity: physical tour of the unit.

The third session covered:

• how to get involved with the MNVP for better representation
• infant feeding
• benefits and myths of breastfeeding, cultural perceptions of breastfeeding and local support
• positioning and attachment
• hand expressing
• responsive feeding
• nappy changing, bathing baby, and skin and cord care
• cultural practices
• ICON (Infant crying is normal; Comforting methods can help; OK to walk away; Never, ever shake a baby)
• signs of an unwell baby
• identifying jaundice on Black babies
• safer sleeping for babies
• mental health in the postnatal period
• group activity: everyone stand up, then sit down when you feel you would seek professional help
• group discussion: barriers to seeking help? Share who they would ask for help (professional and outside of healthcare)
• how and when to ask for or seek medical help
• feedback/evaluations.

Visual aids demonstrated elements such as recognising presentation of sickness and infection in different skin types, while the face-to-face classes enabled meaningful conversations to take place. This, in turn, helped to develop the structure of the classes and build connections in the community.

Challenges

Despite the classes going well, the process wasn’t without its challenges. The proposal of setting up these classes was met with mixed reactions. Some were enthusiastic to try something new in the hope of improving outcomes for an underserved community; some were sceptical that this was, in effect, a form of segregation. Of the original staff approached to support the classes, only four agreed to remain part of the working group and service development.

Additional barriers included clinic space, funding and time. We were forced to be creative with how the classes could be delivered. Weekday clinic capacity was limited, so we held the classes at weekends at hospital sites. Rotas were adapted to factor in staff facilitating the classes and, where this wasn’t possible, time was given back in lieu.

Promoting the classes through midwives was inconsistent, as not everyone bought into the model. Because of uncertainty about numbers attending and the initially restricted venue spaces, we put posters around clinics and approached women attending.

Personalised care

Central to Better Births is the principle that maternity care should be personalised and safe. Personalised care means service users have choice and control over the way their care is planned and delivered, based on what matters to them and their individual needs and preferences. Tailoring antenatal classes to meet these seems like a natural step, demonstrating the need to listen to women and families with compassion. This, in turn, promotes safer care.

Personalised care also has the potential to reduce health inequalities. As MBRRACE-UK has stated: “Maternity outcomes for women are not equal. There remain gaps in mortality rates between women from deprived and affluent areas, women of different ages and women from different ethnic groups.”

Antenatal education needs to be reviewed and adapted to meet the needs of women and birthing people using the service. A growing body of evidence shows that better outcomes and experiences are possible when people are actively involved and can shape their own care and support.

Results

The feedback was positive and the demand for and attendance of subsequent classes increased. I am proud that, after more than a year of the classes, they have continued to grow and serve the local community. Feedback remains positive and Black women’s voices and experiences are being heard, acknowledged and incorporated into care.

My vision was to always scale up the project and offer similar tailored classes to others at risk of poorer outcomes, such as women of Asian heritage. As a midwife, my hope is to continue to empower and better serve our communities, acknowledging individualised risk factors, experiences and voices to improve the services we provide, thus reducing health inequalities.

These classes are not the first of their kind and I hope not the last. We need to think more broadly and increase cultural safety, diversity and awareness, co-designing effective community healthcare models that are flexible, relevant, accessible and welcoming.

Framework for targeted antenatal classes

Trust ethnicity data and reports

• check Trust/Board ethnicity data and reports
• review Trust/Board safety investigation reports – is there a common theme in terms of ethnic groups?

Engagement and listening sessions

• gather views and opinions from members of staff – are they happy to deliver the classes, and to contribute to the content?
• what do service users want to get from the classes – content, online or face-to-face sessions?

Identifying the needs of the ethnic group

• risk factors
• cultural understanding of different aspects of pregnancy, birth and postnatal period
• stereotypes, including mental health stigmas
• local support groups.

Incorporate the generic antenatal classes content

• place of birth options
• stages of labour
• pain relief options
• positions in labour and methods of fetal monitoring
• safe sleeping
• newborn screening tests
• GP check at six weeks.

Tailored content includes:

• risk factors
• diet and exercise
• informed choice and decision-making
• discussion around their own experiences of pregnancy and healthcare – what is important to them?
• cultural practices
• mental health scenarios, when and where to seek help, barriers to seeking help
• contraception
• lifestyle choices (smoking, alcohol use)
• cultural understanding of the postnatal period, including stereotypes, cultural beliefs and choices.

To consider

• support from local community groups
• engagement of staff (unit meetings, listening sessions for staff)
• members of staff from the target demographic to deliver the classes
• information leaflets in the different languages
• admin resources (e.g. booking management via Eventbrite, sending reminders)
• local venues (easy to access, local to the communities, consider using spaces from local groups to increase engagement)
• include service-user feedback
• bi-annual audit of the classes.

Image credit | Alamy | Shutterstock