The National Maternity Safety Inspection Programme is a focussed programme of inspection of 131 maternity units across England.
The inspection phase was completed between August 2022 and December 2023. The aims of the programme include creating a national report of the findings and an improvement resource aimed at providers. Both these outputs will in part focus on healthcare inequalities.
This programme was instigated because of the risks highlighted in the Ockenden Report (March 2022) and the Kirkup review of maternity services at East Kent NHS Trust (October 2022).
This programme of activity is intended to stimulate work to improve maternity services and aims to promote equality of access, experience and outcomes for people who use maternity services. It provides a significant opportunity to signal the importance of maternity safety and equity to providers and stakeholders; encouraging improvement in maternity services and in the way we inspect maternity services.
We carried out this Equality Impact Assessment (EIA) before, during and following our inspection programme, to check any impacts and mitigations of our programme on equality groups.
About the project
The programme commenced in August 2022.
Lead Team
- Deputy Director: Carolyn Jenkinson
- Senior Specialists: Joanne Ward and Victoria Head
- Delivery Manager: Claire Portway
People involved in completing the EIA
Delivery Manager, Senior Specialist, Senior Policy Officer.
Date
10/07/2024
Evidence Gathering and Engagement
Evidence used for this assessment
Much of the approach has been informed through mapping work that evidence outcomes of pregnant women and people who use maternity services in high-risk groups including:
- Safety, Equity and Engagement in Maternity Services ReportSafety, Equity and Engagement in Maternity Services Report (2021), CQC
- Maternity Survey, 2022, CQC
- Maternal Deaths MBRRACE, 2022:Maternal Deaths MBRRACE, 2022: Demographics of Women and birthing people in high-risk groups: Black women (3.7x mortality), Asian (1.8x), Low socioeconomic status (2x than wealthiest), women > 40yrs (2.99x), women <20yrs (1.8x)
- Black Maternity Experiences Survey, 2022, FIVEXMORE
- Breach of Trust, 2021, Maternity Action
- Mapping existing policy interventions to tackle ethnic health inequalities in maternal and neonatal health in England, 2022, NHS Race and Health Observatory
- Equity and Equality: Guidance for LMS, 2021, NHSE
- From Bump to Baby: Maternity and Perinatal Consultation, 2022, Healthwatch
- INVISIBLE: Maternity Experiences of Muslim Women from Racialised Minority Communities, 2022, Muslim Women’s Network UK
- Systemic racism, not broken bodies, 2022, Birthrights
- A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality, 2021, Lancet
- Babies born to Black African and Caribbean families, and to Pakistani families are at higher risk of being stillborn or of neonatal death, than White babies, these disparities are further exacerbated by increased by level of deprivation. Perinatal Mortality, MBRRACE UK, 2022.
- Women of Black African heritage are 83% more likely to suffer a ‘near miss’ in childbirth, and women of Black Caribbean heritage are 80% more likely to (Nair et al, 2014).
- Black women more often experienced unequal treatment compared to white women and 78% of Black women surveyed in the UK do not believe their health is equally protected by the NHS compared to white women (Research by the Joint Committee on Human Rights, September 2020).
- People from ethnic minority groups can be unheard and under-valued by maternity services, both as staff and women and families who use services during the pandemic (Turning the Tide report: October 2020, Black Maternity Experiences Survey, 2022 - FIVEXMORE, Breach of Trust, 2021 - Maternity Action, INVISIBLE: Maternity Experiences of Muslim Women from Racialised Minority Communities, 2022 - Muslim Women’s Network UK)
- The NHS three year delivery plan for maternity and neonatal services notes significant health inequalities exist in maternity and neonatal care in England. For example, outcomes for women and babies from minority ethnic groups are worse than for white women, and outcomes for those living in the most deprived areas are worse than for those in the least deprived (MBRRACE-UK, 2022). The NHS approach to improving equity (Core20PLUS5)
We refer to a broad range of evidence-based guidance in our National Maternity Safety Programme Assessment framework.
Engagement and consultation as part of the assessment
Within the programme we have consulted with the following experts, stakeholder, service users and service user representatives:
Obstetricians in leadership roles: Devender Roberts (NPA, CQC), Tony Kelly (NHSE), Nigel Acheson (Chief Medical Officer, Devon ICS).
Experts in Equality, Diversity and Inclusion: Sola Afuape (NPA EDI - workforce), Benash Nasmeen (Midwife and Cultural Lead Midwife, Co-chair of Birth Rights and the Asian Society of South Asian Midwives, ASAM), Anton Emmanuel (Interim Head of Workforce Race Equality Standard, NHSE).
Forums and Networks: Maternity Roundtable events with staff and leadership held in May 22, Maternity Service Users Equality Steering Group, Society of African and Caribbean Midwives (SOAC), The Asian Society of South Asian Midwives (ASAM)
The following groups attended and inputted on our improvement resource workshop: The Equality and Human Rights Commission, NHS Race and Health Observatory, the Royal College of Obstetricians and Gynaecologists, NHS England, the British Maternal and Fetal Medicine Society, MNSI and over 40 NHS Trusts.
We have sought to actively involve women and birthing people in this project and particularly amplify the voice of women and birthing people from ethnic minority groups wherever possible i.e. by involving Maternity Stakeholder Council, ASAM, Society of African and Caribbean Midwives (SOAC), FIVE X MORE, Maternity Voices Partnership in development of our approach to inspections.
We have featured case studies which show the experiences of women from higher risk groups within our national end-of-programme report. The Data and Insight team used the CQC maternity survey to find specific evidence of feedback from women from an ethnic minority groups to strengthen our evidence and focus on healthcare inequalities.
Inspectors have sought to speak with women and birthing people from all backgrounds, including women and birthing people from ethnic minority groups where possible. Data and insight showing information about the demographics of the local population have been provided to inspectors prior to inspection planning. This helped inspectors assess whether the service is meeting the needs of the local population they serve.
CQC has commissioned a piece of research to capture the experiences of staff from Black and ethnic minority groups to explore equity of access to career progression.
Impact on different groups of people
Age
People of different ages.
Potential impact to consider
We do not anticipate a specific impact in relation to age from this work. Focussed inspections concern maternity services for people of child-bearing age and their babies, although the themed report will not specifically comment on issues related to maternal age or on care of babies.
However, we note that the Maternal Deaths, 2022, MBRRACE reported that women and other birthing people over 40 years old were 2.99 times more likely to die whilst women and other birthing people under 20 years old had a 1.8 times higher risk of death relating to pregnancy and childbirth.
Disability
Disabled people, including those with mental health needs.
Potential impact to consider
Research highlights maternal mental health as an area for concern and perinatal mental health is a factor in maternal mortality / outcomes and experiences of care (MBRRACE Rapid Review Report March-May 2020). In the Maternal Deaths, 2022, MBRRACE, 40% of the deaths postpartum were from suicide.
Focussed inspections may ask how services support and risk assess women and birthing people with a mental health condition, disabilities and/or complex needs (such as substance abuse, or domestic violence sufferer) and provides an opportunity to promote equality by encouraging improvement in maternity services.
Our publications may not specifically explore how maternity services take account of the needs and experiences of women with perinatal mental health needs, long-term health or other complex needs, or women with a learning disability, physical or sensory disabilities, autistic people, or British Sign Language users. However, we may include findings on how maternity services support women and birthing people in a way that promotes patient-centred care, particularly highlighting examples of good practice.
Maternity focussed inspections will not specifically address how well services are meeting the NHS Accessible Information Standard for disability communication needs. This can have a particular impact for disabled women, for example in relation to consent and choices and in recognising and managing pain.
Gender reassignment
Trans people, and non-binary people.
Potential impact to consider
The focused inspections assess maternity services for women, birthing people, and their babies.
CQC acknowledge that people who are non-binary, trans or inter-sex are more likely to experience poor care in the health and social care sector.
We recognise that people may not identify as a particular gender, and the importance of being sensitive to, and aware of, the impact of biases that may influence interactions and care received.
We do not anticipate a specific impact in relation to trans people and birthing people.
Focussed inspections may ask how services support women and birthing people with complex needs – and this could include birthing trans men – this provides an opportunity to promote equality by encouraging improvement in maternity services.
Our publications may not specifically explore how maternity services take account of the needs and experiences of those people who have undergone gender reassignment. However, we may include findings on how maternity services support women and birthing people with specific needs in a way that promotes patient-centred care, particularly highlighting examples of good practice.
We intent to host a podcast as part of the improvement resource that looks at people with different types of protected characteristics and their experience of maternity care.
Marriage and civil partnership
A person has the protected characteristic of marriage and civil partnership if the person is married or is a civil partner.
Potential impact to consider
We do not anticipate a specific impact in relation to marriage or civil partnership status.
Pregnancy and maternity
Potential impact to consider
This work represents an opportunity to promote safety, equity and improvements for maternity care for pregnant women and people. NMSIP was designed to assess intra-partum care and care provided immediately before and following the birth of a baby.
Race
People from minority ethnic backgrounds.
Potential impact to consider
This work represents an opportunity to promote equality for people from ethnic minority groups who use maternity services.
Existing research highlights differential mortality, outcomes, and experiences of services for women and birthing people from ethnic minority groups as detailed above.
We will explore the impact of race on maternity services in both the national report and in our improvement resource. This will look at both the experiences of service users and the experiences of staff.
There are a range of other factors which impact on people from minority ethnic group’s outcomes and disparities in care, this includes whether maternity services;
- respond effectively to Black women’s pain
- communicate effectively (including for consent and choices)
- Accessibility to information and support in other languages
- recognise and respond to emergency or life-threatening situations in a timely way and learn from safety incidents, near-misses and complaints.
For some women, for example newly arrived to the UK, language needs and migration status can impact on this too. For example, poor support with accessibility may result in women and pregnant people avoiding appointments and care, or lead to late presentation to healthcare services due to fear of charges associated with essential maternity care for women with no recourse to public funds (Breach of Trust, 2021, Maternity Action).
The way that safety incidents and complaints are investigated and managed can also have a differential negative impact on women, birthing people and their families, for example following a serious incident or bereavement during pregnancy. We note that ethnicity monitoring of safety data beyond mortality data is very limited at local and national levels.
Focussed inspections do not cover all key lines of enquiry which means that not all factors which impact on people from ethnic minority group’s experience of care or discrimination will be covered within the scope of this work. For example; this round of focussed inspections will not specifically review key lines of enquiry related to community care and will not look in detail at the care of babies.
Inspectors have assessed access to interpretation services and information in different languages to reflect the local demography. Poor communication was identified as a factor in perinatal deaths during COVID-19 period, including poor care, follow up and personalisation on the part of staff (MBRRACE Rapid Review March-May 2020).
The programme looked at staff experiences of racism in maternity services. We commissioned research into the experiences of midwives and obstetricians from minority ethnic groups. Interviewees described feeling “ignored, dismissed or effectively punished by negative treatment” when they spoke up about unfairness. Participants overwhelmingly felt that when they spoke up, issues were “swept under the carpet” or only addressed superficially, with a lack of genuine accountability and organisations adopting a defensive position.
Inspectors spoke with staff from ethnic minority groups on inspection and found that some staff felt they were discriminated against because of their race and ethnic backgrounds. Where we were told this by staff we have highlighted it to trusts in our inspection reports and reported on staff experiences of racism in maternity services more broadly in our national maternity inspection report.
Religion or belief
People with different religions and/or beliefs or no belief.
Potential impact to consider
We do not anticipate a specific impact in relation to religion or belief, although there is an opportunity to promote equality, recognising intersectionality between faith and belief and ethnicity for some women and birthing people.
Focussed inspections will not ask specific questions about how services are responding to religious diversity. However, we will continue to explore what action maternity services have taken to engage women and birthing people representative of their local population. We acknowledge that successful engagement will involve responding to intersectionality and diversity of religion and belief.
Sex
Either male or female, or a group of people like men or boys, women or girls).
Potential impact to consider
We do not anticipate a specific impact in relation to sex.
Sexual orientation
Such as heterosexual, gay, lesbian or bisexual.
Potential impact to consider
Lesbian, gay and bisexual people are more likely to be at risk of inequality or experience poor care than heterosexual people.
McCann et al’s ‘The Views and Experiences of LGBTQ+ people regarding midwifery care: A systematic review of the international evidence’ also highlights many poor experiences of care that LGBTQ+ people have when in maternity services.
Whilst there will not be a dedicated focus on how services are meeting the needs of lesbian, gay and bisexual people, there is an opportunity to promote equality in our inspections and our programme outputs. Within the improvement resource we will be looking at healthcare inequalities through the lenses of different protected characteristics and inviting experts to help us highlight to providers how all service users, no matter how few in a minority groups, can be considered and supported when service planning.
Carers
People with caring responsibilities.
Potential impact to consider
We do not anticipate a specific impact in relation to carers. We talk to pregnant women and people and their partners, families and caregivers when inspecting maternity services.
Socio-economic
People from lower socio-economic backgrounds.
Potential impact to consider
Research highlights living in a deprived area as a factor in maternal mortality, clinical outcomes and experiences of care (Maternal Deaths, MBRRACE-UK, 2022). This study found significant differences in mortality rates between women and birthing people from different areas. Women and birthing people living in the most deprived areas were 2.5 times more likely to die than those who lived in the most affluent areas, and this disparity has increased over time.
Deprivation levels increase the disparity in health outcomes seen in women and pregnant people, and their babies. MBRRACE-UK, 2022, Perinatal Mortality demonstrates that people of ethnic minority groups are more likely to live in social deprivation, and that their disadvantage due to ethnicity is further magnified by increased social deprivation.
Focussed inspections will ask how services support women and birthing people living with deprivation and complex needs. The programme of inspections will explore what action maternity services have taken to engage women and birthing people representative of their local population. We acknowledge that successful services and successful engagement will involve responding to local patterns of deprivation and need.
Intersectionality
Information relating to the intersection of any of these protected groups.
Potential impact to consider
We acknowledge that successful engagement will involve responding to intersectionality and how some women and birthing people may experience discrimination or poor outcomes based on more than one protected characteristic. We will be looking at how services respond to the needs of their population, including where they have high levels of deprivation or ethnic diversity and how this and other protected characteristics may impact care and outcomes.
Human Rights
Where there is a Human Rights implication.
Potential impact to consider
Right to life, right not be discriminated against in connection with other rights
Whilst human rights was not a specific focus, the work engages human rights issues such as bodily integrity and consent (Article 8) and inhumane or degrading treatment (Article 3).
The disparities in mortality and morbidity for Black women, Asian women and women from mixed backgrounds identified above, engage human rights in a fundamental way.
For example, whether maternity services:
- Listen when women and birthing people need to raise a concern.
- Communicate effectively (including for choices and consent).
- Recognise and respond to emergency or life-threatening situations in a timely way and learn from safety incidents, near-misses and complaints.
- Support women, birthing people and their families, partners and caregivers following a safety incident, near miss or bereavement during pregnancy and maternity.
These can each determine whether a woman and birthing person’s right to life (and that of her baby) is protected and whether women, birthing people and their families receive discrimination-free care.
Freedom from inhumane or degrading treatment
Several equality impacts engage human rights. For example, whether maternity services:
- Respond effectively to women and birthing people’s pain.
- Listen when people who use or work in maternity services need to raise a concern.
- Recognise and respond to emergency or life-threatening situations in a timely way.
- Recognise and respond appropriately to Female Genital mutilation in women and birthing people.
- Assess the environment to ensure Women and birthing people’s respect and dignity is maintained.
These can each determine whether women (and their babies) are protected from inhumane or degrading treatment in access, experience and outcomes of care, and engage other human rights.
Right to respect for family and private life, home and correspondence (includes autonomy issues in care and treatment)
- listen when women need to raise a concern or make a complaint.
- communicate effectively (including for choices and consent).
- support women and their families, partners or caregivers following a safety incident, near miss or bereavement during pregnancy and maternity.
- These can determine whether women’s rights in terms of autonomy, family and private life, are protected in access, experience and outcomes of care.
- Assess the environment to ensure this is safe and suitable for the purpose of delivering maternity care, including offering women and birthing people respect and dignity.
Action Planning
Issue Identified: Upskilling of inspectors and managers
Planned Action
Inspectors of the focussed maternity programme, have been encouraged to undertake additional specific training related to equality, diversity and inclusion (EDI) including a bespoke Maternity Inequalities Awareness session. This was designed and developed for inspectors and managers to improve awareness of health inequalities in maternity and to explore how to capture evidence relating to EDI on inspection. Inspectors also are required to have completed mandatory training on Anti-Bias and Fairness, Equality and Human Rights training.
Additional peer support/training around Female Genital Mutilation by working group.
Develop a guidance document for inspectors and specialist advisors to increase awareness about health inequalities in Maternity and unconscious biases.
Lead and Timeframe
Led by Emily Audet, clinical fellow, completed in May 2023
Issue Identified: Trend of findings from inspections found that incidents and clinical outcomes for women and birthing people from ethnic minority groups were not seen through the lens of diversity, equality and inclusion
Planned Action
Additional inspection and interview prompts were added to the inspection framework.
Report writing template and the maternity App to be updated with additional prompts.
Information sharing with inspectors to inform them of the changes.
Lead and Timeframe
Lisa Layton, Inspection Manager, completed this in 2023.
Issue Identified: Terminology used in inspection reports
Planned Action
We have specifically written guidance on terminology around the use of the term parents/caregivers/families - to ensure that inclusive language is used, in recognition that not all caregivers will be parents or families.
Lead and Timeframe
Emily Audet completed this in May 2023.
Issue Identified: Obtaining feedback from women and birthing people to inform the findings of inspections
Planned Action
‘Give feedback on Care’ campaign (including text messages) to obtain feedback.
There are limitations of the current format of Give Feedback on Care (GFoC) as it is not designed to obtain information about women and pregnant people demographics. We have fed this back to the GFoC team to improve future campaigns. We have utilised the CQC’s Maternity survey 2023 to ensure we included the views of women and pregnant people in our national report.
Lead and Timeframe
Senior specialists completed this in March 2024.
Issue Identified: Learning identified from the inspection programme to feed into future inspections
We identified that we didn’t reach and obtain feedback from women and birthing people with protected characteristics as well as we could. This included getting feedback from women and birthing people with a learning disability, autism, members of the LGBT community or people from ethnic minority groups.
Planned Action
Regulatory Leadership and CQC Policy team will continue to work with CQC’s Engagement team to provide ongoing to provide ongoing feedback from women and birth people with protected characteristics. This should include groups who represent women and birthing people with protected characteristics.
Lead and Timeframe
Victoria Head, Senior specialist – This is ongoing, continuous feedback is needed.
Issue Identified: Our inspections identified concerns with the lack of action trusts were taking to ensure that maternity services are accessible and safe for ethnic minority groups
Providers did not always collect and use demographic data to monitor and analyse outcomes for women from ethnic minority groups or look at safety incidents through an equality lens.
Planned Action
One of the four areas of focus for the CQC’s maternity improvement resource is healthcare inequalities. We aim to produce resources for providers that will set out good practice in this area. This includes brief guides, podcasts with experts and videos explaining what good looks like in this area.
Continue to promote and raise awareness within CQC and Trusts about the importance of using demographic data to monitor and analyse outcomes for women from ethnic minority groups.
Lead and Timeframe
Claire Portway
September 19 2024 publication of Maternity Improvement Resource.
Carolyn Jenkinson for promoting awareness of the importance of using demographic data - Ongoing
Monitoring and Review
We will collect feedback on our improvement resource both prior to publication and post publication through our engagement team.
We will have a register of our actions and timescales and will routinely review against this.
Sign off
Sign off from: Diversity and Inclusion Manager
Sign off from: Head of equality, health inequalities and human rights
Review Date: 19 March 2025.