Addressing maternal health inequalities

Last year, I sat speechless in a maternity drop-in session organised by Tower Hamlets Council for Voluntary Service (THCVS), a VCSE organisation in east London. 

Over the course of two hours, we heard many stories of dissatisfaction: healthcare staff not taking women seriously during appointments, racial stereotyping, and a lack of communication or informed consent during procedures. Walking home that evening, I made up my mind to try to understand why this was happening and how it could be addressed through service design. 

Maternity is one of the most cathartic experiences a woman can go through. Why, then, were expectant mothers in Tower Hamlets experiencing stark inequalities in their care? Much attention has been paid to what happens when a woman arrives at hospital to give birth, but for many women there were clearly issues throughout every interaction with services following conception.

The common factor behind health inequality 

Tower Hamlets has one of the biggest non-white British populations at 77.1 per cent, with the largest Bangladeshi population out of any London boroughs, at 34.6 per cent. It is also one of the most deprived areas of London, despite having notable pockets of affluence. 

While it would be easy to paint a narrow picture of ethnicity or financial status as the sole driver of inequality, I learned that these experiences do not result just from factors such as ethnic descent or financial stability, but rather are quite multi-layered. 

Ethnicity, language, social, economic, marital and employment status all interact to create a complex picture which impacts firstly on the ability of expectant mothers to access care, and then to receive equitable care when they come to attend an appointment. 

"...the common factor associated with unequal health outcomes, and the problem that I heard discussed time and time again, was communication"

For example, an expectant mother who works full time is more likely to have an understanding employer and internal policies that would allow her to move her schedule and to attend appointments whenever they arise;  a woman employed informally might have to take unpaid leave to be able to attend an appointment. 

Beyond the ability to actually attend appointments, the common factor associated with unequal health outcomes, and the problem that I heard discussed time and time again, was communication. In particular, an awareness of the services and support available as well as the value of engaging with them. 

One mother shared: “The NHS doesn’t volunteer information. You have to do your own research and know what you are talking about if you want a certain level of care.” 

The state of NHS services 

The NHS, already underfunded and overburdened, struggles to provide personalised care for diverse needs. Staff shortages mean limited time with the patients, with most antenatal appointments being too short to fully address complex non-medical needs or even to have a two-way conversation. 

“What is lacking is the ability to properly integrate external support”

This means that despite services being commissioned to respond to a wide range of needs, as they are in Tower Hamlets, patients in many cases are not being made fully aware of the services, negating the potential benefits. 

A midwife explained to me that she often faces situations where she wants to do more for a particular patient but simply cannot, either because of language barriers or because it is impossible to listen to and convey all of the necessary information in the ten-minute window available. 

What is lacking is the ability to properly integrate external support. As funds are limited and individual, direct collaborations with voluntary services are capacity intensive. 

Possible interventions 

We know how important voluntary and community organisations are in providing practical solutions to causes of inequalities. 

They are highly adaptable and provide personalised, one-to-one assistance that often extends beyond their primary focus, addressing interconnected needs of individuals. 

“A VCSE leader I work with heavily emphasised the importance of working collaboratively, rather than in competition with each other, to provide communities with unified support”

However, among the many systemic barriers they face, the biggest one is often discoverability. This in turn threatens their viability. Relying heavily on funding rounds, if engagement is minimal, there is a chance that smaller organisations may struggle to demonstrate need, despite being able to describe having qualitative impact. A VCSE leader I work with heavily emphasised the importance of working collaboratively, rather than in competition with each other, to provide communities with unified support.

As part of my drive to address these inequalities through service design I envisioned The Nest, a service concept designed to allow maternity professionals to signpost medical and non-medical help and resources to expectant mothers in Tower Hamlets. 

The Nest has three key elements: 

• The Care Conversation: A dialogue tool with 12 questions for GPs and midwives to use at the first antenatal appointment. It helps identify non-medical needs, such as language support or social isolation, early in the maternity journey. 
• The Care Platform: A dynamic, live platform where VCSE organisations can post their services, resources, and events. 
• The Care Sheet: A printed A4 summary of relevant resources, events and support services, handed to expectant mothers to include in their maternity notes. 

If used systematically, these simple steps can make every expectant mother feel equally informed, supported, and cared for beyond the medical sphere. In essence, an approach of this kind this would be the first step towards fully integrating care - making staff working at the frontline, in primary care, aware of services available elsewhere, while giving them the tools to communicate that information quickly and effectively to patients. 

As I continue refining this concept, I hope it inspires further dialogue about addressing inequalities in maternity care, not just in Tower Hamlets but across the UK.  

Sharvari Joshi is a service designer and researcher. She is currently researching maternal health inequalities faced by global majority women while accessing 999 and 111 services, as part of a funded project by London Ambulance Service NHS Trust. You can follow Sharvari on LinkedIn.