How lessons learned during Covid-19 are helping Cheshire & Merseyside address equity and equality in maternity care

It is now widely recognised that significant health inequalities exist in maternity and neonatal care in England. MBRRACE-UK, which investigates deaths during pregnancy, childbirth, and the year after birth, is just one annual report that has revealed the extent of these disparities. In November 2022, it revealed that black women are four times more likely to die from childbirth than white women. Maternal death rates in deprived areas are also on the rise, with women in the most deprived areas 2.5 times more likely to die than those in the least deprived areas.

In a report on black maternal support from the Women and Equalities Committee in April 2023, there was a call for faster progress. Chair of the Committee, Rt Hon Caroline Nokes MP, said that “we cannot let these women remain invisible to the systems supposed to support them.”

The NHS has responded with its three-year delivery plan for maternity and neonatal services, which was published in March 2023. Insights from population health data was highlighted as being one of the key tools that will be used to reduce inequalities for all in access, experience, and outcomes – and to provide targeted support where health inequalities exist in line with the principles of proportionate universalism.

Closing the gap – how the pandemic prompted change.

There is clearly work to be done, and some of the statistics make for difficult reading. However, there are pockets of proactivity. One region that has made positive strides over the past three years is Cheshire and Merseyside, with the Cheshire and Merseyside Women’s Health and Maternity Partnership being at the forefront of those efforts.

A partnership programme bringing together a cross-section of organisations in the NHS aiming to improve women's health and maternity experiences, has been focused on addressing health inequalities in terms of outcomes, access, and services since it was established in 2015. However, Covid-19 threw the issue into even sharper focus. It proved to be a catalyst for accelerated change that is now embedded across the integrated care system.

“In terms of health inequalities, they can be quite stark across our ICS footprint, which covers 2.5 million people. Liverpool and Knowsley, for example, are in the top three of the most deprived in the country,” explains Catherine McClennan, Director, Cheshire and Merseyside Women’s Health and Maternity Programme (now incorporated into the Cheshire & Merseyside Integrated Care Board).

“Pregnancy is one period in a person’s life where those healthcare inequalities are emphasized. While it was incredibly challenging, the pandemic did enable us to find solutions quite quickly in terms of how we address some of those health inequalities.”

Once the impact of Covid on pregnant women became clear, including the transfer of Covid through the umbilical cord, health and care systems needed to swing into action quickly, a difficult task in the face of fake news and vaccine anxiety amongst some groups.

One of the barriers for Cheshire and Merseyside during the early days was the lack of detailed data and information about the women that were coming forward for the vaccine, along with those that were hesitant about receiving it.

“We didn’t know at the start how many women were coming forward and we didn’t have information about those that weren’t,” says Catherine. “We didn’t know where they were living, what their ethnicity was, and why some of them were hesitant about getting the vaccine. So, we started to look at how we could develop a pregnancy dashboard that would allow us to track data using NHS numbers and help us focus on interventions.

“We could also envision additional benefits, such as cutting down on duplication of records from both primary care and out in the community; and reducing the amount of workforce time and effort that was going into manually looking at records.”

The Cheshire and Merseyside pregnancy dashboard

The Cheshire and Merseyside Women’s Health and Maternity Partnership worked with their population health intelligence colleagues at CIPHA (the Combined Intelligence for Population Health Action) and Graphnet Health to develop an interactive pregnancy dashboard. The data that flowed into that dashboard gave Cheshire and Merseyside a clear picture of how many women were coming forward to be vaccinated, which stage of gestation they were in, age, ethnicity, any long-term conditions, and the socioeconomic factors in terms of where they lived.

“It provided us with a rich pool of intelligence and shone a light on the activity that we needed to prioritise,” said Catherine. “We then took that data and worked collaboratively across the system – not just with health but with communities, including through our own community engagement team who have lots of connections with local groups and leaders.”

The Cheshire and Merseyside Women’s Health and Maternity Partnership then used that data and interaction with local communities to take the vaccination to their citizens. That included a roving vaccination bus, which attracted hundreds of people.

“What became apparent was that much of the success around vaccination uptake amongst pregnant women was related to how we were communicating with them – the language, the promotion of it. We learned a lot about how to engage with our people.

“We also quickly started to understand some of the other health issues that we needed to look at. We tapped into the experience of our team, including the many multi-lingual employees that are well connected with local communities, to try and address those areas. When we went out into the community, we tended to find that people then started engaging with us about the other factors that were encroaching on their lives – there were lots of discussions around poverty, debt, domestic violence, and we could then signpost them to other organisations to help and support.”

In terms of health equity, in December 2021, Cheshire and Merseyside had a vaccination rate of 56.4% amongst pregnant women, which had increased to 70.8% by December 2022. To put that into perspective, the year before the figure had been zero.

What’s next? 

Although the pandemic sparked the development of the pregnancy dashboard, the journey certainly hasn’t ended there. There are numerous opportunities for the usage of maternity data and population health intelligence to further address healthcare inequalities across Cheshire and Merseyside. Since Covid, the data has enabled Cheshire and Merseyside to identify other health factors and work that needs to be done. One of the resulting initiatives has been broadening the remit of the roving bus, which now offers several women’s services.

“It continues to address Covid vaccination, but we’re also looking at flu vaccinations, and other health outcomes – such as how do we reduce smoking during pregnancy, and how do we help and support those with mental health challenges,” explains Catherine. “We’re also focusing on gynecological conditions, including cervical screening rates.”

“We’re continuing to use the pregnancy dashboard. We are developing it, we keep looking at it and in terms of intelligence, it has helped us to showcase the key work that needs to be done and what we need to prioritize in terms of population health.”  

Finally, for Catherine, and her team at Cheshire and Merseyside Women’s Health and Maternity Partnership, as well as her colleagues across the ICS and Graphnet Health, it’s important to emphasise that technology is a means to an end. The most important part of the story is the women, children, and families receiving better support as a result of the work being done after the data has been collected and analysed.  

“It’s all about making those numbers and those digital platforms bring to life what is actually happening in people's lives and in their communities,” says Catherine. “Having worked with several families, including many that struggled with pregnancies and birth during the pandemic, it feels good to be moving forward in a positive direction, and putting initiatives in place to make quality maternal and neonatal care easily accessible to all.”