Successful co-production can help tackle inequalities in maternal health outcomes

Findings from the MBRRACE-UK report published in October 2023 are a stark reminder of persistent inequalities in birth outcomes for women from ethnic minorities in the UK.1 In 2019-21, the risk of maternal death was 3.8 times higher among black women and 1.8 times higher among Asian women compared with white women in the UK.1

Despite several calls to end inequalities through individualised high quality care and targeted interventions, women from ethnic minority groups often feel they are not listened to or have rarely been asked about solutions.2 That’s why it’s so important to involve women from ethnic minorities in developing interventions if we want to improve outcomes and patient care. Public involvement is recognised as important in both health service delivery and research design and delivery.234

Uptake and initiation of timely antenatal care is vital in ensuring good perinatal outcomes for women and babies. The MBRRACE-UK report showed that the proportion of women who received recommended levels of antenatal care were low among those who died.1 Women from some ethnic minority groups tend to attend antenatal care later.5 In order to increase the timely uptake of antenatal care in an ethnically diverse and socio-economically disadvantaged area, a project team that I led developed a community-based intervention using a co-production approach.6

The goal was to co-produce a tailored intervention best suited to meet the needs of a diverse community. Therefore, it was crucial to engage the right people that represented the community. The project team invested time in understanding and mapping the ethnic diversity of the community and adopting suitable methods for reaching out to groups who would otherwise have been excluded. Engagement with a representative group of local service users with lived experiences (mothers/fathers), was immensely helpful in bridging the gap between the project team and the community to tailor the intervention to meet local needs. The co-production conversations highlighted existing gaps in early pregnancy support and information, challenges in knowing how to access antenatal care and the important role friends and family members play in providing women in early pregnancy with information about how to initiate antenatal care.6 Service users highlighted that any written material should be concise and humanised, with the use of images to convey messages. Accordingly, a range of materials, including postcards and posters, were developed and translated into the four most widely spoken community languages (Bengali, Urdu, Polish, and Romanian). In addition, having a forum, with a range of key stakeholders from the target population including frontline maternity care professionals, expectant and recent mothers/fathers, and representatives from community organisations was key to ensuring community agency throughout intervention development and implementation.

Offering flexibility in co-production methods helped maximise participation. The project team offered a combination of virtual co-production methods, ranging from online zoom based interactive workshops to one-to-one phone or video calls. This offered service users and providers the option to engage with the programme in a way that was convenient for them. Some women stated that they did not feel comfortable speaking in front of others in an online workshop, so one-to-one phone calls provided a way for these women to be included, enabling their voices to be heard.

Virtual workshops were helpful in generating more discussion and ideas than one-to-one conversations. Having an experienced professional facilitator, with the right skills to engage a diverse audience, and use of appropriate easy-to-navigate digital technologies maximised engagement. However, promoting participation largely through virtual means, or through local early years provider groups (which were also being held online at the time due to covid-19 restrictions), contributed to the potential risk of excluding those with limited digital capital and women who did not have access to digital devices (including smart phones). This was rectified to some extent through reaching out to local community organisations, specifically those working with marginalised groups, and by encouraging participants to spread the opportunity to others through word of mouth. Nevertheless, most of the individuals involved found out about the co-production engagement either directly or indirectly through online means. This highlighted the need for additional measures to ensure that digital exclusion is not a barrier to taking part in co-production.

Ensuring that there was a shared understanding of the aims before and during co-production among all the individuals was crucial. Clearly articulating the aims of the co-production process ensured alignment of perspectives with the overall purpose of the project. Before the workshop, focused discussions between the multi-disciplinary project team and facilitators helped to create an appropriate framework for the format, content, and outputs for the co-production processes and to tackle any practical considerations. Explicitly communicating intended outcomes at the start of each session with ongoing reminders throughout enhanced communication and enabled participants to keep themselves on track.

It was vital to allow adequate time for individuals/people with lived experience to talk about their experiences and perspectives and often the conversations exceeded the anticipated duration. While focused prompts helped to directly align the content of the conversations with the aim of the co-production project, it was found to be imperative to allow adequate time —preferably full days, rather than a few hours, for group sessions.

Although the co-production workshops were aimed at developing the components of a community-based intervention,6 it opened up conversations on a range of underlying issues and women commented positively on the opportunity the workshops provided them to meet their peers after a period of limited social contact due to covid-19. Notably, a number of women spoke about their difficult or even traumatic experiences of pregnancy and maternity care during covid-19 lockdowns and commented that taking part in co-production conversations provided them with a safe space to talk and an opportunity to debrief about their experiences.

The process was iterative, with co-produced ideas fed back to women and partners throughout the programme to stimulate new ideas, which were further built upon as the process continued. Once we concluded all co-production activities, the project team returned to participants to ensure their input was understood and interpreted correctly and that the participants took joint ownership of the priorities along with the project team.

The experience from this project in an ethnically diverse socially disadvantaged community in England showed the power of co-production in fostering inclusivity, engagement, shared understanding and a fair balance of power while developing solutions to tackle maternal health inequalities. While co-production approaches are helpful in ensuring that women from ethnically diverse and socially disadvantaged backgrounds have a voice in their care to maximise positive health outcomes for themselves and their babies, the project demonstrated that the success of the approach depends on a number of factors both in the underlying ethos and the methodology.