This Equality impact assessment (EIA) was prepared by Equality, diversity and human rights team with the maternity project group, for Nigel Acheson, Deputy Chief Inspector, Hospitals Directorate.
1: Aims and objectives
CQC is undertaking a programme of focussed inspections of maternity services.
We have undertaken a piece of work alongside this programme, to explore and highlight issues related to three key themes which impact on maternity services; safety culture and teamwork; maternity equity and how services engage with women who use maternity services.
We have gathered information related to these themes during inspections and ongoing monitoring of maternity services and related activities and will use its independent voice to publish its findings in a themed report in Autumn 2021.
This project is intended to stimulate faster work to improve maternity services and promote equality. It provides a significant opportunity to signal the importance of maternity equity to providers and stakeholders; encouraging improvement in maternity services and in the way we inspect maternity services.
We are an active partner in the maternity transformation partnership. We recognise that improvement in maternity services is not fast enough and existing inequalities have been exacerbated by COVID-19. Existing research highlights differential mortality, outcomes and experiences of services for women in different ethnic groups, as a serious concern:
- Black women are four to five times more likely to die in pregnancy and childbirth than white women MBRRACE report: January 2021. For women of mixed heritage this is 3 times more and for Asian women 2 times more.
- Black women are eight times more likely to be admitted to hospital with COVID-19 during pregnancy than white women, while Asian women are four times more likely. More than half of pregnant women admitted to hospital with COVID-19 infection in pregnancy were from black or other ethnic minority groups (UKOSS report: May 2020).
We have published a themed report commenting on its findings from the focussed inspection programme, in relation to three specific themes:
- Equity: how services have responded to the Chief Midwifery Officer’s call for services to take 4 specific actions to support Black and minority ethnic women, including women living in deprived areas and women with mental health and complex needs (COVID 4 actions letter).
- Engagement: how services have worked with their Maternity Voices Partnerships to engage with their local population during the pandemic, and
- Teamworking and culture: how service leaders have promoted a good safety culture and responded to challenges, including maternity equity and engagement.
Our themed report is based on findings from focused inspections and related monitoring activity, including interviews with Maternity Voices Partnership chairs and Board-level Safety Champions. This work therefore does not comment on all our lines of enquiry and will not review all maternity services. This project recognises that not all the complex factors contributing to maternity equity, for example, will be within the scope of this work.
This work will also help to inform development of our future regulatory approach and identify areas where we could consider further action outside of this project, in its role as regulator.
NHSE letter from the Chief Midwifery Officer to maternity services on COVID 4 actions.
We have previously published a briefing on our findings from maternity inspections Getting Safer Faster in March 2020 – news story.
2. Engagement and involvement
National Maternity Voices, who represent women who use maternity services and Five x More (who represent Black women who are five times more likely to die during pregnancy and childbirth), have supported the development of this project with advice and co-production work to develop our research methodology.
We have worked with our colleagues with experience of inspecting and delivering maternity services to develop the project.
We are an active partner in the Maternity Transformation Programme and continue to engage with NHS England Maternity Transformation Team.
We also collate and publish views of women who use services in the Maternity Survey which has run since 2007. The current survey sampled women who gave birth in February 2021, and we have recently collaborated with NHS England and NHS Improvement to run another survey in 2022. Historically the survey has not achieved the level of response from Black women that we would have liked, however the survey method was redesigned in 2021 to address issues of under-representation of certain groups of women (for example by age and ethnicity) and we are analysing the data to check what progress has been achieved. We also recognise that organisations such as Five x More have achieved a high levels of responses from Black women, in their targeted survey work. For example, the Black Maternity Experience Survey 2021 and there are opportunities here for learning.
3. Impact and mitigation
Specific equality issues by protected characteristics
This work provides a general opportunity to promote equality by encouraging improvement in maternity services. The impacts below were logged during the development of the project and themed report.
Impact
We do not anticipate a specific impact in relation to age from this work. Focussed inspections concern maternity services for women 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 MBRRACE Rapid Review Report March-May 2020 found differences in mortality rates between women of different ages and a greater risk for women aged over 35 years old.
Mitigation
Focussed inspections continue to ask services how care is personalised and how individual needs are taken into account and if particular concerns are identified by inspection teams, they can be escalated for action, including in relation to maternal age (ongoing – action 1).
Impact
We do not anticipate a specific impact in relation to carers/people with caring responsibilities from this work. Focussed inspections concern maternity services for women, who are more likely to be carer /people with caring responsibilities, although the themed report will not specifically comment on issues related to caring responsibilities.
Mitigation
Covered in Age section.
Impact
- 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).
- Focussed inspections may ask how services support women with a mental health and complex needs, in the context of the Covid 4 actions, and provides an opportunity to promote equality by encouraging improvement in maternity services.
- The themed report may include some findings on how maternity services support women with mental health and complex needs. The themed report will 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 or BSL users.
- Focussed inspections will not specifically address how well services are meeting the NHS Accessible Information Standard for disability communication needs. 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). This can have a particular impact for disabled women, for example in relation to consent and choices and in recognising and managing pain.
Mitigation
- Covered in Age section.
- Issues affecting women with a learning disability and women experiencing sensory or physical disabilities, including BSL users; and how the NHS Accessible Information Standard is applied in maternity services and are noted here as an area for further consideration outside of this project, for example in ongoing monitoring and engagement.
Impact
This work represents an opportunity to promote equality for Black and minority ethnic women who use maternity services - maternity equity is a specific focus of the themed report.
Existing research highlights differential mortality, outcomes and experiences of services for women in different ethnic groups, as a serious concern:
- Black women are four to five times more likely to die in pregnancy and childbirth than white women (MBRRACE report: January 2021). For women of mixed heritage this is 3 times more and for Asian women 2 times more.
- 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).
- Poor care was identified as a factor in perinatal deaths during COVID-19 period, including poor communication, identification of risk, follow up and personalised care on the part of staff (MBRRACE Rapid Review: March - May 2020).
The COVID-19 pandemic has had a disproportionate impact in terms of ethnicity;
- Black women are eight times more likely to be admitted to hospital with COVID-19 during pregnancy than white women, while Asian women are four times more likely. More than half of pregnant women admitted to hospital with COVID-19 infection in pregnancy were from black or other ethnic minority groups (UKOSS report: May 2020).
- Black and minority ethnic women 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).
There are a range of other factors which impact on Black and minority ethnic women’s outcomes and disparities in care, this includes whether maternity services;
- listen when women need to raise a concern
- respond effectively to Black women’s pain
- communicate effectively (including for consent and choices)
- 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, women may avoid appointments and care or present to healthcare services at a late stage due to fear of charges associated with essential maternity care for women with no recourse to public funds.
Research also shows mortality rates remain higher for Black or Black British and Asian or Asian British babies and Black children have an increased risk of stillbirth and neonatal death (Better Births report: March 2020). Large-scale study data on 4.6 million pregnancies in seven countries suggests the risk of miscarriage for black women is 43% higher than for white women. Support for women following miscarriage and bereavement is an area for improvement and may not adequately reflect Black women’s different experiences and needs.
The way that safety incidents and complaints are investigated and managed can also have a differential negative impact on women and 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 Black and minority ethnic women’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 line of enquiry related to pain and will not look in detail at the care of babies.
Mitigation
- Build specific questions into focussed inspections of maternity services about how they have responded to the COVID 4 actions letter from the Chief Midwifery Officer (included in focussed inspection framework), including asking these questions of maternity services leadership teams (completed), and board-level safety champions if possible.
- Actively involve women in this project and amplify Black women’s voices within this work wherever possible i.e. by involving Five x More and National Maternity Voices in development of our approach and work together to interpret findings (external engagement during project development completed, including workshop sessions in May, July).
- Ensure interviews with MVPs include areas with more diverse populations and with Black and minority ethnic women chairs, where possible (completed).
- Publish a themed report exploring what action maternity services have taken to engage and meet the needs of women from Black and minority ethnic backgrounds (in context of COVID 4 actions) and how services and MVPs are working together to do this (Autumn 2021, action 2). Include key challenges and any examples of good practice and learning from the focussed inspections (completed).
- Identify opportunities for inspection teams to develop their knowledge and understanding of inequality and engagement in maternity services, alongside this project (workshop sessions with Five x More and National Maternity Voices completed, May).
- Consider further work with Black staff and on topics which are out of scope for the focussed inspections, outside of this project (action 3).
- Focussed inspections continue to ask services how care is personalised and how individual needs are taken into account and if particular concerns are identified by inspection teams, they will be escalated for action (ongoing, action 1).
- We recognise that maternity equity is a complex area and some impacts identified fall out of scope for this project - these issues are noted for further consideration in other parts of our work and are noted in the human rights duties section and action plan (action 3 and ongoing).
Impact
Focussed inspections concern maternity services for women and their babies.
Mitigation
This work is intended to stimulate faster work to improve maternity services and therefore provides an opportunity to promote equality for all women using these services.
Impact
We do not anticipate a specific impact in relation to trans people and birthing people.
Mitigation
- We have separate work in development for an adult trans care pathway to support care in a variety of health and social care settings.
- Focussed inspections continue to ask services how care is personalised and how individual needs are taken into account and if particular concerns are identified by inspection teams, they can be escalated for action (ongoing, action 1).
Impact
We do not anticipate a specific impact in relation to marriage or civil partnership status.
Mitigation
Covered in Age section.
Impact
- This project is intended to stimulate faster work to improve maternity services and provides an opportunity to promote equality for all women using these services.
- The ongoing Ockenden Review highlights the importance of high quality services for pregnant women and their babies, where women and their families are listened to, especially when raising a concern or making a complaint (Ockenden Review Interim Report, Dec 2020).
- Focussed inspections will not examine in detail how incidents and complaints are investigated or managed although if particular concerns are identified by inspection teams, they can be escalated for action.
Mitigation
- Focussed inspections continue to ask how services are responding to the Ockenden Inquiry. The themed report will comment on how services are engaging with women in their local area, in a way that reflects their local population (Autumn 2021, action 2).
- How maternity services investigate and manage and learn from incidents and complaints is noted as an area for further consideration in relation to equality (action 3).
Impact
- We do not anticipate a specific impact in relation to religion or belief, although there will is an opportunity to promote equality, recognising intersectionality between faith and belief and ethnicity for some women.
- The themed report will explore what action maternity services have taken to engage women representative of their local population. We acknowledge that successful engagement will involve responding to intersectionality and diversity of religion and belief.
- Focussed inspections will not ask specific questions about how services are responding to religious diversity.
Mitigation
- Covered in Age section.
- Focussed inspections will ask specific questions of maternity services about how they have responded to the Covid 4 actions letter from the Chief Midwifery Officer. The themed report will explore what action maternity services have taken to engage and meet the needs of women from their local population and how services and MVPs are working together to do this (Autumn 2021, action 2).
- Issues affecting women with different faiths and beliefs who use maternity services are noted here for inclusion in the themed report if they are identified and as a possible area for further consideration outside of this project, for example in ongoing monitoring, engagement and survey work (action 3).
Impact
- We do not anticipate a specific impact in relation to sexual orientation.
Mitigation
- Covered in Age section.
- Issues affecting lesbian and bisexual women who use maternity services are noted here as a possible area for further consideration outside of this project, for example in ongoing monitoring and engagement and survey work (action 3).
Cross-cutting equality issues
Impact
- Research highlights living in a deprived area as a factor in maternal mortality / outcomes and experiences of care (MBRRACE Rapid Review Report: March - May 2020). This study found significant differences in mortality rates between women from different areas and of different ages. Women living in the most deprived areas were almost three times more likely to die than those who lived in the most affluent areas.
- The NHS Long term plan points out that; ‘Women who receive continuity of carer are 16% less likely to lose their baby, 19% less likely to lose their baby before 24 weeks and 24% less likely to experience pre-term birth’ and notes that continuity of carer will be ‘targeted towards women from Black and minority ethnic groups and those living in deprived areas, for whom midwifery-led continuity of carer is linked to significant improvements in clinical outcomes.”
- Focussed inspections will ask how services support women living with deprivation and complex needs, (in the context of the COVID 4 actions) and provides an opportunity to promote equality by encouraging improvement in maternity services.
- The themed report will explore what action maternity services have taken to engage women representative of their local population. We acknowledge that successful engagement will involve responding to local patterns of deprivation and need.
- This work will not specifically explore how maternity services take account of the needs and experiences of women living with deprivation and complex needs, although the themed report may include some findings on how maternity services support this group of women.
Mitigation
- Focussed inspections will continue to ask maternity services about implementation of continuity of carer programmes which have been shown to have a positive impact on women living with deprivation, including women from Black and minority ethnic backgrounds (ongoing).
- Focussed inspections continue to ask services how care is personalised and how individual needs are taken into account and if particular concerns are identified by inspection teams, they can be escalated for action (ongoing, action 1).
- Issues affecting women living with deprivation including women with complex needs, women with a learning disability and women with sensory or physical disabilities, including BSL users; including how the NHS Accessible Information Standard is applied in maternity services and are noted here as an area for further consideration outside of this project, for example in ongoing monitoring and engagement. (action 3).
4: Human Rights duties assessment
Human rights duties compliance
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 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 and families following a safety incident, near miss or bereavement during pregnancy and maternity.
- can each determine whether a woman’s right to life (and that of her baby) is protected and whether women and families receive discrimination-free care.
We recognise that human rights impacts are also likely to affect those women with other protected characteristics in interconnected ways. For example, whether disabled women’s voices are heard and whether her pain/voice/needs are taken seriously.
Mitigation/opportunity
This work presents an opportunity to promote equality in relation to human rights. Maternity equity in terms of ethnicity will be a specific focus of the themed report and this work is intended to have a particular impact in relation to Black and minority ethnic women who use maternity services. Focussed inspections will ask specific questions of maternity services about how they have responded to the COVID 4 actions letter from the Chief Midwifery Officer. The themed report will explore what action maternity services have taken to engage and meet the needs of women from Black and minority ethnic backgrounds and how services and MVPs are working together to do this (Autumn 2021, action 2). Focussed inspections continue to ask services how care is personalised and how individual needs are taken into account and any issues arising will be addressed by inspection teams (ongoing, action 1).
We recognise that maternity equity is a complex area and some impacts identified above fall out of scope for this project – these issues are noted for further consideration (action 3).
Human rights duties compliance
Several equality impacts engage human rights. For example, whether maternity services:
- respond effectively to Black women’s pain
- listen when women need to raise a concern
- recognise and respond to emergency or life-threatening situations in a timely way
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.
Mitigation/opportunity
Covered by Right to Life.
Human rights duties compliance
We do not anticipate a specific impact in relation to the right to liberty from this work.
Mitigation/opportunity
Any issues arising will be addressed by inspection teams.
Human rights duties compliance
As identified above, several equality impacts engage human rights. For example, whether maternity services:
- listen when women need to raise a concern or make a complaint
- communicate effectively (including for choices and consent)
- support women and families following a safety incident, near miss or bereavement during pregnancy and maternity,
can determine whether women’s rights in terms of autonomy, family and private life, are protected in access, experience and outcomes of care.
Mitigation/opportunity
Covered by Right to life.
5. Action planning
Action 1 – Voices of women, methodology and approach
- Actively involve women in this project and amplify Black women’s voices within this work wherever possible i.e. by involving Five x More and National Maternity Voices in development of our approach, work together to interpret emerging findings (ongoing).
- Use this project to explore and report on how maternity services engage with, and support women from Black and minority ethnic backgrounds, in their local areas – as per action required by the COVID 4 actions from the Chief Midwifery Officer. This includes building specific questions into interviews with maternity services leadership teams, and board-level safety champions wherever possible (completed March 2021).
- Produce information for MVP chairs and for CQC inspectors, who may be unfamiliar with each other’s roles (April 2021) and include MVP areas with more diverse populations to ensure good data in interview sample on how services are responding to the Covid 4 actions (completed April 2021).
- Continue to work with Five x More and National Maternity Voices to inform evidence gathering and development of the themed report (ongoing 2021, action 2).
- Prepare a themed report of our findings on what action maternity services have taken to engage and meet the needs of women from Black and minority ethnic backgrounds (in context of Covid 4 actions) and how services and MVPs are working together to do this. Include key challenges and any examples of good practice and learning from the focussed inspections (Autumn 2021, lived experience case study included. Also covered by action 2).
- Continue to ask services how care is personalised and how individual needs are taken into account during focussed inspections and address particular concerns as identified by inspection teams (ongoing, action 1).
CQC is also taking further action prompted by this project, for example:
- Working with Five x More and National Maternity Voices to deliver learning for inspectors on maternity equity and engagement, based on women’s lived experiences (May 2021, action 1) and identify other opportunities for inspection teams and other CQC colleagues, to develop their knowledge and understanding of inequality and engagement in maternity services (ongoing, action 3).
Action owner
Head of Inspection, with maternity project team, learning lead.
Action timescale
Timescales as identified above.
Date completed
All actions begun by April 2021, completed by September 2021 or are ongoing, as above. This EIA to be reviewed by October 2021, progress to date against all actions noted September 2021.
Themed report published Sept 2021, including lived experience case study.
Action 2 - impact and review
- Use our independent voice to publish a themed report and share findings from this work with the system to stimulate improvement on maternity equity and engagement, including identifying challenges and any good practice (Autumn 2021).
- Work with system partners, Five x More and National Maternity Voices to disseminate the findings of the report and maximise impact (Autumn 2021).
- Consider how CQC can use findings from the themed report and this impact assessment, in its own work and future inspection methodologies (ongoing).
- Review this equality impact assessment by October 2021 (progress to date noted, September 2021)).
Action owner
Deputy chief inspector with maternity project team, engagement lead.
Action timescale
Timescales as identified above.
Date completed
Themed report published, September 2021, including lived experience case study.
Work with partners to disseminate report and work to inform future approach ongoing, September 2021.
This EIA to be reviewed by October 2021, progress to date against all actions noted here, September 2021.
Action 3 – Further work beyond this project
We recognise that maternity equity is a complex area and during the scoping of this project, equality issues relating to wider themes of CQC’s work have been identified as possible areas for further work.
This includes some specific themes in terms of equity and ethnicity such as whether maternity services
- listen when women need to raise a concern
- respond effectively to women’s pain
- 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 and families following a safety incident, near miss or bereavement during pregnancy and maternity.
This also includes impacts for women, including Black and minority ethnic women, with other protected characteristics, women experiencing deprivation, women with disability, mental health and other complex needs, some of which will also be relevant to the care of babies.
For this reason, we have used this equality impact assessment to highlight areas where we could consider further action outside of this project to support its equality objectives and promote equality. For example:
- Use the impacts identified in sections 3 (specific equality issues) and section 4 (human rights), together with learning from engagement with Five x More and National Maternity Voices, to inform the next review of the assessment framework for the maternity and children’s and young people’s services assessment framework, drawing on the specific findings from this project (ongoing).
- Consider how we can use different types of methodologies and approaches, for example review of notes/incident reports, case tracking, using experts by experience and the National Maternity Survey, to strengthen inspection and enforcement work, drawing on equality and human rights concerns identified in this equality impact assessment. This could include looking at how services respond to Black women’s pain, emergency presentations and whether consent and choices are communicated effectively (ongoing).
- Consider how to develop a learning resource on maternity equity and engagement for inspectors which includes lived experience material (learning sessions completed in May, recording available to all staff, July 21).
- Consider how we can improve how we collect and use data and intelligence to respond pro-actively to equality and human rights risks in maternity services, surface inequalities and inform risk decision-making. For example, explore available data on pregnant women who attend emergency departments or workforce equality in maternity services.
- Reflecting on progress in hearing from under-represented groups of women during the 2021 Maternity Survey, further consider how we can improve how we gather and act on the experiences of women most likely to experience discrimination or receive poor care in maternity services - in particular Black women, South Asian women and women from mixed ethnic backgrounds and women in other minority groups, including disabled women, BSL users and those with other protected characteristics who are likely to face barriers to equal maternity care. This could include ongoing monitoring, engagement and survey work and will be informed our joint work and learning from engagement with Five x More and National Maternity Voices.
- Consider how we can improve how we gather and act on the experiences of maternity staff from Black and minority ethnic backgrounds to inform this project and future work.
- Review and improve who we work with and how we work together in future to improve our regulatory model and equality outcomes for women who use maternity services. This will be informed by the equality and human rights impacts identified in sections 3 and 4 and by and importantly, by our joint work and learning from engagement with Five x More and National Maternity Voices.
- Consider other ways to use our independent voice to highlight concerns (and good practice or innovation) to help reduce inequalities and promote human rights for women who use maternity services. For example in publishing other data we hold, influencing system partners and highlighting challenges in State of Care or other work. Again, this will be informed by our learning from engagement with Five x More and National Maternity Voices.
Action owner
Deputy chief inspector
Action timescale
Initial scoping for these actions will develop alongside this project, then agreed actions as part of CQC equality objectives or the themed report from this work.
Date completed
All actions begun by September 2021 and will be ongoing.
Ongoing work will be informed by learning from engagement with our external partners and aligned with CQC’s programme of work on our equality objectives for 2021-25 which were published in July 2021, alongside our strategy.
6: EIA sign off and review
This equality impact assessment and action plan was approved by:
- CQC Maternity Working Group received equality impact assessment in April, progress updates in July, September 2021.
- CQC Equality, Diversity and Human Rights Manager on 8 September 2021.
- CQC Chief Inspector for Hospitals on 16 September 2021.
Nigel Acheson, Deputy Chief Inspector, Hospitals, is responsible for delivering the action plan, which will be reviewed in October 2021 (progress noted and equality impact assessment updated in September 2021).
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