Maternity care, a critical component of healthcare, is marked by pronounced socioeconomic and racial disparities. In the United Kingdom, systemic challenges stemming from entrenched biases and structural inequities affect marginalised communities, particularly women and families from Black, Asian, and Mixed ethnic groups as well as those living in poverty. Additionally, staff from Black, Asian, and other minority groups in the UK National Health Services (NHS) report poorer experiences working within the NHS . This inequity not only affects the quality of care provision but also impacts outcomes for service users and the maternity workforce. Recognising this, it is crucial to implement initiatives that prioritise inclusive and equitable service delivery.

An initial proposal spearheaded by The Jen Group aimed to engage local stakeholders to design and deliver a training module on addressing inequities within the maternity workforce. However, upon critical evaluation, concerns arose regarding the potential inauthenticity of such a unilateral approach. A refined strategy was then developed in discussions with the initial stakeholder, with the goal of involving a diverse cohort of partners in an intensive co-production and delivery process. Potential partners were to be reflective of varied backgrounds, offering a rich tapestry of lived and/or professional experiences related to socioeconomic and racial inequity. Partners were recruited through networking, electronic flyers, and continuous interaction.

After onboarding, co-production meetings were initiated and anchored in recognising individuals as assets, fostering mutual relationships, and facilitating a space for improved capacity to address maternity inequities. The co-production group was eventually named the Maternity Equity Collaborative, the members being called partners, and their output called the Maternity Equity Conversations. The conversations emphasised the creation of a supportive space for dialogue on maternity equity which enhanced understanding, challenged inequitable practices, and catalysed safe and trauma-informed practices. After participating in the Maternity Equity Conversations, health system staff were asked to gauge improvements in their understanding of maternity equity, their knowledge of the impact of inequity within maternity and neonatal services, their skills in championing equity within these services, and their ability to counter inequitable practices. Participants provided feedback through immediate post-course evaluations as well as detailed reflections sent via email after the course. Additionally, the Maternity Equity Collaborative’s partners offered reflections on the project's overall execution.

This report details a qualitative evaluation conducted with a variety of stakeholders, during the weeks of October 2nd and 9th 2023. They include: 

- The Jen Group senior partners who were commissioned to do the work.
- The Maternity Equity Collaborative partners, consisting of individuals with lived experiences who co-produced the Maternity Equity Conversations.
- Staff from the health system who participated in the Maternity Equity Conversations.

This report aims to complement earlier evaluations, providing a comprehensive understanding of the pilot's impact and informing future iterations of the Maternity Equity Conversations.

Preparation

The project’s co-production approach unfolded in two stages. In the initial phase, the Jen Group senior partners deliberated on the optimal format for the project. After careful analysis and consultations, they realised the need for a more inclusive methodology that prioritised firsthand experiences over conventional hierarchical structures. This insight transitioned the project into its second phase: the implementation of a genuine co-production strategy. In this phase, decision-making power was intentionally democratised, ensuring service users had significant influence. These users were recognised as essential collaborators, appropriately compensated for their contributions, and treated with consistent respect.

Reassessing Initial Approaches and Ethical Considerations

Initial plans to approach the project involved consulting with stakeholders, including service user representatives, through focus groups, surveys, and interviews. However, due to moral and ethical concerns, there was a shift in this initial plan. Particularly, the Jen Group senior partners' identities as white women raised questions about the authenticity and ethics of solely designing a programme that was intended for diverse communities.

As a result, they reassessed the approach to prioritise co-production:

“We approached the commissioner and said that we're not feeling comfortable with this. We want this to be a co-production project; we want to hand over that power to the service users... and us to facilitate it.” 

Incorporating Diverse Perspectives and Extensive Research

The Jen Group senior partners gathered insights from their mixed heritage families, colleagues from diverse backgrounds and immersed themselves in readings and accounts that spoke about the experiences of various communities.

National reports and narratives which highlighted specific community experiences, like Muslim women and black women, also became integral in shaping their approach:

“You know, we're stakeholders in this because my family is mixed heritage... Lots of reading around... So, there's one called Invisible, which is about Muslim women's experiences and one called Birthrights, about black women's experiences. So, all of those things informed our approach.”  

Prioritising Partnership and Respect

The Jen Group senior partners adopted the principle of partnership, which involved treating everyone involved, especially those providing lived experiences, as valued partners. This respect was shown by compensating individuals for their time and expertise, and working flexibly with the availabilities of the group, a practice that stood out, especially for those who previously offered their experiences without any reward:

".. it was about us taking a step back really... And we, you know, that was a deliberate use of language from the very beginning... part of that was paying them which was a surprise for some of them because they had been used by services in the past to provide their lived experience expertise and had not been rewarded for it."

Embracing Lived Experience and Co-Production

The importance of drawing from personal lived experiences to inform the project was evident. By acknowledging and valuing their personal journeys and challenges, the Jen Group senior partners were better able to understand and advocate for genuine co-production:

“my own lived experience of having been through a mental health journey brought me into the place of co-production … and understanding it from both sides.”

Collectively, these themes depict a shift from traditional project approaches towards one that was collaboratively designed, deeply researched, and rooted in respect and partnership.

Drivers of Maternity Equity Collaborative Partners’ Involvement

The Maternity Equity Collaborative partners’ involvement in the project was influenced by several interconnected factors.

Direct Experience with Maternity Services

Partners were frequently in contact with maternity service users. Their interactions gave them firsthand knowledge of the challenges faced by women and families.

A partner explained:

"I am quite heavily involved in maternity work... And then when I saw this opportunity, I felt that through this experience, I would be able to convey the stories of the people I've listened to... and aim to enhance the maternity experience for service users because I'm also a service user."

Commitment to Addressing Health Inequalities

The desire to actively rectify health disparities was another motivator for partners, particularly those already in the healthcare space.

Reflecting on this, a partner shared:

"But I saw it and thought, I'd like to be part of that because a lot of the work I was doing was around health inequalities."

Personal Interactions with Maternity Services

The personal experiences of partners with maternity services were another motivating factor. Their encounters made them uniquely positioned to empathise with and represent the needs of the target users.

This sentiment was captured by a partner:

"being someone who had been through maternity services locally, at least twice by that point, I was keen to be involved... and represent those facing health inequalities."

The reasons listed above show that partners were motivated by a variety of professional, altruistic, and personal motives to partake in the project.

Approach

The Maternity Equity Collaborative partners were interviewed about their approach to co-production and the methodologies they employed throughout the collaboration. Their insights offer a window into the nuances and considerations that shaped their co-production journey. The subsequent sections delineate their perspectives, supported by direct quotes to provide a comprehensive picture of their approach.

Recruitment and Onboarding

Partners underwent a selection process, as illustrated by the quote below:

"Now and then they had an interview with me and then we... later on, we created the Maternity Equity Collaborative."

Deep Engagement with the Topic

Participants connected personally with the material. This is evidenced by the commitment to finetuning resources and content to avoid potential harm and ensure relevance. Beyond the inclusion of personal experiences, external research was employed to examine various resources and ensure the materials chosen were suitable.

"... we wanted it to be the best thing ever that we could deliver."

Iterative decision-making

This involved continuous discussions, taking votes, and prioritising group consensus over individual ideas. A representative quote captures this approach:

"And then we'd come to the group's decision a lot of time by just taking a vote as well..."

As the discussions progressed, the group's understanding and aspirations for the project evolved from a course to a conversation:

"Initially, we wanted to do a training course... we ended up that we would make it a conversation."

The project shifted from a structured training approach to fostering open conversations – ‘Maternity Equity Conversations.’ This decision stemmed from recognising the complexities of the topic and the need for safe spaces for discussion:

"So that we can get everyone to feel... comfortable first and foremost to have the conversation."

The group remained open to change, learning from each session, and adjusting the approach accordingly, and this evolution is still ongoing:

"And it is still evolving as we continue to have discussions and we continue to learn from each other, even after the project."

These themes highlight the Maternity Equity Collaborative’s dedication to creating a thoughtful, adaptable, and collaborative project that prioritised the lived experiences and insights of each of its partners.

Facilitators

From the focus group interviews with the Maternity Equity Collaborative partners, several key aspects that made their collaboration more effective and fulfilling were identified. These factors ranged from logistical elements to interpersonal dynamics. The following sections detail their experiences, supplemented with direct quotes from partners for a richer understanding.

Support in Modeling a Safe Space

The expertise of the Jen Group senior partners was viewed as pivotal in guiding the co-production process. Their approach to facilitation was viewed as supportive in creating a nurturing environment, enabling participants to share freely, even in moments of vulnerability.

"I think one of the big strengths was working with the Jen Group, so I really appreciated their expertise, their background that they had in training in how to facilitate working together, coproduction, call it whatever you want to."

Diverse Experiences of the Group

The richness and diversity of experiences within the group acted as a bedrock for informed discussions. Participants acknowledged and respected each other's unique experiences, from personal maternity stories to professional insights.

"So, for instance, out of the group, … we recently had children and had used the maternity services… we had experience with it firsthand."

Co-producing Without Hierarchies

The group's dynamics were notably egalitarian, with members expressing a sense of feeling valued and heard. The absence of a defined hierarchy fostered an atmosphere of mutual respect, allowing each participant's perspective to shine.

"There was no sort of hierarchy… everyone brought something valuable to the table. Experiencing that was a really unique experience for me."

Learning in an Environment of Psychological Safety

The co-production process was not just about producing an outcome but also about individual and collective growth. Interviewees noted a culture where self-reflection was encouraged, but in a manner that ensured individuals felt secure. This balance was considered key in allowing participants to honestly assess their feelings and biases.

"How do you hold a safe space for yourself … when things start to become a little bit more difficult? What are the tools that you have and that you can glean from other people in the group to create a safe space for yourself?"

Emotional intelligence and compassionate interactions were consistent themes throughout the process. Members supported one another during challenging discussions, ensuring everyone felt safe and understood.

"… I remember thinking wow, what a way to hold a safe space that she's let me unload. But at the same time, she's saying but you do what you're comfortable with."

Disagreements and differences in opinion were not seen as obstacles but as opportunities for growth and understanding. The group's approach to such instances was always rooted in respect, allowing for constructive and collaborative resolutions.

"And then there's the other side of then hearing someone else's experience and their thoughts about a particular situation for which they're passionate about, and then being respectful."

Time

Time was considered a valuable resource. In the absence of intense time pressures, participants felt free to deeply consider issues and to allow space for reflection, thus revisiting them with fresh perspectives.

"Like if we felt that something just didn't sit right, to just take a breath, take a pause, and then come back to it again at a later stage."

Challenges

Partners were also prompted to reflect upon and articulate some of the challenges they encountered. These challenges are common to any collaborative effort, but it was important to explore them given the sensitive nature of the topic at hand and the diverse backgrounds of the participants. The following sections delve into the primary challenges identified by the partners, supplemented by their personal accounts to provide more insight into their experiences.

Convergence of Diverse Opinions

Integrating a plethora of diverse experiences, journeys, and expertise into a unified decision-making process was considered both challenging and worthwhile. The group was a rich fusion of varying perspectives. While these differences enriched conversations, they occasionally led to discomfort. The group's awareness of the potential ramifications of their decisions, especially when it came to the safety and comfort of participants, further intensified this challenge. However, the group learned to embrace these moments of discord, using them as opportunities for introspection and growth.

"We all come with our own experiences, our own journeys, our own expertise that we bring. And it was really difficult actually sometimes to figure out what decisions should be made in relation to specific things."

"We all had such different views in regard to all the things that we discussed. And so, it was really nice to have moments where there was a bit of silence and you realise that oh, well, that's a different opinion."

Staying Focused

The early stages of collaboration were marked by enthusiastic discussions about equity and personal stories. While these interactions were illuminating, balancing them with maintaining a focus on achieving the goal of the project was considered somewhat difficult, particularly given the complexity of the project.

"But it was really hard to stay focused on the task ahead as well because there's just so many layers to what we're looking at and how do we start, where do we start?"

Attrition

The group also faced some attrition, leading to the emergence of a core group that carried the mandate forward, with varying levels of participation among its members.

"I think what happened was just different people had different priorities at the time and so a few people along the way, had to drop off for whatever reason."

Time

While expressing appreciation for the time to consider issues in more depth, there was also an expressed desire for more time to delve deeper into the multifaceted issues faced by ethnic minority groups in maternity services. The allotted time was considered a limiting factor in their capacity to comprehensively research and understand the complex layers of maternity inequity and its drivers.

"I wish there had been more time actually for researching and studying and really going into depth about the issues that women face in maternity services, especially for those ethnic minority groups."

Therefore, there was a sense that thorough exploration would have required additional time.

"Although we managed to look at it from a service user perspective, in terms of experiences mentioned, when you look at statistics and data, I don't think we've been able to do it justice."

Drivers of Participants’ Involvement

Bridging the Gap

Participants' involvement was influenced by their awareness of existing gaps in their professional knowledge and skills. Participants perceived the project as a pivotal point for personal and professional growth, enhancing their expertise, understanding community needs, and self-assessment. Expressing this sentiment, one participant shared:

"And I felt like I didn't have that knowledge and that skill set, and I saw this as an opportunity to bridge that gap, so I thought, I'm gonna do this."

Seeking Better Cultural Understanding

Another motivating factor for participants was the aspiration to improve their cultural understanding and communication techniques to better serve ethnic minorities. Recognising the present challenges in community outreach, they highlighted the importance of better-informed strategies:

"I really wanted to learn about how I can encompass protected characteristics and communicate better with the community... Is it that we're not providing enough information in different languages? I wanted to hear from the service users on how we can help."

Desire for Reflective Practice

Participants viewed the Maternity Equity Conversations as a space for introspection and reflective practice. The unique content of the conversations thus influenced their decision to join:

"Because I've never had an opportunity to have that style of training before... I wanted to sense check my own understanding and make sure I was on the right page for everybody, as it's not something that we've had offered to us before."

Impact on The Jen Group Senior Partners

Approach to Advocating for Change

The Jen Group senior partners reflected on the importance of and fulfilment that came from the experience of creating safe spaces for open conversations. One noted that their approach to advocacy has changed, emphasising listening over confrontation. The conversations were seen as encouraging self-reflection and an understanding that advocating for change is a complex process, often requiring patience and understanding.

"The strength of the conversations were the Maternity Equity Conversations were very much about providing a safe space where anybody from those services could access together and to create that safety where those questions could be posed, and those statistics and images could be used as prompts. And those conversations could be had where people could actually start just processing for themselves thinking things through for themselves." 

Fulfillment

The process of co-production, though messy and challenging, was deeply rewarding for the Jen Group senior partners. They likened it to creating art, full of doubts and challenges, but ultimately beautiful in its outcome.

"And it's just so rewarding. When you've gone through a messy process it's a bit like creating something, you know, creating art, it gets messy and you're doubtful, and you're wondering whether it's going to happen or not. And then it does and it's just it's a beautiful, beautiful thing." 

Impact on Participants

Self-reflection

Engaging with the co-produced materials had a profound impact on participants' awareness of racial disparities. It facilitated a shift in their perspective, encouraging them to view societal constructs and personal experiences through an equity-focused lens. Participants began to be more attentive to social and cultural biases in their own lived experiences and those of others. Furthermore, this exposure prompted participants to reflect on their positions of power, recognising the need to be conscious of the inadvertent perpetuation of inequities. They expressed a growing desire to deconstruct these perceived barriers and create a more approachable atmosphere.

"Because my mom's French, my dad's half French, half English. I was brought up in Ireland... when you got kneecapped in Ireland, if you were the wrong religion or whatever."

"Because I always have an open-door policy... it's their perception of barriers that are there. So, for me, I found it really interesting and how I can break those barriers down." 

Discomfort as Consciousness Raising

Participants acknowledged that the uncomfortable discussions the Maternity Equity Conversations triggered were essential for raising their consciousness about equity issues. These conversations pushed them out of their comfort zones but also sensitised them to various issues. Despite the initial discomfort, participants recognised the necessity of such conversations and how they contributed to their personal growth.

"So actually, as uncomfortable as it was, and as unsettling as it was, I wouldn't actually change it because it had the effect that it needed to.”  

Skills and Confidence to be Upstanders

Participants felt that the safe space provided during the conversations gave them the skills and confidence to handle challenging conversations outside those confines. They became more adept at navigating complex discussions, and thoughtful about ensuring that everyone felt heard and respected. This newfound confidence extended to addressing issues related to diversity, equity, and inclusion in their professional roles.

"I think having that safe space in me being in those professionals in that safe space, probably gave us more confidence to have those conversations outside of that area as well."

Participants also cited tangible examples of how they had used the perspective shift in their ongoing work, with a focus on going from passive observers to active upstanders and allies.

"And so, I've started working with EDI midwives on a little project and it seems like such a tiny thing, but it's you know how to say somebody's name. So many people are or their names aren't pronounced properly or they choose to have a westernised name because people don't know how to say their name. And you know, and it's, it's massive and I thought, Okay, …I'm gonna see if I can support as a member of the senior leadership team a way to advertise that and make people understand.”

“We've got a non-binary midwife joining us now…I'm already thinking, Where am I going to get them changing facilities, they're not going to be able to use our changing rooms, you know, stuff like that. So, we've preempted those conversations in those thoughts before that employee’s joined us. I think that's given us definitely made us think global, for sure."

Impact on the Maternity Equity Collaborative Partners

Learning How to Make Others Feel Heard

The Maternity Equity Collaborative partners expressed a sense of personal growth through their involvement in the collaborative. This included developing the skills to actively listen, respect diverse perspectives, and ensure that the voices of people they engage in conversation are heard, creating a culture of genuine collaboration and reflection.

As one partner noted,

"I walked away thinking oh, wow, so this is what group work looks like. Because I've never been great at group work.”

"It's about life skills... what it looks like to listen to one another what it looks like to respect one another what it looks like to appreciate that we all have different experiences and different views."

"And I think another thing as well is that it is okay to have a different opinion but how I think now it's how do I put my opinion across even though it will be different from yours... how do I appreciate your opinion and actually, sometimes it's okay to get to a place to say we agree to disagree."

Continual Growth and Reflection

The experience of co-producing the Maternity Equity Conversations was also perceived as having a lasting impact, not only directly through their involvement in the project but also in their professional lives and work in their communities. As one partner reflected,

"And I mean, it's quite funny because even now, when I go back in the community, and I speak to people, my perspective on how I engage and hear different people's voices and value them has shifted, it has changed."

Improved Capacity to Facilitate Growth for Others

The partners expressed an improved capacity to also support the learning of others and to promote growth and self-reflection for others even when addressing uncomfortable topics. This learning was also demonstrated when the co-production sessions culminated in the Maternity Equity Conversations which they delivered.

This is evident in these words:

"And I think that's what we brought along with us on the maternity equity collaborative journey. We wanted people to be in the room with us, be present, very present. But be comfortable, be comfortable with the uncomfortable, be comfortable and feel safe enough to actually express their true views and be comfortable enough to reflect on things in their life that maybe did make them feel uncomfortable."