Driving and sustaining improvements in services for minoritised communities
Quality improvement (QI) is well established in maternity services. Many of us are familiar with driver diagrams, Plan Do Study Act (PDSA) cycles, and outcome measures, and we rely on them to improve safety and experience for women and babies.
Anti‑racism, by contrast, can feel less tangible: harder to define, more uncomfortable to discuss, and sometimes positioned as separate from “core” improvement work. Our experience over the past year has shown us that these two approaches are not only compatible, but inseparable if we are serious about tackling inequalities in maternal and neonatal outcomes.
Maternity services in England continue to face profound challenges: widening health inequalities, workforce pressures, and persistent disparities in outcomes for women from racialised and minoritised communities. Traditional QI methods can help us improve reliability and reduce variation, but without an explicit equity lens they risk reinforcing existing biases.
The Learning Action Network
The NHS Race and Health Observatory’s Learning Action Network (LAN) provided a structured opportunity to bring anti‑racism and QI together in a way that felt both practical and purposeful.
Alongside a number of other trusts, each focusing on one of four priority area (postpartum haemorrhage, perinatal mental health, gestational diabetes, and pre-term birth), the aim was to embed anti‑racism principles into established QI methodologies, enabling our teams to identify bias, de‑bias clinical pathways, and improve care.
The programme combined technical training in the Anti-Racism Model for Improvement with space for reflection and challenge. Monthly online sessions, in‑person learning events, and team‑based coaching created a community of practice where teams could learn from each other and confront difficult questions: Who does this pathway work best for? Whose outcomes are we measuring? Whose voices are missing?
For our multidisciplinary team, this way of working reshaped how we approached our improvement aim around gestational diabetes (GDM).
Inequalities in gestational diabetes
Women who experience GDM are at significantly increased risk of developing Type 2 Diabetes Mellitus (T2DM), and this risk is disproportionately higher among some ethnic minority groups. Despite this, uptake of postnatal screening and referral to NHS diabetes prevention programmes has historically been low. The LAN encouraged us to explore how system design, health literacy, and cultural barriers may contribute to inequalities.
We began by looking at our local population data which identified that South Asian women experienced the highest prevalence of GDM within our population. We then engaged directly with the communities we serve with a focus on speaking with South Asian women who had experienced GDM. Through community engagement events, we aimed to listen to women’s experiences of GDM, to better understand barriers and facilitators to care. Understanding the lived experiences of local communities was instrumental in shaping our approach to improving postnatal care pathways for women with GDM.
Our 3 key drivers for change
- We changed thelocal referral process to the Diabetes Prevention Programme, bespoke for women with GDM, from a ‘self-referral’ system to direct referrals from maternity services at 36 weeks of pregnancy. This approach improves referrals for marginalised women at highest risk of developing T2DM following pregnancy, particularly supporting women for whom health literacy has previously been a barrier to care, and provides emphasis of the importance of diabetes prevention following GDM.
- Working collaboratively, weco-developed translated resources focused on preventing T2DM following GDM. Specialist staff supported the filming of short guidance videos in five languages – English, Hindi, Bengali, Arabic and Urdu – accompanied by translated hardcopy cards for women to take home. Key messages included the importance of postnatal and annual screening via their General Practice (GP), attendance at community diabetes prevention programmes, healthy lifestyle advice, and access to contraception and pregnancy planning services.
- Wedeveloped and disseminated targeted staff education across maternity services to increase knowledge and confidence of postnatal care pathways following GDM. This has supported staff to have meaningful, culturally sensitive conversations with women about diabetes prevention.
Some of the outcomes have been striking. Weekly referrals to the Diabetes Prevention Programme increased, with over 60% of women with GDM being referred by 36 weeks’ gestation. Staff are now able to provide women with translated and accessible resources, supporting health literacy. Perhaps more importantly, across local health boards the nature of the conversations around diabetes prevention has changed to include women with GDM within broader diabetes prevention efforts.
Reflections and next steps
This work has not been without challenges. It has required time, openness to discomfort, and a willingness to question long‑held assumptions. Anti‑racism QI is slower and messier than traditional approaches, but it is also vital in reducing inequity.
Our next steps are about sustainability: embedding these approaches into routine practice, strengthening links with primary care, and continuing to measure equity, not just activity. We also aim to get further feedback from women on their use of the animations and evaluate impact through use of more PDSA cycles. The LAN has reinforced for us that anti‑racism is not a parallel agenda to quality improvement, it is how we ensure that improvement genuinely reaches those who need it most.
This project was guided by the ‘inch wide, mile deep’ ethos – taking a detailed approach to tackling inequalities in one area. This approach allowed us to stay focused on our project aims, while also uncovering wider barriers to care and system level challenges that contribute to persistent disparities in maternity care. We look forward to applying the learning from this project along with our improved skills in anti‑racism QI, to future equity-focused improvement work in maternity care.
Dr Kylie Watson is a consultant midwife at Manchester University NHS Foundation Trust.
With support from Derin Webb, Bethan McEvoy, Susan McAuliffe, Elizabeth Dapre, Dr Victoria Palin, Professor Jenny Myers.