Recognising inequality and making the choice to act

There is a critical difference between recognising a problem and changing outcomes. Like many clinicians working in high-performing maternity units, we believed we were delivering equitable care.  

Our intentions were sound, our protocols evidence-based, and our outcomes broadly aligned with national standards. Yet, after joining the NHS Race and Health Observatory’s Learning Action Network (LAN) we began to interrogate our data more rigorously, and a different reality emerged. 

Beginning with the data

It is often said that “you cannot fix what you cannot measure.”

What became apparent early in this work is that disparities do not always announce themselves in day-to-day clinical practice. They sit quietly within datasets, masked by averages and obscured by our own cognitive blind spots. 

When we stratified our postpartum haemorrhage (PPH) outcomes by ethnicity, the findings were sobering. Despite our best efforts, disparities existed within our unit. This was not a failure of intent but of visibility. Data revealed what we had not seen. 

This moment was pivotal. It shifted the narrative from whether inequity exists to what we are prepared to do about it. 

Beyond the echo chamber

We started by assembling the right team. Not an echo chamber of aligned perspectives, but a multidisciplinary group with varied lived experiences, clinical insights, and intellectual frameworks. 

Our approach was grounded in quality improvement (QI) methodology, particularly iterative Plan–Do–Study–Act (PDSA) cycles. What initially appeared to be a linear process quickly revealed itself to be dynamic and non-linear. 

We learned that interventions rarely work perfectly the first time. They require refinement, retesting, and critical re-examination. This iterative flow of knowledge is central to meaningful change. 

Coaching support played a crucial role in this journey. It provided not only strategic direction but also accountability. In complex systems, where inertia can easily take hold, structured support ensures momentum is sustained. 

Equally important was learning from other units. Hearing both successes and challenges, including examples of inertia, helped contextualise our own progress. It reminded us that transformation is not immediate, but it is possible. 

From reaction to prevention 

One of the most impactful insights from this work was deceptively simple: we needed to reframe PPH from a condition we respond to into one we actively prevent. 

This led to the development of a visual intervention; a clinical poster focused on third-stage prevention strategies. While seemingly modest, this marked a turning point. It shifted clinician mindset from passive management to proactive prevention. 

And importantly, it reinforced a critical message: PPH is not inevitable. It is, in many cases, preventable. 

Rethinking clinical assessment 

Another key area of exploration was clinical assessment. Specifically, how traditional markers of deterioration may fail in patients with darker skin tones. 

Many of our standard assessments rely on visual cues such as pallor. However, these indicators are less reliable in individuals with darker skin. This creates a risk of delayed recognition and intervention. In the context of PPH, acting later means a cascade of higher blood loss   

By explicitly addressing these limitations, we were able to begin reshaping clinical awareness. Education around alternative signs of deterioration became essential. 

Widening impact and opening dialogues 

The impact of this work extended beyond our unit.  

We presented our findings at multiple platforms, including Royal College of Obstetricians and Gynaecologists (RCOG) PPH Study Day, the RCOG International Conference (oral and poster presentations), and an international conference in Australia. Locally, the work was also shared at the Imperial Health Equity Conference. 

These forums allowed us to contribute to a growing global conversation on equity in maternity care. Importantly, they also created opportunities for cross-institutional learning which helped to accelerate the spread of effective interventions. 

The responsibility we share

This journey has not only changed our systems, it has changed us. 

As clinicians, we are trained to diagnose and treat. But this work required us to step into a different role: to question, to challenge, and to redesign. It demanded humility to accept that despite our expertise, we were part of a system with blind spots. 

It also reinforced a powerful truth: change does not happen in leaps – small, consistent improvements, when sustained over time, can deliver impact far beyond initial expectations.  

We knew that change was possible, but we were keen to also consider the question of sustainability.  

There is a risk that without continued focus, the momentum behind equity work may diminish. Initiatives can lose visibility. Priorities can shift. Progress can stall. 

This is why equity cannot be the responsibility of a few, it must be the responsibility of all. We need to be advocates within the system. Every clinician, every leader, every organisation has a role to play in putting anti-racism principles into practice. Without this collective commitment, even the most impactful work risks fading into the background.

Miss Karen Joash is a consultant in obstetrics and gynaecology at Imperial College Healthcare NHS Trust. She is lead for postnatal care and perinatal mental health at Queen Charlotte’s and Chelsea Hospital and Head of School at the London School of Obstetrics and Gynaecology & Community Sexual and Reproductive Health.