Thinking differently about inequality in highly diverse areas

At Barts Health, we care for a highly diverse population across East London. Many women experience social deprivation alongside structural barriers that influence their care and outcomes. But deprivation only goes so far in explaining inequality. 

The women and birthing people we care for from the global majority account for around 70% of all our bookings. Around 30% of the population we serve identify that English is not their first language, and also identify literacy levels being poor in English as well as their preferred spoken language, specifically in female populations.  

We know that despite a sustained focus on postpartum haemorrhage, preventable harm still occurs, and that harm disproportionately affects certain groups. 

Taking part in the NHS Race and Health Observatory’s Learning Action Network helped us look more closely at how anti‑racism and quality improvement need to sit together in practice, rather than being treated as separate agendas. 

Rethinking how we use data

One of the earliest areas we focused on was data. Like many services, we had access to large amounts of information, but not all of it was easily understood or accessible to staff across disciplines. Through the Learning Action Network, we improved our all‑staff dashboard so that outcomes could be viewed through the lens of deprivation and ethnicity. 

This shift was important. It allowed teams to see patterns that were previously hidden within overall figures, including where women were disproportionately experiencing severe haemorrhage, stillbirth, neonatal death, and related adverse outcomes. Once this information was visible, it began to shape our quality improvement priorities in a more focused and honest way. The data did not give us easy answers, but it gave us better questions to ask. 

Focusing on postpartum haemorrhage 

Reviews of incidents showed that delayed recognition of blood loss following birth could lead to serious and sometimes unexpected outcomes. These issues did not sit neatly within any single professional group’s role, which made a multidisciplinary approach essential. 

We brought together midwives, obstetricians, anaesthetists and wider maternity staff to develop a practical response. This collaboration led to the creation of BLEAP, a simple prompt for Blood Loss Evaluation at Perineal Repair. The intention was to support consistent assessment at a critical point in care, where bleeding can be underestimated or missed. 

To support implementation, the multidisciplinary team developed a short training video lasting around ten minutes, which was co-designed with our Maternity and Neonatal Voices Partnership (MNVP) co-chairs. This is now part of mandatory training for staff each time it is delivered. Keeping the training concise and clearly linked to real clinical practice has helped it feel relevant rather than burdensome. 

Alongside this, we strengthened our work on anaemia management, decolonising our antenatal anaemia management guideline with an anti-racism approach and holding a co-created event improving education and awareness of anaemia in our local community and providing information regarding iron rich diets that reflect the dietary habits of the populations we serve. It was recognised that for our communities, anaemia, both as a long-term challenge and when developing for the first time in pregnancy, was a major issue for our service users. Antenatal anaemia management has such an impact on haemorrhage severity and recovery, it was essential for us to link these strands of work together within a broader focus on improving public health advice and access to iron supplementation. 

Involving women in shaping information 

We also looked at patient information, recognising that safety is closely linked to what women understand about their bodies and when to seek help. This was particularly critical based on the linguistic, religious, cultural and ethnic diversity of our trust’s locality.  

Through co‑design with communities including a world café style event, feedback on drafts, and co-design with our MNVP chairs we reviewed how information was written and shared. Listening to women’s experiences helped us identify gaps and assumptions in our existing materials. This has informed changes to how we communicate about bleeding, anaemia, and postnatal warning signs, with the aim of making information clearer and more relevant to women’s lives. The challenge was designing information in a way which service users said was most engaging and informative versus aligning it to the Trust standard patient information format. We were unable to reconcile the two ultimately, but have instead remained committed to delivering the information in the format that our service users told us they wanted and needed.  

Reflections and next steps 

Using disaggregated data, examining the impact ethnicity had or may have has become a golden thread through quality improvement activity throughout maternity, and in our quality and safety reporting across the service.  

Combining anti‑racism with quality improvement has changed how we approach patient safety and learning responses from safety incidents. It requires us to pay closer attention to variation, to be open about uncomfortable findings, and to avoid default explanations that place responsibility on individuals rather than systems.  

By embedding Anti-Racism Implementation Advisory Groups across all our hospitals, we are developing a much clearer understanding of how racism impacts our workforce and the women and families we care for.  

Crucially, these groups are enabling our teams to lead the changes needed to improve both staff experience and patient care. Being part of the Learning and Action Network, and seeing this work spread across the organisation, has given me increasing confidence that we are growing as a service, have a better understanding our communities, our service users and our workforce, and translating that insight into action. 

Shereen Nimmo is Group Director of Midwifery at Barts Health NHS Trust.