Reducing Neonatal Inequality

Does Training Impact Midwives Understanding of Implicit Bias and the Care of Black, Asian and Minority Ethnic Babies?

Bea Chubb @Mrs_Chubbs_ Becky Cockings @Becky81RM Emma Symonds @emmasymonds24 Vanessa Heaslip @ HeaslipVanessa Janine Valentine

Background

In 2021, the MBRRACE-UK report into maternal deaths revealed that there has been no statistically significant change in the disparity of outcomes for black and Asian women since 2014 ; black women are four times as likely to die, during pregnancy or shortly afterwards, than white women, while Asian women are almost twice as likely to die . Sadly, these disparities continue and affect the babies of black and Asian women. Within the first four weeks of life Asian babies have a 60% higher risk of dying, while black parents are 45% more likely to experience this devastating loss than white parents.

Interventions to reduce stillbirth and neonatal death have had more effect on reducing the rates for white families and there are recognised inequalities throughout care in neonatal units with black babies suffering most (Sigurdson, 2019). Knight et al (2021) discussed microaggression and bias as factors contributing to poor outcomes in the UK, similarly in the USA, Suliman (2021) suggested that disparities occur as a result of racism within the care that is provided, not because of the race of mothers and their babies.

A 2021 report into maternity training provision indicated that less than a third of UK trusts provide cultural specific training (Ledger et al, 2021) which made the authors reflect on their own training in which exclusively white mannequins were used.

1000 words for £1000

The authors entered a Quality Improvement (QI) competition, ‘1000 words for £1000’-write 1000 words about something that could improve care and win £1000 to put this into practice. We considered all white resuscitation dolls and text books (Mukwende, 2021), alongside non-inclusive language and lack of specific training as barriers to having open conversations and the ability to fully care for all babies – ‘Can’t see, can’t treat’.

After winning, we requested the purchase of black resuscitation dolls to adapt training. However, with support from Bournemouth University we were encouraged to take this further and lead a bigger QI project, developing a training package for midwives and evaluating current knowledge, attitudes, and measuring the impact of the training.

Midwife 2

Methods

In partnership with the Equality, Diversity and Inclusion lead, a training package was created for midwives. Topics covered include implicit bias, stereotyping and microaggression and the how these can impact care. Alongside this, clinical scenarios were explored, including jaundice, assessment of perfusion at birth and beyond, and reviewing ‘red flag’ advice for parents. By ensuring co-production, including discussions with Somerset Diverse Communities, we were able to present lived experiences of black mothers in maternity care and also ensure this training was culturally sensitive.

Anonymous pre and post-training surveys were developed using simple yes or no questions and free text answers to capture basic demographics, baseline understanding pre-training and evaluation of the training and midwives understanding post-training. Descriptive analysis was used for the statistics and thematic analysis was used for the free text answers.

Will this training change your practice as a midwife?

Do you feel that maternity guidelines are supportive and inclusive for all women and babies?

7 Steps of QI

The 7 steps of QI, grounded in theory from the world-renowned Institute for Healthcare Improvement, is the approach utilised within our NHS Foundation Trust and was used in this project. As part of the Plan Do Study Act (PDSA) cycle of the 7 steps we ran a pilot training session to give time to make changes and improvements to both the training package itself and the data collection if required.

Midwife 1

Results

76.1% of midwives within the trust were trained and positively 98% of midwives will change their practice following training with areas mentioned including documentation, advice to parents and assessment at birth. 42% of midwives said they would now feel confident to challenge stereotypes in practice and would take more time with their care. Similarly, 98% of midwives expressed they had gained new knowledge and understanding from the training. 96% of midwives felt that the APGAR scoring system was not suitable.

100% of midwives indicated that trusts should be doing more to ensure their guidelines are fully inclusive and felt that healthcare settings were impacted by bias. Midwives were asked if they felt there were any differences when assessing babies from different ethnicities, pre-training 46% felt there were no differences compared with 93% recognising these differences post-training. Surprisingly, only 62% of the midwives had heard of implicit bias before the training session.

The thematic analysis found three themes, a quote highlighting each has been includedShocked about inequality and impact of bias - “Ididn’trealisetherewassomuchinequality”

Midwife 4

Positive about change - ”founditreallyusefulandwillchangemypracticeinapositiveway” Midwife 5

Not ready to accept - “asamainlywhiteBritishgroupitisinevitable” Midwife 6

Future Practice

A key recommendation for practice from this project is that training equipment needs to be representative of the population and while training mannequins alone are not the answer, they do allow a starting point for conversations and understanding. Training, alongside these mannequins for maternity staff must include recognition of the rates of inequality, both for women and babies and impact of bias. Trainers need the knowledge to be able to give evidenced based answers to questions that are raised regarding assessment of babies from black and Asian backgrounds, as recommended by Healthcare Sa fety Investigation Branch (HSIB) in 2021 following the death of a three-month-old baby. We must consider language used and use of the APGAR scoring system as it stands today and ensure that care provided promotes equity. Continued poor awareness of implicit bias and its subsequent effect on patient safety must be understood to provide families with safe and personalised care (Parker, Corden and Heaton 2011; NHS England, 2016) and work to reduce unacceptable disparities. Maternity units need to look with fresh eyes at their guidelines to ensure they are inclusive, and training and equipment nee ds to be representative of the population.

Following the presentation of this project NHS England and NHS Improvement - South-West have purchased mannequins for all maternity trusts in the SouthWest region which is an exciting first step.