 All right, well now we turn to the most important part of the evening up to get to our presentation with these two incredible researchers in maternity care. So I'm going to introduce and then I'm going to hand the microphone over to Dr. Shubi. So first I'm going to introduce you to Esther Sharma. Esther Sharma is a UK registered midwife and research midwife at the University of Bedfordshire in the UK where she is part of a team developing a tailored community based intervention to increase access to anti-natal care. She has 10 years of clinical experience in the UK and holds an MSc Public Health from London School of Hygiene and Tropical Medicine where she's also pursuing doctoral research looking at maternity experiences of Afghan refugee women on the move. Our second presenter who's actually going to present first is Dr. Shubi Putisere is a reader in maternal and child public health and the director of the maternal and child health research centre at the University of Bedfordshire in the UK. Her research focuses on improving access to and quality of health care for mothers, babies and families and for developing services and interventions for those who are most vulnerable and disadvantaged nationally and globally. I'm sure it is so it's such an honour to see you all and to welcome all of you and I'm going to hand over the presenter rights now to Dr. Shubi so let me just make sure you can see your sides and off you go. Thank you so much. Okay thanks so much Jane and I'm just checking can you all hear me okay? You sound great. Yes excellent thank you. So thank you Jane and first of all thank you very much for having us. It is a really great pleasure to be able to speak to you all and to also to be able to listen to other speakers and to the listeners out there to the audience thank you for joining us. It is absolutely lovely to know that you know there are listeners out from around the world so as Jane said I'm Shubi Puthasheri I am an associate professor in maternal and child health and also I am leading the maternal and child health research centre at the University of Bedfordshire. So Esther and I will be talking about an ongoing project that we're conducting to enhance antinatal care uptake in a ethnically diverse socially disadvantaged area in the UK. So the plan is I'll kick off with a quick overview of the project and Esther will follow on about the intervention that we are currently rolling out in the community and we will be happy to take questions in the end. So the overall aim of this project is to enhance timely initiation and optimum uptake of antinatal care in an ethnically diverse area in the UK. So the specific objectives are we wanted to understand why women are starting antinatal care late and why women do not attend the recommended number of antinatal care appointments in this area. I will talk about the area in a minute. The second objective is to work with mothers, fathers and maternity care providers such as doctors and midwives to jointly produce a tailored community-based initiative to help women to start antinatal care on time and also to ensure that they have adequate antinatal care appointments. So we are conducting this project in two phases. In phase one, we analyzed routinely collected data from the local NHS maternity unit on all women who gave birth over a nine-year period. Firstly, to understand the patterns with respect to the timing of the start of antinatal care and also the factors that are associated with late antinatal care initiation. In phase two, as I said before, we are rolling out an intervention that was co-produced with women and healthcare professionals to enhance the timely uptake of antinatal care. So now about the area that we are focusing on. As I said before, it's a very ethnically diverse area with approximately 55% of the population being of Black and minority ethnical origin and the area is also ranked as the 59th most deprived area from about more than 300 local authorities in England according to the indices of multiple deprivation. And sadly, the health of people in this area is generally worse than the national average. Life expectancy for men and women are both lower than the national average. Looking at other outcomes, infant mortality rate in this area is higher than the national average. It's also the same with respect to babies born before term and also babies born with lower birth weight. And we did an initial mapping of areas of antinatal care initiation in the postcode districts. And it was very, very clear that in some areas, very high proportions of women started antinatal care late. So now to tell you a little bit more about phase one, what we did was we extracted data from the maternity information system from the local hospital over a nine-year period. And we conducted analysis using it. It is part of a big project, but we conducted data with respect to the timing of the week of gestation when they started antinatal care and also how many antinatal care appointments they had. So we analyzed about more than 45,000 births. And what we found was that overall, more than one third of the births were mothers from one of the ethnic minority groups such as Black Arabian, Black African, Indian, Pakistani, and Bangladeshi background. And a great majority, over 80 per cent, lived in three most deprived area, deprived area quintiles nationally. And about one-fifth or just over one-fifth of the mothers had their first antinatal care appointment later than 12 weeks. And we also found that mothers from all ethnic minority groups were significantly more likely to have their booking appointment later than 12 weeks compared to white British mothers. And the highest proportion of late booking occurred among Black African mothers, followed by mothers from Black Arabian background. More than two-thirds of the mothers who booked late lived in the two most deprived area quintiles. We also found a link between late antinatal care initiation link and outcomes. More than one-fourth of pre-term and lower birth rate babies were born to mothers who started antinatal care late. So I am going to stop there and pass on to Esther, who's going to talk about the, about our intervention. Thanks so much. Esther, you need to rejoin with your microphone. Sorry, I think when you went out, you just came back in with a headset. It's okay. The joys of online meetings. You just need to click on the little blue icon and just go through the login again. Can you hear me now? Yeah, you sound perfect. Thank you so much. Great. Apologies for that. Okay. Thank you, Shuby, for that introduction. And I'm going to, as Shuby mentioned, I'm going to be talking now about the actual intervention that we are currently rolling out. So we started our work actually by, in terms of thinking about how we developed the intervention by doing quite a significant piece of co-production work. We wanted the local intervention to be very much co-produced with women and partners who have used maternity services recently and who are living in the local area. So they know their local area best, they know their local maternity services, they've recently experienced it and that was really important to us. So we conducted this, this, this, a number of co-production workshops and conversations with, with local women and partners in order to develop this tailor-made intervention to address the women who are starting their antenatal care late or who aren't necessarily attending all of their midwifery appointments. But we also, as well as engaging with women and their partners, we also wanted to bring local professionals as well, working with pregnant women in the local area. So what we did was we simultaneously held co-production workshops and conversations with both women and partners, as well as professionals. So with the women, with respect to the co-production work we did with women and partners, we, this was done last summer, so it's worth mentioning, well, last early summer, so it's worth mentioning that this is off the back of some lockdowns that we had, the COVID lockdowns that we'd had earlier in the year. So we had, had to shift our, our plans a little bit. We had initially been planning to run face-to-face focus groups in the community with a crush so that local women could come and, and take part in these, these kind of co-production workshops. But as it, as the situation stood, because of the, the pandemic, we had to shift our co-production methods quite significantly. So we ended up taking a blended approach and actually that in itself was learning for us. And certainly if you're doing co-production work in your, in your local areas, this might be something that's of interest. So we ended up basically using fully remote co-production methods. And we had a combination of Zoom online workshops and one-to-one co-production conversations with women and partners. So the, the, we ended up having three online workshops and then, and then 11 one-to-one conversations. But the, the great benefit we found was that we were able to really be a lot more flexible rather than saying we're running a face-to-face co-production workshop at a certain time, at a certain place. And we were able to kind of be a lot more flexible to adjust around women's work schedules if they were pregnant or all their babies naps if they'd recently had a baby and so on. And we also held an externally facilitated co-production workshop for local professionals. And we had 11 professionals attending that workshop from a really wide range of agencies. So obviously we had midwives working in the local area, both community-based and hospital-based, but we also had the early years, the local early years provider. We had the leisure services because they actually run some exercise classes for pregnant women. We had the local youth service involved and some other agencies as well. So it was very broad, which was, was, was fantastic actually. And then we also held a couple of one-to-one conversations with people that weren't able to attend the workshop. And in addition to that, we ran a session with student midwives, finally with student midwives and co-produced, run a co-production workshop with them as well. So the findings of the workshop were really interesting actually. One of the things that we unexpectedly found, particularly when running the co-production workshops and having those co-production conversations with women was that it really provided for them a safe space to talk about. Many actually, the trauma of being pregnant and having a baby in the pandemic, it wasn't what we intended. But as we, as we, we, we had these conversations, women just, the need just to talk about, about their recent experiences and what they perceived as being safe space was, was very evident. But in terms of the, the actual work that we were, we were the sort of the outcomes that we were looking for, we, we found that there were really kind of three areas that women and partners and professionals identified as, as aspects of early pregnancy that we could incorporate into our, into developing our, our intervention. So the first, the first was the information about how to refer to antenatal care in the first instance. And we did, we did find that among a group of women, there was some confusion about what the referral pathway is and the referral process. Obviously again, would have been more difficult, but this was, the difficulties about this were exacerbated because of the pandemic and because of the limited ability to be able to physically go to the GP or physically go without appointments to the hospital, for example. But there was definitely a need to understand how to refer to a midwife in the first place. Secondly, the other, another finding that emerged was how to access information and support in early pregnancy. And a lot of women talked about the sort of the gap in finding out they're pregnant and then and seeing the midwife of their first booking appointment and the gap in information and support. And again, particularly mental health support came out in quite a bit in conversations that we had with women. Again, I think exacerbated by the pandemic. But, but, but some of the, the key identify key areas about this were identified by how to care for yourself, what to expect in early pregnancy. And partners were saying they wanted more information about early pregnancy, that there was really nothing out there for them support for mental health, but also what to do in an emergency. You know, what's the pathway for if a woman starts bleeding in early pregnancy, for example. And then finally, the timeline for pregnancy. So women were saying that they got all this information of booking about the timeline and what happens when, but that's an awful lot to take on in one go. And they would have found it helpful to have more of a drip, drip approach to this information that's being provided and maybe kind of have a little bit more of a high level overview about the timeline for pregnancy earlier on in early pregnancy, rather than waiting for their booking appointment. So they wanted to know sort of what are the key, what are the key touch points, what are the key appointments, what happens when in their antinatal care. I will just say that another thing that we found, although we did find one of the great advantages of being able to do this co-production work remotely was, as I mentioned, our ability to be very flexible and take a very flexible approach. The disadvantage was that we weren't able to engage with women who are potentially digitally excluded. And so that is something that we would have been able to hopefully do if we were holding face to face workshops. But unfortunately, we weren't able to do that. We did attempt to draw women in who don't have access to the internet, but it was very, very difficult to do that. And we weren't able to do that in that respect. So as a result of our co-production workshops, we then went on to develop our intervention, our community-based, tailored intervention to increase uptake of antinatal care and early initiation of antinatal care. And so in developing this, we thought about we thought of it in three ways. So firstly, the message, what do we need to say? Secondly, the medium, what kind of resources will we use to say it? And thirdly, the method, how will we say it? Obviously, there's some overlap in that, but those are the three key aspects of the intervention that we considered when we developed it. So in terms of the message, I won't go over all of this. I've mentioned quite a bit of it already, but it was very much about what to do after a positive pregnancy test, the referral mechanism, timelines, local support and contact, self-care and what to contact if there's any problems or concerns. In terms of the medium, some of the things that were talked about were targeted social media ads, online information, posters in, for example, specifically in women's spaces like women's gyms or on the back of toilet doors and things like that. A couple of women who took part in the intervention, the co-production workshop has had an idea about having business cards, very discreet, small cards that could be left near, for example, near pregnancy tests, so that if a woman finds out she's pregnant, she can also receive that information in a very sort of simple, straightforward way. Messaging about leaflets came out loud and clear from both the professionals and the women and partners. Generally people found leaflets are really unhelpful, not very user-friendly. Often their experience of leaflets was that the language wasn't very straightforward or human and so we've got a loud and clear message that people don't want no more leaflets with lots of information on it. People also wanted to receive the information through peers and through peer support and only pregnancy groups and also through faith leaders as well. Finally, the methods. As I mentioned, we've got a lot of feedback about written information needing to be more easy to read and easy to understand, more visual, using community languages and we have developed a range of written material, but not leaflets. So we've, as you can see in this slide, we've developed these cards, slightly larger than business cards, so we could incorporate all the information that was important, but still they're fairly small cards and we've had this translated into the main community languages and it really, it's got the visuals on there. It just says if you're pregnant, to summarize anyway, it just says if you're pregnant, you need to start antinatal care within 10 weeks of pregnancy, which is the national guidelines in the UK here, and then on the back of the business card there's information about how to refer via a GP or via self-referral mechanisms and one of the things that from our care production work that women talked about was the challenge in accessing GP services at the moment because of the pandemic and not being able to have that face-to-face contact with a GP who would then, in order for the GP to refer them to midwifery services, but also for some women using the online self-referral form just isn't feasible, it maybe don't have access to a smartphone or a computer where they can what's quite a lengthy form. So we've incorporated a phone number that women who have difficulties either in accessing a GP or completing the online referral form, a phone number where they can phone and refer themselves by phone and that's something particularly that non-English-speaking women would find help from which is identified in our care production work. And we've also incorporated an element of verbal information as well as part of our intervention, so instead of just kind of indiscriminately handing out information or leaflets or anything like that, we very much engage with people, have a discussion with them and communicate those key messages and that's been in a range of settings. So moving on to that then, in terms of actually delivering the intervention, which is the phase of the project that we're in now, we've recruited, we've just come to an end of that stage, but we had recruited three volunteer antenatal care champions who were a mixture of final year student midwives and newly qualified midwives and I was working with them to actually deliver the intervention. And we did that in a number of different ways, but mainly through either one-to-one conversations with people, through street engagement or through engaging with people in areas of high footfall or through group community sessions. So just to sort of paint the picture a little bit of what that might look like, we may go to a shopping centre or for example stand outside a local library or community centre, where there's areas where there's really high footfall in the community and we would engage with people one-to-one and have conversations about with the community as a whole about why early antenatal care is important and how to access antenatal care. And just to emphasise again, this isn't just information we're giving to women or to women who are pregnant, this is information that we're giving to everyone because one of the things that sort of came out from our co-production work was the fact that when women find out they're pregnant they may not know what to do, so they ask friends or family members for information and advice. So we wanted to make sure that the whole community has that information. So if a woman finds out she's pregnant and talks to a family member they can say oh well actually I recently found out through talking to somebody in High Street that this is the steps you can take to refer to a midwife for example. So we've also run as a set group community sessions, so for example we've been working with a local Roma organisation, we know that there are particular issues about access to antenatal care for women in the Roma community, so we've worked quite closely with them to deliver some group sessions and their beneficiaries in one of their community spaces and we've also delivered a training session to them specifically so that they're then able to provide information to beneficiaries that they're working with when we're maybe not around. So in terms of the next steps then we are just coming to the end of actually delivering that intervention. So the next step we've been will be really to evaluate the intervention. We've got quite a broad evaluation package, some of which has been actually sort of happening simultaneously to the intervention delivery and some of which will happen afterwards. So we really want to find out first of all how consistently are we delivering the intervention and there's obviously a number of us involved and we want to make sure that we're all saying the same things giving out the same key messages and making sure that we are communicating the same things even though we might be working in different contexts and different times. Also how acceptable is the intervention so to those who receive it and these two things we've been doing simultaneously to actually delivering the intervention. So we have a short very easy to use survey that we ask people who we've spoken to to complete and in terms of the intervention fidelity we are observed in terms of how well we're how consistently we're delivering the intervention and then we're going to do some after we finished our intervention delivery we'll be conducting some semi-structured interviews and questionnaires and focus groups to really understand the experiences of those who those who receive the intervention in more depth and then finally we'll run a further data analysis to understand what difference in terms of sort of the actual data has the intervention made. So that brings me to a close now and we're very happy to take thank you for listening we're very happy to take any questions. And while the audience is thinking of the questions and as our last facilitator said we see a few people in the audience that we can call on who are very experienced midwives so I'm sure they've got some thoughts. So I work in as a clinician full-time now and I'm not sure are you familiar with the concept Sharon Ryzen's concept of centering pregnancy that was developed at Yale because I think that's something that might as you are able to bring more people effectively and early into prenatal care centering actually folks is very much on what you said is it's called centering pregnancy and it's group prenatal care where we facilitate groups and they actually get about 10 times as much education typically and they tend to be folks that you might not normally associate with attending regular prenatal care so I wondered if you've heard about centering and if that's something that you actually have in the UK. Thank you, thank you Jane. As for San Mavere, I mean Jane would you like to tell us what this concept is about do you say it's centering? Yeah so in the 90s there was a midwife at Yale who did her research on what you just said about trying to enhance prenatal care for folks that you might normally associate with being very good at showing up or attending or feeling safe so she developed she actually wrote this as part of her I think it was her doctoral thesis when she was at Yale and it's called centering and you can actually do it for any kind of medical or any kind of issue but you actually do group prenatal care where you come in the client and their partner will have their private visit for a few minutes but the actual delivery of the education and the intervention is that they're teaching themselves and they're all at the same amount of week so they're all to you about the same time so you're delivering it's exactly following along from what you just said so I think it's something that would be very interesting maybe to integrate in your groups when you've well I've captured to the wrong word but when you've successfully got these folks to start coming then this is like a gift to them to say this is for you and you're going to run and be the facilitators and kind of teach yourself about the importance of health and feeling safe and talk about intimate partner violence and talk about STIs and everything else it's a very comprehensive educational way of learning about wellness and pregnancy and birth yeah yeah thank you so much Jane no it is a very interesting concept and see what our grounding philosophy is that we are trying to kind of take services into the community and also to places which have traditionally been kind of not viewed as places to you know to to to to disseminate health messages for example as Esther said you know shopping centers um street engagement our places of worship I mean traditionally this has not been you know seen as places where we can you know kind of provide health services Trump so one of the things that we are learning is that when we take these kind of services or messages out into the community um again as Esther said we are in the process of doing this evaluation but I think really the the sense that we're getting is it gets a lot more acceptable and it also you know I mean we're talking about women who fail to reach health services so the whole concept of taking it out into the community and also this corporate action that we have used um and that is also kind of very very important especially when you're working with women from diverse ethnicity um and in cultural backgrounds women who are new to the country you know we're talking about women who actually fail to reach the health service so um again the UK I mean from as far as we know there are in many projects which have adopted this kind of similar approach um so in a way we are testing whether this is going to work and the the feeling I mean Esther can add more to that um the the the perspectives that we get is all the sense that we're getting is that this is going to be I mean this is this is feasible um and this is probably I mean the next stages is to is to is to test this more at a national level because at the moment we are focused on a small area um so our feeling is that this is an approach going forward to capture you know vulnerable and disadvantaged women um this would you know work um in terms of enabling them to access maternity feeling time um Esther do you want to add anything in terms of the evaluations and reflections just um yeah I mean I think um I think that's sort of broadly covered it I think it's interesting what you say Jane and I know there's certainly been another big study in the UK to look at group antenatal care for example um I suppose our piece is just just before that it's about sort of getting getting women in the first instance um rather than the piece about what happens when they're in um so I think it has a little bit just before and Asubi said I mean there really really has been there's been worked on in this area um in low middle income countries but almost nothing as far as we're aware certainly nothing that's been written up in the peer reviewed literature at least um to really understand you know what we can do about this issue about women in high income countries who aren't engaging um till quite late with maternity services and it's certainly been been quite um interesting kind of hearing a very very wide range of reasons why that might be in in this particular area the way um we're researching this um I think yeah Ella Ella's got really timely timely question it just jumps into that and it's it's mostly about your research I don't know if you can speak to but Ella Cain asked are you able to explore reasons why women choose not I guess do not choose or choose not to access services so I know that's that's something that's probably if we could all solve that problem we wouldn't all be sitting here but I'd love to hear or we'd all love to hear if you've got any reasons why you think they're not um feeling safe to access our services I mean the systematic review that we are conducting as that is leading on that so as that would be something yeah so um I mean certainly from our um from the conversations we've had with women um I mean I think thank you Ella that's a just a really interesting question and I suppose there's two there's two aspects um to it that I that I'm sort of that come to mind um so your specific question was um reasons why women do not choose to access services so in terms of that certainly from our work what we found is um from our co-production work um we've certainly found that among some groups of women there is a huge amount of fear about engaging with maternity services um and the fear being that they will be charged so this is something that we're probably quite a few of us will be familiar with but particularly for migrant communities there's a big big issue about charging in the in the NHS and so although maternity care should be free at the point of use um there's concerns among some migrant communities that they will be that they will be charged um and um and there's also there's it was interesting actually um also that that maybe for women who come from countries where health systems run quite differently expectations are are different so for example um you know in some countries where women would have a named medical lead maternity care they may see the same doctor over and over be able to because it's maybe under a private system be able to access the doctor whenever they want whereas um and whereas in the NHS it's um there isn't always that continuity and um it's maybe not as accessible in the same kind of way always that that maybe women have previously experienced um the other the other sort of point for your question is sort of thinking about it oh you've just left another comment thank you would there be other reasons for British born women um there would be and certainly you know kind of in the wider research there there are reasons that are identified I mean that's um that's uh so for example what is um what we found as well from some of the conversations we had were um some women talked about from South Asian backgrounds talked about um the evil eye and um not wanting to talk about pregnancy um because of fear of what may happen to the baby if they talk about their pregnancy early on um there's certainly a loss in the literature so not what we've kind of found directly through our um our primary research but um but certainly from our systematic review of the literature there's you know we know that there are systemic structural factors um that impacts why women don't um engage with British born women to engage with maternity services um which are very wide ranges probably slightly beyond the scope of um of the discussion tonight but certainly that absolutely there are there are structural factors there's we know that there's institutional racism we know that there's um uh language barriers we know that there's um women have been treated badly before and whether that's maternity care or or in the health system in in general and they're not wanting to um understandably repeat those those experiences and um so yeah I mean I think there's there's a wide whole other whole other discussion um there to be had but yeah absolutely thank you for your question Ella and I think I just put in a request for our return performance next year so that we can hear more from how your co-production is going because I think you know I think as I said at the start I think this is a universal issue where women have felt not safe or not heard and how can we how can we include everyone in the conversation so that they're able to effectively take care of themselves and their baby so um I think we're about to wrap up so um Ella says this is an excellent project these two widen so let's all give a big hand to Esther and Dr Shuby fantastic we heart you we wish you all the best with your ongoing research and thank you so much to everyone involved and thanks for coming and thanks for your engagement in the conversation so