Student thesis: Doctoral ThesisDoctor of Philosophy


Health inequalities are caused by social factors such as poverty, social deprivation, isolation, oppression, stigma and discrimination. Race, ethnicity, gender, class and other social risk factors intersect to exacerbate the effect of health inequalities. Factors associated with poor childbirth outcomes and experiences of maternity care include; Black and minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. These women struggle to access and engage with services and it is not known what aspects of maternity care work to improve their outcomes and experiences. Two theoretical concepts are used to explore these issues, ‘sydemics’; the interacting health and social problems that contribute to the excess burden of disease in a specific population and ‘candidacy’; the interacting factors that determine people’s eligibility for healthcare.

This research aimed to uncover the mechanisms that lead to improved experiences and outcomes through an evaluation of two specialist models of maternity care. One model of care takes a local approach and was placed within an area of significant health inequality. The other model was based within a hospital setting and provides care for women based on an inclusion criteria of social risk factors. Using a realist approach a synthesis of qualitative literature and focus groups with midwives working in the specialist models was conducted to develop preliminary theories regarding how, for whom and under what circumstances the model of care is thought to work. Quantitative data on birth outcome and service use measures for 1000 women accessing different models, including standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. Longitudinal interviews with 20 women with social risk factors were conducted to refine the theories.

A statistically significant relationship was found between the indices of multiple deprivation score and the number of social risk factors women were experiencing. This adds validity to the use of the deprivation score to identify women at higher social risk. Although Black and minority ethnic women, those with low socioeconomic status and social risk factors were significantly more likely to receive the specialist models of care, women experienced substandard care when they were not in the presence of a known midwife or obstetrician. The specialist model of care appeared to mitigate the effects of inequality on poor access and engagement with maternity services and

revealed no adverse outcomes compared to other models of care. Women receiving the specialist models of care were significantly more likely to use water for pain relief in labour, have skin to skin contact with their baby shortly after birth, and be referred to social care and support services. Maternity care based in the community setting was associated with a significant decrease in preterm birth and low birth weight, and an increase in induction of labour. A subgroup analysis found that the improved preterm birth outcome was particularly significant for women with the highest level of social complexity. The qualitative analysis highlighted possible mechanisms for these findings that were related to access, interpreter services, education, information and choice, continuity of care, social, emotional and practical support and stigma, discrimination, and perceptions of surveillance. Women described the benefits of seeing a known healthcare professional during pregnancy and particularly valued not having to repeat often difficult social and medical histories. Women accessing the specialist models described feeling able to disclose difficult circumstances to a known and trusted midwife. Women in the hospital-based model described a lack of local, community support and had difficulty integrating into unfamiliar support services. This was not reported by the women accessing the community-based specialist model. Finally, women in the community-based model described a trusting relationship with the whole team rather than one named midwife, this appeared to strengthen their perception of support with no negative effects.

This research highlights how carefully considered place-based care with a focus on continuity can create safe spaces for women and identify their specific needs. The quantitative data highlighted interesting relationships between all community-based models of care and neonatal outcomes that require further testing in future research. A particularly important contribution to knowledge was the identification of causal mechanisms for the inequalities often seen in maternal and infant health outcomes, such as women’s perceptions of surveillance, discrimination and paternalistic care. Models of care with strict inclusion criteria may risk excluding women at increased risk who are yet to disclose social risk factors, leading to continued fragmented care where they are less likely to disclose and remain ‘under the radar’. The identification of specific mechanisms will allow those developing maternity services to structure models of care around local need without losing the core aspects that lead to improved outcomes. These mechanisms, in which contexts they are activated, and what outcomes they effect are detailed in six refined CMO configurations. These configurations provide a framework for future models of care for women with low socioeconomic status and social risk factors.

Date of Award6 Jan 2021
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorJane Sandall (Supervisor), James Harris (Supervisor) & Angela Harden (Supervisor)

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