Maternal mortality and morbidity have been at the forefront of the public health agenda for the past three decades. However, despite global efforts, avoidable injury and death remain a considerable burden, with devastating and wide-ranging impacts. Approximately two million stillbirths take place every year, with 40 percent occurring during labour.¹ The WHO Global Patient Safety Action Plan 2021-2030 highlights the importance of safety improvement programmes, with Safe Maternal and Newborn Care selected as the focus for World Patient Safety Day 2021.² Alongside the reduction of avoidable injury and death, it is essential to improve women’s experience of healthcare during pregnancy and childbirth. Despite the heterogeneity of challenges to provide safe maternal and newborn care both within and between countries, inequities in access and use permeate every system.

Mothers from ethnic minority backgrounds, those with underlying health conditions, and those who are socially deprived and facing other forms of disadvantage emerge as important groups at risk. Maternal mortality rates for Black women and Asian women are, respectively, four and two times higher than those observed in white women in the United Kingdom, and stillbirth rates are higher in ethnic minority groups than white groups.^3,4 The covid-19 pandemic has further exacerbated these disparities, with evidence suggesting women from ethnic minority backgrounds may be at a higher risk of complications from covid-19.⁵ Vaccination is important for pregnant women, with emerging evidence of increased risk for severe illness and premature birth. Covid-19 vaccine hesitancy is high among pregnant women and people from ethnic minorities and needs to be addressed.^6,7 At a time when healthcare systems are under extreme pressure, these underserved groups must be kept safe and the entrenchment of existing inequities avoided.

Whether in low or high resource settings, governments, policy makers, and providers must address both systemic biases and the impact of socioeconomic determinants on maternal healthcare to reduce disparities in both access and safety outcomes.⁸ In the United Kingdom, strategies have included continuity of care targets in the NHS Long Term Plan for women from ethnic minority backgrounds and deprived groups, the establishment of the Black Women’s Maternal Health Awareness week, and initiatives from the Royal Colleges to improve experiences and outcomes for ethnic minority women.^3,9 The empowerment of women and communities, and strategies to minimise discrimination have a place in all health systems.

In maternal healthcare, patient involvement and continuity of care are particularly essential, with patient-centred care known to improve patient and health worker relationships, safety of care, shared decision-making, and self-management.¹⁰ All women should be able to develop personalised care plans and responsive environments must be established, enabling the provision of equitable care with staff and patients feeling safe, respected, and able to speak up when they identify a potential issue.⁸ A systems thinking perspective must be embraced, focusing on the way the system’s constituent parts interrelate, and how they can evolve sustainably to improve safety of maternal and newborn healthcare.

Strategies are needed to overcome the barriers for equitable access to maternal and newborn health services. Interventions could include translators and outreach programmes to engage women from immigrant communities. Patient and family education can improve women’s skills to navigate health systems, increasing awareness and confidence to advocate for better and safer care. Further research to understand the impact of interventions is essential to identify evidence-based strategies, and understand how and if they work, and for which women.¹¹ Partners being unable to be with women during their care in the covid-19 pandemic has highlighted the importance of women’s psychological safety and having someone to advocate for them during this vulnerable time, and the emotional toll of real or perceived lack of safety should not be underestimated.

The global patient safety movement must place patient engagement and experience at the centre of efforts to continue reducing avoidable harm and death, and improving safety, in maternal and newborn care. Unacceptable inequities remain prevalent and women’s empowerment and involvement are essential to tackle these. Consideration is needed about how and by whom priorities for safety and quality improvement are determined. Women should be involved in co-assessment of these priorities and the strategic implementation of service delivery changes. There is still much work to be done; by working together with women who use these services, progress can be made toward providing a safer and more equitable service for all.

Alexandra Shaw, Policy Fellow and Global Patient Safety Lead, NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London @Shaw1Alexandra

Ana Luísa Neves, Associate Director and Advanced Research Fellow, NIHR Imperial Patient Safety Translational Research Centre,Institute of Global Health Innovation, Imperial College London @ana_luisa_neves

Gianluca Fontana, Operations Director and Senior Policy Fellow, NIHR Imperial Patient Safety Translational Research Centre,Institute of Global Health Innovation, Imperial College London @CHP_Gian

Neelam Dhingra-Kumar, Unit Head, WHO Patient Safety Flagship/A Decade of Patient Safety 2021-2030, World Health Organization @Neelam_Dhingra1

Mike Durkin, Senior Advisor on Patient Safety Policy and Leadership, NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London

Ara Darzi, Director, NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London 

References:

1. Stillbirth, World Health Organization. Available from: https://www.who.int/health-topics/stillbirth [Accessed 6^th September 2021].
2. Global Patient Safety Action Plan 2021-2030: towards eliminating avoidable harm in health care. Geneva: World Health Organization; 2021.
3. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18. MBRRACE-UK. 2020.
4. Office for National Statistics. Births and infant mortality by ethnicity in England and Wales: 2007 to 2019. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/childhealth/articles/birthsandinfantmortalitybyethnicityinenglandandwales/2007to2019 [Accessed 6th September 2021].
5. Saving Lives, Improving Mothers’ Care. Rapid report: Learning from SARS-CoV-2 related and associated maternal deaths in the UK. MBRRACE-UK. 2020.
6. The Royal College of Obstetricians and Gynaecologists. Maternity Colleges express concern over vaccine hesitancy in pregnant women. Available from: https://www.rcog.org.uk/en/news/maternity-colleges-express-concern-over-vaccine-hesitancy-in-pregnant-women/ [Accessed 1^st September 2021].
7. Razai M, Osama T, McKechnie DGJ, Majeed A. Covid-19 vaccine hesitancy among ethnic minority groups. 2021; 372: n513. Available from: doi: 10.1136/bmj.n513
8. Strategies toward ending preventable maternal mortality (EPMM). The World Health Organization. 2015.
9. The NHS Long Term Plan. NHS. 2019.
10. Severinsson E, Haruna M, Rönnerhag M, Holm A, Hansen B, Berggren I. Evidence of Linkages between Patient Safety and Person-Centred Care in the Maternity and Obstetric Context – An Integrative Review. Open Journal of Nursing. 2017; 7; 378-398. Available from: doi: 4236/ojn.2017.73030
11. Johnsen H, Ghavami Kivi N, Morrison C H, Juhl M, Christensen U, Villadsen SF. Addressing ethnic disparity in antenatal care: a qualitative evaluation of midwives’ experiences with the MAMAACT intervention. BMC Pregnancy and Childbirth. 2020. 20:118. Available from: doi: 10.1186/s12884-020-2807-4