Understanding local themes for Black maternity service users booking late (over 16 weeks’ gestation)
Outcomes and learning
Outcomes
From the thematic analysis, the 6 overarching reasons for late booking were identified as:
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transfer of care from abroad
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transfer of care from another UK NHS maternity unit
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complex needs, such as safeguarding concerns, navigating the asylum system, learning disability and homelessness
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data error or poor data quality (inaccurately classed as over 16 weeks on EPIC, booked prior to 12 weeks). Data quality substantially improved from 2022 to 2023, going from a 46% error rate to 8%. This is due to our digital midwifery team and EPR data analysts and midwifery workforce embedding these improvements in practice
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unaware of pregnancy
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provider error or miscommunication (service user attempted to access care before but was signposted incorrectly by another healthcare provider).
Learning
The poor data quality during digital transformation may have contributed to the widely accepted ideology locally that Black women present later for their booking appointment than other ethnic groups. We found that this is not often the case; for example, one of the causes of late booking appointment was found to be a delay by the provider.
One service user in this sample attended the emergency department several times with hyperemesis. At one appointment, she was advised that a referral to maternity had been made for her. She asked about this referral at a subsequent attendance at the emergency department and was told to be patient. It was found that this referral had not taken place. Her blood test results were also not checked for several weeks, leading to a delay in treatment. She was eventually booked after the recommended gestation for combined screening, so quad screening was offered.
In conclusion, trends can be misleading for minority groups that suggest a monolithic presentation. Individual Black women attempt to access care and trust the word of healthcare professionals despite the rhetoric from public health reports and social media.
To address this, we need to improve communication from other hospital departments and primary care when treating pregnant patients, including accurate signposting to local maternity services.
As a continuous learning system, we will now monitor our data on an annual basis to support improving care in line with national recommendations, especially on public health messaging for folic acid and vitamin D supplementation for this target group (see NICE's guideline on maternal and child nutrition). Alongside annual data audits, we have recommended a wider audit of late bookers from other ethnicities to understand the context of these findings.
In Frimley, our units are geographically positioned in the South East region near 2 major international airports, so we see a high proportion of transfers of care from abroad, military families who relocate frequently during pregnancy, and asylum seekers and migrant families. This audit found that the majority (64%) of our late bookers in 2023 were a transfer of care from the UK or abroad. It is important to consider local context, and we highlighted a need for a better process of community midwives uploading transfer of care evidence to electronic patient notes from previous care providers. We are also improving links across the system, in particular for the voluntary sector and asylum seeker hotels, to support service users who are transferring their care mid-pregnancy and signposting them to relevant organisations, for example an early referral to healthcare professionals if new to the area.
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