Title: The REACH Pregnancy Programme (Research for Equitable Antenatal Care and Health)
Funder: Department of Health and Social Care

Abstract: Aims and objectives We aim to generate high quality evidence on how to improve access to, and enhance the value and experience of, antenatal care (ANC) for socially disadvantaged and ethnically diverse women. We will conduct four work packages (WP) with the following research questions: WP1: What is the effectiveness and cost effectiveness of a community-based intervention for increasing early uptake of ANC and improving health outcomes? WP2: What are the optimum methods for testing the effectiveness of group-based ANC in an NHS setting serving populations with high levels of social deprivation and cultural, linguistic and ethnic diversity? WP3: What is the effectiveness and cost effectiveness of group-based antenatal care for improving health and safety outcomes for women and babies and satisfaction with ANC.? WP4: How can user involvement in planning, monitoring and improving maternity services be strengthened so that it is more effective and equitable? Background and rationale Inequalities in maternal and infant mortality and morbidity are a challenge for public health policy and service delivery in the UK. Antenatal care (ANC) can prevent adverse outcomes for both mothers and babies and has an important role in giving every child the best start in life. Effective approaches are needed to overcome the challenges in delivering accessible and engaging care, particularly in socially disadvantaged and ethnically diverse communities where there are high rates of late and irregular ANC uptake and large numbers of women with complex medical and social needs. Research plan WP1: Cluster randomized controlled trial (RCT) of a community intervention to increase early uptake of ANC The trial will aim to raise awareness of the value of early uptake of ANC for the health of women and children, and support women in how and when to access ANC. The intervention will be implemented in 10 wards throughout North East London and beyond into Essex and Hertfordshire. It will consist of: (i) training a group of peer volunteers to promote ANC through social networks; (ii) development and distribution of campaign materials; and (iii) community events to promote key messages. Each component will be developed using a community co-design process. The primary outcome will be the proportion of pregnant women who have started ANC by the end of the 12thweek of pregnancy, secondary outcomes will include: antenatal admissions, emergency caesarean; pre-term birth and low birth weight. WP2: A pilot study of group-based ANC The pilot trial will assess the feasibility of full trial methods, determine the most appropriate primary outcome and adapt group-based antenatal care for settings with high levels of ethnic diversity. WP3: An RCT of group-based ANC The trial will take place within the maternity services at Barts Health NHS Trust. ANC in the intervention arm will be delivered in groups of 8 to 12 women who have expected delivery dates within the same month. Primary and secondary outcomes will include maternal and infant health and safety outcomes; satisfaction with care will be a secondary outcome. Outcomes will be measured via validated instruments. WP4: Strengthening effective and equitable user involvement in maternity services This WP involves: a) Systematic review to investigate what is known about strategies to engage underserved groups of women in improving maternity services; b) a web-based national survey of all (n= 152) Maternity Service Liaison Committees (MSLCs) to assess the strategies used to support effective and equitable user involvement; c) support to three local MSLCs to strengthen their user involvement; and d) co-develop and disseminate a practical e-handbook on equitable and effective user involvement in maternity services. Dissemination & projected outputs The findings will be presented at national/international conferences, published in peer reviewed and practitioner journals and reported as briefing papers to health care commissioners and managers. The main output will be high quality evidence on effectiveness and cost effectiveness of interventions which may impact on health services and women. If group-based antenatal care is effective it has the potential to radically alter ANC practice for the benefit of women. Relevant expertise of the research team, ethics and governance The lead and co-applicants collectively represent a wide range of disciplines and professions. Between them they have led many trials, including cluster RCTs. All have proven track records in applied health research and have worked with participants of minority ethnic groups. Two users/patients with personal experience of theservice will also work actively with the team. The investigators group will report to the overall programme steering committee. Ethical approval will be sought for all studies within the programme. Justification of costs The majority of research costs will go on staffing to ensure sufficient capacity and appropriate expertise. Other significant costs cover costs of a clinical trials unit, the costs of co-designing the community-based intervention to ensure relevance, vouchers for participants and translation and interpreting costs for recruitment to ensure inclusion of diverse groups.

Lay abstract: This research aims to improve access to, experiences of, and benefits from, antenatal care for pregnant women living in areas with poverty and mixed ethnic groups. The research team is led by Professor Angela Harden (Barts Health NHS Trust/University of East London) and comprises a team of experienced researchers, as well as two local women who have used the maternity services and have experience of representing women's views. For women to get the full benefits of antenatal care, it is recommended that they begin their antenatal care early in pregnancy. Our previous research investigated reasons why some women have their first antenatal appointment late. Whilst starting antenatal care early is important, the women we interviewed told us how important positive experiences of care are too. This research programme therefore contains four parts: Improving women s access to antenatal care (part 1). Together with communities in North East London and beyond we will design an intervention to support women to access care early . The intervention will be delivered in 10 randomly selected wards and we will analyse hospital data to see whether pregnant women living in those wards begin their antenatal care earlier, and see greater benefits for both themselves and their babies, than those living in other wards. Improving women s experiences of antenatal care (parts 2 and 3). We will evaluate group-based antenatal care, which involves delivering antenatal care to groups of women at the same stage of pregnancy, rather than individually. Group-based antenatal care has been delivered in many other countries and research has found that women both like it and benefit from it. However, it hasn't yet been properly evaluated in the UK. We will evaluate it within the Barts Health maternity service. We will first find ways of making group antenatal care work for all pregnant women, including those who do not speak fluent English (around a quarter of women served by Barts Health). We will then invite women to take part in the research study. Of those who agree, half will have their antenatal care in groups and half individually. We will analyse hospital data and ask the women about their experiences towards the end of their pregnancies and four months later, to find out whether women who have had their care in groups see greater benefits for themselves and their babies and are more satisfied than those who have had their care individually. Strengthening women s involvement in planning and improving maternity services (part 4). We will find out how maternity services across the country have involved local women in shaping services, we will support the Barts Health to involve more women, more effectively, and we will develop a handbook to share what we have learned.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH