Title: Models of maternity care for women living socially complex lives: What works, for whom, and in what circumstances?
Funder: Department of Health and Social Care

Abstract: What are the aims of this research?To explore what models of maternity care are effective in improving clinical outcomes for women and infants living with complex social risk factors, and how. Based on the findings, a feasible model of care will be developed for formal evaluation in future research. Why is it important?Many women and children in the UK who live in poverty and face difficult social circumstances struggle to engage with maternity services. These circumstances can include social isolation, young motherhood, homelessness, difficulty speaking or understanding English, domestic violence, women with mental illness and substance abuse problems. The most recent national surveillance reports of infant and maternal mortality (MBRRACE 2015, 2016) found that pregnancies to women living in socially deprived areas are over 50% more likely to end in stillbirth or neonatal death, and were associated with an increased risk of maternal death. This group of women also report worse experiences of maternity care than any other group of women in the UK. The reasons for this are not fully understood but it is likely to be partly due to inequality of access to services and education, discrimination within the system, and how maternity care is perceived by different groups of women. A recent national maternity review has prioritised a reduction in the poor outcomes experienced by socially disadvantaged populations and women with socially complex lives.Standard maternity care in the UK usually involves pregnant women seeing a number of different healthcare professionals. Care is fragmented and women have often never met the midwife looking after them in childbirth. Although there is high quality evidence that relational models of midwifery care improve outcomes and experiences, there is a significant knowledge gap around the mechanisms, including their effectiveness for women with social risk factors. Identifying what models work in improving outcomes, for whom, in what context, and how, will enable the development of safe maternity care for this at risk population. How will the research be carried out? A realist review of current literature and expert opinion around maternity care for women living socially complex lives. The aim of this review is to conduct an analysis of programme theories and key principles informing specialist models of care and to identify what works, for whom, in what circumstances. A programme theory and logic model will be developed using the findings of the review to guide the realist evaluation. A realist evaluation of two different models providing maternity care to women with complex social risk factors will be carried out using the findings of the review. Through immersion in the two settings this research will take an ethnographic approach and include following the cohort through their pregnancy journey, conducting in-depth interviews with the women, their families, and the care providers. A full analysis of each setting will be carried out to examine the mutual influence of the context and care delivered in each model, its impact on practitioner-mother interactions, women's experiences, clinical outcomes and cost effectiveness. How will the findings be used to improve services for women and their infants?This research will be concluded by developing a theoretically informed model of care aimed at reducing health inequalities for women with complex social risk factors. Using implementation science methods, this model would be formally evaluated as a future project in order to have impact on patients and the public within 5 years. The findings will be disseminated to service users, providers and commissioners. The cohort studied will be followed up to explore future health outcomes, engagement with early year's services and subsequent pregnancies through post-doctoral life course work.

Lay abstract: What are the aims of this research?To explore how women living socially complex lives, experience, access and engage with maternity services, and what impact this has on their clinical outcomes. This will provide an understanding of how maternity care can be organised to improve childbirth outcomes and experiences for this vulnerable population of women and infants. Based on the findings of the research, a model of maternity care for women living socially complex lives will be developed and tested in future research. Why is it important? Thirty seven percent of all women and children in London, where this research will be carried out, are living below the poverty line, this is significantly higher than the rest of the UK.Complex social circumstances associated with poor childbirth outcomes and experiences of maternity care include; poverty, young motherhood, homelessness, difficulty speaking or understanding English, domestic violence, mental illness and substance abuse. The most recent national reports of infant and maternal mortality found that pregnancies to women living in socially deprived areas are over 50% more likely to end in stillbirth or neonatal death, and carry an increased risk of premature birth and maternal death. These women also report worse experiences of maternity care than any other group of women in the UK and struggle to access and engage with maternity services. The reasons for this are not fully understood but it is likely to be partly due to inequality of access to services and education, discrimination within the system, as well as maternity care having less priority for women dealing with other issues such as poverty and domestic violence. The recent national maternity review 'Better Births' prioritised a reduction in the poor outcomes experienced by socially disadvantaged populations and women living socially complex lives.Standard maternity care in the UK usually involves women seeing a number of different healthcare professionals throughout pregnancy and postnatally. Care is fragmented and women have often never met the midwife who is looking after them in childbirth. Although there is compelling evidence showing women are less likely to experience premature birth, and are at a lower risk of losing their babies when they know their care provider, it is not understood why. It is also not known what type of care is acceptable to women living socially complex lives, for example some specialist models of care may be seen to be stigmatising or isolating for some groups of women. Identifying what works in improving childbirth outcomes and experiences, for what women, in what context, and how, will enable the development of safe, appropriate maternity care for this at risk population. How will the research be carried out? Realist Review: Gather information from existing literature, experts in health inequalities, service users and key stakeholders for models of maternity care for women with social risk factors, on what is believed to improve women's outcomes and experiences and why this is thought to be. A theory will then be developed that aims to explain how and why particular models of care are supposed to work, this theory will then be tested through rigorous research methods. Realist Evaluation Using the review findings, an evaluation of two different models providing maternity care to women with complex social risk factors in London will be carried out. This will involve following women through their pregnancy journey, speaking to them and their families about how they are experiencing care. The evaluation will include an analysis of the care being provided, including in-depth discussions with care providers to explore how the model of care is organised, resource use, and measurements of women's and infants' childbirth outcomes. How will the findings be used to improve services for women and their infants?The findings of the research will be published and shared with service users, providers and commissioners, with key messages for successful implementation of services for this vulnerable population. This research will conclude by developing a model of maternity care aimed at improving clinical outcomes and experiences for women living socially complex lives. The model will be formally tested in future research in order to have impact on patients and the public within 5 years. Key outcomes such as rates of stillbirth, premature birth, neonatal and maternal death will be measured to assess the effect of the model, as well as its cost effectiveness and acceptability to women and care providers. The families studied will also be followed up to explore the women and children's health outcomes, engagement with early year's services and subsequent pregnancies.

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