Barriers faced by pregnant women on low income when trying to access maternity care
Evidence Hub
What barriers do pregnant women living on low income experience when trying to access maternity care? Perspectives from care providers and healthcare professionals.
This piece of work is part of the Supporting Engagement with and Access to Maternity Services (SEAMS) study, which is funded by the NIHR School for Public Health Research (SPHR). You can read more about the SEAMS study, here: Supporting engagement with and access to maternity services – NIHR School for Public Health Research
Quick-read summary
Women living on low incomes in England are at greater risk of experiencing poor birth outcomes, including stillbirth, neonatal death, preterm birth, low-birth weight and maternal mortality. Women facing financial difficulties, and have poor access to educational, social and health resources engage less with health services throughout their pregnancy.
Previous research has identified this could be due to social stressors, low health literacy, digital exclusion, lack of social support, language barriers, difficulty with transport, and experiencing stigma and judgement from healthcare professionals. This study aimed to explore professionals’ perspectives of what barriers pregnant women living on low income experience when accessing maternity care.
We interviewed 17 professionals working in the NHS, local authority or VCSE organisations in the North East of England.
We found three levels of barriers that professionals perceived pregnant women living on low income experience when trying to access maternity care. These are:
- Structural – including digital exclusion, language-related barriers, and staff shortages
- Interactional – including limited social networks impacting partner involvement, and experiences of racism and discrimination
- Individual – including costs of travel to appointments, hidden costs of pregnancy and a fear of professionals and services.
This study has highlighted the barriers as identified by professionals who work and interact with maternity services daily. This study has allowed us to identify actionable recommendations that can reduce some of the barriers that women face, allowing for easier access to maternity care.
Who is this evidence useful for?
Policymakers and commissioners who design and fund maternity services, service leaders who manage services, practitioners (including VCSE colleagues) who deliver services to women.
Academics who are interested in exploring barriers to accessing healthcare services, including maternity services, for people living on low income.
Detailed summary
What is the issue?
Women living on low income and from disadvantaged backgrounds experience higher rates of poor birth outcomes compared to those from higher socioeconomic groups. Evidence has shown that they often face multiple overlapping barriers to accessing maternity care, including social stressors, low health literacy, limited digital access, lack of support, language and communication barriers, difficulties with transport, and stigma or judgement from professionals. These barriers can result in lower engagement with maternity care. Previous research has primarily focused on experiences of women experiencing socioeconomic disadvantage, little is known about how healthcare professionals understand and respond to the barriers they identify in practice.
We aimed to explore healthcare professionals’ perceptions of the barriers pregnant women living on low income face when attempting to access maternity care. Understanding these barriers from the perspective is essential for developing strategies to enhance the accessibility and quality of maternity care for all women.
Research summary
We conducted a qualitative interview study.
- We conducted one-to-one interviews with professionals (including midwives, health visitors or practitioners working in the Voluntary Community and Social Enterprise (VCSE) sector).
- Recruiting participants from a local North East NHS Foundation Trust maternity department, North East local authorities and VCSE organisations in the North East.
- The study was informed by Poverty Proofing© approach developed by North East charity Children North East (CNE).
- We conducted four workshops – three with key stakeholders, commissioners, healthcare professionals and VCSE practitioners, and one with public members. These workshops detailed preliminary findings, and with the input from stakeholder, professionals, practitioners and public members, actionable recommendations were identified
What did the research find?
We identified a number of barriers that pregnant women living on low income experience when attempting to access maternity care.
Structural
This theme includes any societal and policy factors that were identified to influence the experiences of pregnant women, and include digital exclusion, language barriers and understaffing of services.
Professionals highlighted that women who did not have access to digital technologies were unable to engage with their electronic patient/maternity care records. For example, being unable to book and manage appointments. While some professionals reported using paper notes with these women, this was not the norm. Language was reported as a barrier for women where English is not a first language. Professionals reported that the interpretation systems in place were not always professional, difficult to book and often not reliable. Finally, professionals were aware that budget cuts to services were impacting women attending appointments. Professionals reported that the maternity support workers role was changing, and that they would no longer be assisting in the antenatal clinics, resulting in a lack of continuity of care for women.
Interactional
This theme focuses on relationships of pregnant women with individuals within the systems that they engage with, and include a lack of a social support network, the involvement and engagement of fathers and partners, and racism and discrimination within services.
Professionals reported that women who lacked a social network struggled to engage with antenatal care for a variety of reasons. Professionals within the NHS were aware of VCSE organisations providing social support via social groups, however, the VCSE professionals reported that there was low turn out to these groups for those requiring additional social support. Professionals also noted that women who lacked fathers’ and partners’ engagement and support also engaged less with services, often reporting that partners would not attend appointments, or would comment that they felt uncomfortable being in a ‘women’s space’. Finally, professionals noted that they had witnessed discrimination and racism within maternity care. They felt that this discrimination and racism was not just committed by professionals but also by admin support.
Individual
This theme incudes barriers and factors stemming from the personal characteristics and circumstances of the pregnant women, and include travel barriers, hidden costs of pregnancy, a fear and unfamiliarity of professionals and service and additional support for those with complex needs.
Professionals reported that the cost of travel was one barrier, while the uncertainty of the travel network and system was another barrier, that prevented women from engaging with services. The hidden costs included the costs for suitable housing, prescription costs (for example, heartburn medication) and preparing for the babies’ arrival.
Professionals reported women engaging better with VCSE practitioners and organisations because they were not in uniform. Some professionals such as health visitors reported additional barriers to engagement due to a lack of understanding of their role. Finally, those with complex needs, such as mental health, drug and alcohol, homelessness and domestic violence, require additional support and guidance to fully engage with services, which often these women did not receive. Other professionals reported that these women needed separate care pathways that allowed for additional support but these were not in place currently.
Why is this important?
The findings from this study present professionals’ perspectives of the different challenges pregnant women living on low income face when accessing maternity care.
It highlights that barriers do not operate in isolation but intersect across the levels. Professionals reported that for women living on low income, individual barriers like unfamiliarity with travel structures and a fear of professional services were intensified by interaction challenges like lack of partner involvement or experiencing discrimination, while also being shaped by structural barriers including digital exclusion and language difficulties with a lack of interpreter services.
This study allows us to develop actionable recommendations that are implementable across the system to help reduce barriers, making accessing healthcare more equitable.
How were people/community groups/patients involved in this work?
This study involved academics, VCSE organisations, public members, community experts and key stakeholders. It included nine public members, providing input into the funding application, assisting in the developing of study materials, recruitment methods and provided input into the language used in study documents.
Recommendations for policy/practice
We have co-developed the following recommendations:
- Provide recycled smart phones and pre-paid SIM cards for those who need assistance to access digital technologies
- Professional interpreters should be used in all appointments where English is not the first language of the pregnant women
- Offer free travel on public transport (using pre-paid travel vouchers) on the day of maternity appointments
- Provide appointments outside of normal clinic hours to support engagement from partners
- Strengthen inequality training for health care providers.
The findings from this study are being used to develop a toolkit of recommendations for policy makers and professionals.
What happens next?
The next steps for this work are:
- Explore pregnant women’s experiences of accessing maternity care, when living on low income
- Explore the financial and time cost of accessing hospital based antenatal care for women living on low income
- Develop a toolkit of actionable and implementable recommendations
- Share findings widely though meetings with local and national stakeholders
Read the full research paper
Find out more
Contact Dr Kerry Brennan-Tovey – [email protected]
Acknowledgements
This study was funded by the NIHR School for Public Health Research. It was supported by the NIHR ARC North East and North Cumbria, including through funded researcher time. It was also supported by the NIHR ARC West Midlands. Other partners in the study were: NIHR SPHR schools – University of Bristol, PHRESH, LiLaC. Children North East, OHID and Newcastle upon Tyne Hospitals NHS Foundation Trust.