New SPHR research explores the barriers pregnant women living on low-income face while accessing maternity care, through the lens of healthcare professionals. Published in BMC Pregnancy and Childbirth, Professionals highlighted a range of challenges such as language and communication, a lack of social support networks and the cost and time of travel. Researchers identify key recommendations to improve access to maternity services.
In England, women living on low income have an increased risk of pregnancy complications such as stillbirth, neonatal death or preterm birth. Women with poor access to financial, educational, and social and health resources engage less with health and care services throughout their pregnancy. This is due to a range of reasons such as social stressors, low health literacy, digital exclusion, lack of support, language barriers, transport difficulties, and stigma and judgement from healthcare professionals. Whilst we know about the experiences of these women, little is known about how healthcare professionals understand and respond to these barriers.
As part of the SPHR project Supporting Engagement with and Access to Maternity Services led by Fuse, researchers explored professionals’ perceptions of the barriers pregnant women living on low-income face when accessing maternity care. Interviews were conducted with 17 participants, including professionals from maternity services, local authorities and the voluntary sector. Recruitment of professionals was in the North East of England via a local NHS Foundation Trust, local authorities and VCSE organisations that the researcher team had links with.
The crucial finding from this work is that the overall picture is more complex than it may first seem, barriers operate at multiple and interconnected levels, for example, structural, interactional and individual.
Professionals spoke about how digital exclusion, language difficulties and NHS staffing pressures can make it harder for women to even receive appointment information. At the same time, limited social support, experiences of discrimination and difficulties involving partners can reduce engagement with services. Alongside this, the cost of travel, hidden pregnancy-related expenses, housing instability and fear of being judged all make attending appointments more challenging.
These barriers do not exist in isolation. For many women, they intersect and reinforce one another. A woman who cannot afford to travel to appointments may also have no access to childcare and feel anxious about being judged. To add to this, English might not be their first language, and they might have limited access to digital technologies such as smartphones, SIM cards with sufficient data and the app BadgerNet (an app that enables pregnant people to view their records, appointment details and other information). Professionals recognised that this combination of barriers can make accessing ‘free’ NHS maternity care far from straightforward.
Researchers highlight that improving maternity care access is not just about encouraging women to attend appointments, it requires system-level changes that acknowledge poverty as a structural issue.
Key recommendations
Researchers call for policymakers, commissioners, NHS leaders and service providers to recognise that maternity care may be free at point of delivery, but it is not free to access. Practical, achievable changes could make a significant difference. These include:
- Providing recycled smart phones and prepaid SIM cards to reduce digital exclusion
- Improve the quality and consistency of interpretation services
- Introducing prepaid or free travel vouchers for maternity appointments
- Offering greater flexibility in appointment times to support partner involvement
- Strengthen inclusive training (i.e., cultural competency)
These recommendations will be developed and expanded into a practical toolkit and shared with policymakers, commissioners and practitioners across the system. More broadly, it is vital that services routinely take a poverty-informed approach to designing maternity services so that systems do not unintentionally exclude the women who need the services most.
Principal Investigator on the study, Prof Judith Rankin said:
“Our study highlights the intersecting barriers to accessing maternity services for those living on low income from the perspective of a range of professionals involved in maternity care. These factors need to be considered in designing maternity services so that inequalities aren’t worsened.”
First author on the study Dr Kerry Brennan-Tovey said:
“This is an important and timely study exploring the barriers that pregnant women living on low-income face and experience when attempting to access maternity services. The study provides insights into these barriers and allows us to develop actionable recommendations to reduce barriers to accessing care for all women.”
Co-Principal Investigator on the study Dr Ryc Aquino commented:
“Our study shows the cumulative impacts of the barriers faced by women living on low incomes when accessing maternity care. The perspective of professionals is needed to address these barriers and is timely, particularly given the growing evidence on the impact of the cost-of-living crisis on pregnant women and new mothers.”
While previous research has documented women’s experiences of disadvantage, this study is the first qualitative study in England to explore these barriers from the perspective of professionals working across the NHS, Local Authorities and Voluntary, Community and Social Enterprise (VCSE) organisations and people working most closely with women.
This is important because professionals are the people delivering and navigating the health and care system every day. Their insights reveal how current service design creates barriers to engagement, for example, through digital systems, inflexible appointment times, or the use of complex medical language.
The research was shaped by working with the charity Children North East, who developed the Poverty Proofing© approach, and co-developed with public members with recent lived experience of pregnancy while living on low income. This strengthened both the analysis and the policy recommendations.
Looking ahead
Next steps for this work include:
- Exploring women’s perspectives and experiences of barriers to accessing maternity care
- Exploring the costs associated with accessing maternity care
- Developing a toolkit of actionable recommendations to share with policymakers, commissioners and practitioners across the system
- Sharing our findings in the form of online presentations at local and national meetings
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“This is an important and timely study exploring the barriers that pregnant women living on low-income face and experience when attempting to access maternity services. The study provides insights into these barriers and allows us to develop actionable recommendations to reduce barriers to accessing care for all women.” Dr Kerry Brennan-Tovey
