A Constructivist Grounded Theory examining how trauma and the social determinants of health impacted perinatal women during the COVID-19 pandemic, and the role of caseloading midwives in tackling widening health inequalities in England.

Background England is an unfair nation, with deep-rooted inequalities that have shown no signs of improvement since the COVID-19 pandemic. Research indicates that the Social Determinants of Health (SDoH) - the root causes of health and wellbeing - negatively impact perinatal health inequalities. The evidence on the SDoH is poorly implemented in maternity care policy and interventions designed to address inequalities. Midwifery Continuity of Care (MCoC) models targeted at improving perinatal mortality and morbidity for women and babies facing multiple disadvantage, including socioeconomic inequalities, have a significant role to play in improving birth outcomes, experiences, and equity within the wider public health agenda. This doctoral study explored the social complexities women faced and their experiences of these during the COVID-19 pandemic. In addition, the research explored the experiences of NHS midwives working in a MCoC model in a city in the south of England, to better understand how midwives tackled widening inequalities within the context of the COVID-19 pandemic. Examining these domains provided evidence on the social complexities women experienced during this global health crisis, mechanisms that underpin the known benefits of MCoC, and the evolving public health role of MCoC midwives in England. Methods A qualitative, Constructivist Grounded Theory (ConGT) was conducted during the COVID-19 pandemic. Semi-structured interviews with twenty-three perinatal women and thirteen MCoC midwives were conducted remotely, either by telephone or via Microsoft™ Teams or Zoom™. Data were analysed using ConGT techniques of initial, focused, and advanced coding, along with constant comparison and theoretical sampling. Findings This research identified two core categories. The first - ‘sucking it up and getting on with it’ revealed the pervasiveness of trauma and the survival-based behaviours women had developed in response to their previous experiences. Most perinatal women were survivors of Adverse Childhood Experiences and/or traumatic experiences in later life. These experiences were cumulative and were compounded by intersectional, structural inequalities, including the SDoH. This first category, supported by multiple subcategories, highlighted the pervasiveness of trauma on women’s health and well-being during the perinatal period. These experiences significantly influenced women’s survival strategies and maternity care journeys. The second core category - ‘we’re only really scratching the surface of the complexities women face’, explained the challenges MCoC midwives faced when tackling widening inequalities. With a lack of prioritisation and investment in their professional development, plus limited community resources, MCoC midwives frequently ‘stepped up’ in place of other organisations and professionals in order to meet women’s needs. Midwives demonstrated remarkable resilience and agility, fostering strong, relationally attuned, and empathic relationships with women. Working in the MCoC model promoted the chance of midwives to establish a relationally attuned relationship with women, which enhanced midwives’ professional curiosity and the quality-of-care women received - allowing for better identification of the psychosocial issues women faced. To maintain integrity in the healthcare system, midwives attempted to influence the SDoH impacting women’s lives such as housing and income inequalities, contraception, and perinatal mental health. Targeted efforts to address perinatal inequalities in the research setting were threatened by factors including inadequate data collection, and a lack of midwifery presence at strategic levels to influence local public health interventions. Conclusion This study highlights a critical gap in trauma-informed care within NHS maternity services. Moreover, despite compelling evidence on the impact of the SDoH on population health, these factors remain insufficiently addressed in maternity policy, education, and practice. This study offers several recommendations to improve maternity care and inform policy reform. Crucially, in order for maternity services to effectively support women with complex social factors and to keep pace with the changing needs and demands of society, the professional development of midwives must be prioritised. Training about the impact of trauma and the SDoH on the life chances of women and their babies must be prioritised. In parallel, policymakers must foster stronger collaboration between midwifery, integrated care systems, Local Authorities and wider partners to enhance service delivery and drive meaningful improvements in population health.