COVID Maternity Equalities Project

Purpose and Background of the Project:

Prior to the COVID-19 pandemic, there were already deep inequalities in maternity care and outcomes in England. Black women were already five times more likely to die during pregnancy, birth and the postpartum period, and Asian women three times more likely, than white women. During the pandemic there have been substantial shifts in the way that maternity care is delivered in Britain. However, the effects of these changes on maternity outcomes have not been measured, and it is also unclear whether these changes have widened or narrowed existing inequality gaps. There is an opportunity to learn lessons about how services may mitigate existing inequalities through service innovation.

The purpose of this project is to identify the impact of COVID-19 and associated modifications to maternity care (such as the use of remote consultations, changes to process of diagnosis of gestational diabetes, and reduction in appointments) on inequalities in maternity care (in stillbirth, preterm birth, mode of birth such as caesarean section, and postpartum complications), and learn lessons to inform recommendations regarding ongoing modifications and changes to maternity care in the future.

Rationale for the project:

This is a new project first funded by the Health Foundation in 2021 which proposes to use data from NHS England and subsequent qualitative analysis to understand the impact of the COVID-19 pandemic on inequalities in maternity care.

During the COVID-19 pandemic maternity units have had to modify care provision rapidly and have faced staffing challenges. There are concerns that the service modifications have introduced new forms of inequalities, such as digital (where access to care via digital means disadvantages to those without devices or internet access). Initial results from the pandemic are heterogeneous: a possible increase in the rate of stillbirth in a single London unit (Khalil et al. JAMA 2020) not mirrored in national figures for the ‘first wave’ of the COVID-19 pandemic in the UK (ONS 2021); an observed reduction in extreme prematurity in Denmark (Hedermann et al. Archives of Disease in Childhood Fetal and Neonatal 2020). Women of ethnic minority groups have been disproportionally affected by COVID-19 infection (Knight M et al, BMJ 2020), but it is unclear whether ethnicity directly, or marginalisation and disadvantage or inequality in accessing care has contributed to this disparity.

This project speaks explicitly to recommendation 7 of Public Health England (PHE) report "Beyond the data: Understanding the impact of COVID-19 on BAME groups" (PHE 2020) in that it seeks to ‘Ensure that COVID-19 recovery strategies actively reduce inequalities caused by the wider determinants of health to create long term sustainable change.’

Restoration of services is currently heterogeneous and there is an urgent need for information to guide prioritisation of services both in this restoration phase and in any future peak. This is to ensure that modifications to services are justified, do not worsen maternal or fetal outcomes, and look to narrow existing inequalities.

The study team are aware of the sensitivity of investigating maternity outcomes by ethnic group. The study team do not intend to produce results published by trust name and do not intend to negatively identify maternity units or produce any sort of ranking. The study team have been careful to include a wide range of stakeholders and experts in the Steering Group, together with a Women's Reference Group which represents the diverse population accessing maternity care. The investigator group includes two lay coinvestigators from RCOG's Women's Network and the Caribbean and African Health Network who are able to directly represent women from diverse backgrounds. Statisticians from Bristol University are advisory to the data processing methodology. Neither the lay coinvestigators nor individuals from Bristol University will be determining the purposes or the means of data processing. Outputs, using aggregated data with small numbers suppressed, will be co-produced as a team in order to respect the sensitivity of this topic.

Project plan:

This project aims to answer three questions using routinely collected maternity data:

i) How have the COVID-19 driven modifications to maternity services impacted on maternity outcomes overall, and on the inequality gap in these outcomes?

ii) To what extent has ethnicity contributed to the inequality gap in maternity outcomes before and during the pandemic?

iii) Which units have narrower inequality gaps in maternity outcomes during the pandemic?

How data provided by NHS England will be used in the study:

This study will use Hospital Episode Statistics (HES) Admitted Patient Care (APC) data on mother and child provided by NHS England to describe national trends and unit-level differences in key maternity outcomes by ethnic and socioeconomic group. The team will then seek to identify maternity units where there is evidence of good practice (a narrowing in inequalities in maternity outcomes) during the pandemic and approach these units to obtain consent to investigate these further through service-level interviews (i.e. interviews with clinicians and women's representatives in order to identify service changes in these units during the pandemic). There has been no engagement with these units prior to this request, as data is required to identify participant units, but preliminary approaches to three units to assess feasibility suggested that being approached as a 'positive deviant' (i.e. a unit where changes in practice during the COVID-19 pandemic narrowed existing gaps in outcomes between women from different ethnic groups, or if these do not exist, a unit where the impact on existing inequalities was as small as possible) would be viewed favourably.

Through use of the HES data from NHS England and the subsequent service-level interviews, the project will provide recommendations regarding which service modifications (for example, types of telephone clinics; use of remote blood pressure monitoring) will provide a positive impact on equality in maternity care. These can then inform rapidly implemented change, improve the quality and safety of maternity care and ensure that all women, irrespective of their background or place of residence, have access to safe maternity care. Data from NHS England on maternity care and outcomes is not currently published by hospital by ethnic and socioeconomic group and thus pseudonymised data is required in order to generate these totals and enable further investigation. Requesting HES data minimises the data burden on NHS staff by ensuring we use routinely collected data.

PREVIOUS DATA REQUEST

Data was restricted to a cohort for births from 1st January 2018 to 31st March 2021 that is derived from hospital admissions records that contain valid information about either mode of birth or outcome of delivery. The study team estimate that this will be approximately 1.8 million women and their babies (approximately 1.8 million births). All historic admissions episodes from 2000-2017 should be provided for all individuals with a record in this cohort. By looking at women’s previous admissions in HES, it is possible to derive their previous medical and maternity history, as well as use ethnicity as recorded in a previous admission if it is missing from the birth record; these processes have been used by other researchers. Since this is a national project, data from all English NHS trusts is required.

Organisations involved:

The organisations involved in data processing for the study are the Royal College of Obstetricians and Gynaecologists (RCOG), supported by researchers from Queen Mary University of London (QMUL). The project was commissioned by the Health Foundation and The Healthcare Improvement Studies (THIS) Institute to understand the impact of COVID-19 on maternity outcomes and health inequalities. The RCOG is leading and hosting the project and is the sole data controller.

RCOG’s secure server is hosted by Microsoft Azure. Microsoft Limited will store the Data as contracted by RCOG.

The data will be kept and used by both employees of the RCOG and of Queen Mary (any individuals involved in the data processing who are not substantively employed by the RCOG or by QMUL have an RCOG honorary contract). QMUL is the primary employer of the principal investigator. This project has been co-developed with two lay co-investigators in order to ensure it encompasses the concerns of women and particularly women from ethnic minority groups.

RCOG’s legal bases for processing the requested data are GDPR Article 6(1)(f) - legitimate interests, and Article 9(2)(h)- health care. This project has completed a legitimate interests assessment, and the balancing test shows that the individual’s interests do not override the legitimate interests of RCOG in undertaking the project. Article 9(2)(h) applies because the processing will support the management of health care systems to provide equitable outcomes to women and babies from all ethnic backgrounds. This project supports the need for the healthcare system to reflect upon the impact of service changes made during the pandemic and assess the equity of their impact.

References:

Khalil A, von Dadelszen P, Draycott T et al. Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic. JAMA 2020;324(7):705-706. doi:10.1001/jama.2020.12746

ONS. Provisional births in England and Wales: 2020. 2021. Available from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/articles/provisionalbirthsinenglandandwales/2020andquarter1jantomar2021

Hedermann G, Hedley P, Baekvad-Hansen M et al. Danish premature births during the COVID-19 lockdown. Archives of Disease in Childhood - Fetal and Neonatal Edition 2021;106:93-95.

Knight M, Bunch K, Vousden N et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2107

Public Health England. Beyond the Data: Understanding the impact of COVID-19 on BAME communities. 2020. Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf

The Hospital Episode Statistics (HES) data provided by NHS England will enable the following outputs:

(1) Peer-reviewed publications (to be submitted to journals including the British Medical Journal, BJOG: An International Journal of Obstetrics and Gynaecology, PLoS Medicine, PLoS One) supplemented with online resources detailing

(a) national and regional changes to maternity outcomes by ethnic and socioeconomic group during the pandemic: target date late 2021/ early 2022 (aimed at academic and policy audience).

(b) associations between service changes and maternity outcomes by ethnic group: target date March 2022 (aimed at an academic and policy audience).

(2) A list of units to be approached for further qualitative analysis. Units which constitute ‘positive deviants’ (i.e. any units where changes in practice during the COVID-19 pandemic narrowed existing gaps in outcomes between women from different ethnic groups, or if these do not exist, units where the impact on existing inequalities was as small as possible) in their approach to ethnic and socioeconomic inequality during the pandemic will be chosen in consultation with a lay group. Ten such units are anticipated to be identified on the basis of maternity care and outcomes (eg differences in stillbirth, preterm birth, and caesarean section rates).

(3) A final report on service changes associated with adverse outcomes and ethnic inequality to inform policy and guideline changes. This will have a supplementary lay and policy briefing to enable change (aimed at the public and at policymakers).

All outputs will be coproduced with patients and the public (including academic outputs). The report and supplementary lay briefing will be freely available. We will make every effort within funding constraints to enable published papers to be open access.

All published outputs will be aggregated with small number suppression in line with the HES analysis guide.

Note on patient and public involvement (PPI): This project is supported by a Women's Reference Group. This group, which will have 5-6 meetings throughout the year, is made up of 25 women chosen from over 200 who applied, who together represent a diverse range of experience (diversity of ethnicity, socioeconomic group, birth experience, parity, geography) supported by the PPI team at the RCOG and a qualitative researcher. This group will provide direct input into the selection criteria for units identified for qualitative investigation and a framework of lived experience of the pandemic, as well as ensuring that what is important to women is highlighted in the recommendations made. The team also has two lay co-investigators who each lead representative networks of women, who have provided direct input into the conduct of the study, the desired outputs, and the design of the qualitative aspects of the study in which they have expertise.

A wide network of stakeholders has formally committed to the project including the Royal College of Midwives (RCM), NHS England, the Care Quality Commission (CQC), the Governments of the devolved nations of the UK, charities and National Maternity Voices. This network will facilitate bi-directional dissemination, mobilising outputs down to practitioners and end users and up to policy makers. Dissemination of the key findings via social media will enable us to reach women directly, drawing specifically on the RCOG’s Women’s Network and Voices panels.

UPDATE: At present, two scientific manuscripts related to the project are under review, and another manuscript will be submitted in the next few months. As we will need time to respond to queries from reviewers, we would like to retain the data received until 11/08/2025.

OUTPUTS 2024

Maternal and baby birth records were identified using a combination of ICD-10 and OPCS codes or HES fields. Records of women who gave birth and babies born in England between 1st January 2018 and 31st March 2021 were included in the study.

RCOG used maternal and neonatal composite indicators to rank NHS Trusts. Outcomes were chosen following a literature review of studies using routinely available hospital data. The final list of outcomes was reviewed and approved by the Women’s Reference Group. RCOG restricted the analysis to singleton births. RCOG calculated the incidence rate of the maternal and neonatal composite indicators, and individual adverse outcomes in the pre-pandemic and pandemic period at a national level. Results are being written up for submission to a peer reviewed journal.

RCOG used difference-in-differences (DiD) analysis to calculate the ‘inequality gap’ in each Trust. RCOG ranked Trusts by their DiD. Trusts that had a smaller ‘inequality gap’ difference from prepandemic to the pandemic and 95% CIs were statistically significant for both neonatal and maternal composite indicators or either one of them, were identified as positive deviants. RCOG also identified Trusts as comparators for interview. These had reduced inequalities but not significantly.

RCOG interviewed 20 staff from 6 out of the 9 positive deviant trusts identified in the analysis mentioned above, and 4 comparators. We analysed the data using reflective thematic analysis, before taking a top-down approach to the resulting codes to identify key facilitators to best practice. The interviews and analysis have been completed and are being written up for submission to a peer reviewed journal.

The initial analysis on the impact of the Covid-19 pandemic on ethnic inequalities in adverse maternity outcomes was presented at the British Maternal & Fetal Medicine Society (BMFMS) in 2022.

The academic outputs will inform evidence and policy specifically through the RCOG’s links to the Race Equality Taskforce and through that to the NHS Race Observatory. The RCOG hosts a dedicated webpage to the project which updates O&G clinicians and members of the public about the project. The link to this page can be found here. This page also includes a brief video from one of the members of the Women’s Reference Group, sharing her experience of giving birth during the pandemic.

The production of an animation is part of the dissemination activities. It generates an engaging short, animated clip (90 seconds) that can be accessed by a lay audience. A dissemination event was organised by the team bringing together Clinical staff, Academic staff, co applicants, steering group members, Race Equality taskforce members, Women’s reference group, Health Foundation and RCOG Staff. This created an opportunity for further engagement and networking. It also raised the awareness of the project findings.

The initial analysis on the impact of the Covid-19 pandemic on ethnic inequalities in adverse maternity outcomes was presented at the British Maternal & Fetal Medicine Society (BMFMS) in 2022. Currently two scientific papers are under review for publication.

The academic outputs will inform evidence and policy specifically through the RCOG’s links to the Race Equality Taskforce and through that to the NHS Race Observatory.

The RCOG hosts a dedicated webpage to the project which updates O&G clinicians and members of the public about the project. The link to this page can be found here. This page also includes a brief video from one of the members of the Women’s Reference Group, sharing her experience of giving birth during the pandemic.

The production of an animation is part of the dissemination activities. It generates an engaging short animated clip (90 seconds) that can be accessed by a lay audience.

A dissemination event was organised by the team bringing together Clinical staff, Academic staff, co applicants, steering group members, Race Equality taskforce members, Women’s reference group, Health Foundation and RCOG Staff. This created an opportunity for further engagement and networking. It also raised the awareness of the project findings.

Purpose and Background of the Project:

Prior to the COVID-19 pandemic, there were already deep inequalities in maternity care and outcomes in England. Black women were already five times more likely to die during pregnancy, birth and the postpartum period, and Asian women three times more likely, than white women. During the pandemic there have been substantial shifts in the way that maternity care is delivered in Britain. However, the effects of these changes on maternity outcomes have not been measured, and it is also unclear whether these changes have widened or narrowed existing inequality gaps. There is an opportunity to learn lessons about how services may mitigate existing inequalities through service innovation.

The purpose of this project is to identify the impact of COVID-19 and associated modifications to maternity care (such as the use of remote consultations, changes to process of diagnosis of gestational diabetes, and reduction in appointments) on inequalities in maternity care (in stillbirth, preterm birth, mode of birth such as caesarean section, and postpartum complications), and learn lessons to inform recommendations regarding ongoing modifications and changes to maternity care in the future.

Rationale for the project:

This is a new project first funded by the Health Foundation in 2021 which proposes to use data from NHS Digital and subsequent qualitative analysis to understand the impact of the COVID-19 pandemic on inequalities in maternity care.

During the COVID-19 pandemic maternity units have had to modify care provision rapidly and have faced staffing challenges. There are concerns that the service modifications have introduced new forms of inequalities, such as digital (where access to care via digital means disadvantages to those without devices or internet access). Initial results from the pandemic are heterogeneous: a possible increase in the rate of stillbirth in a single London unit (Khalil et al. JAMA 2020) not mirrored in national figures for the ‘first wave’ of the COVID-19 pandemic in the UK (ONS 2021); an observed reduction in extreme prematurity in Denmark (Hedermann et al. Archives of Disease in Childhood Fetal and Neonatal 2020). Women of ethnic minority groups have been disproportionally affected by COVID-19 infection (Knight M et al, BMJ 2020), but it is unclear whether ethnicity directly, or marginalisation and disadvantage or inequality in accessing care has contributed to this disparity.

This project speaks explicitly to recommendation 7 of Public Health England (PHE) report "Beyond the data: Understanding the impact of COVID-19 on BAME groups" (PHE 2020) in that it seeks to ‘Ensure that COVID-19 recovery strategies actively reduce inequalities caused by the wider determinants of health to create long term sustainable change.’

Restoration of services is currently heterogeneous and there is an urgent need for information to guide prioritisation of services both in this restoration phase and in any future peak. This is to ensure that modifications to services are justified, do not worsen maternal or fetal outcomes, and look to narrow existing inequalities.

The study team are aware of the sensitivity of investigating maternity outcomes by ethnic group. The study team do not intend to produce results published by trust name and do not intend to negatively identify maternity units or produce any sort of ranking. The study team have been careful to include a wide range of stakeholders and experts in the Steering Group, together with a Women's Reference Group which represents the diverse population accessing maternity care. The investigator group includes two lay coinvestigators from RCOG's Women's Network and the Caribbean and African Health Network who are able to directly represent women from diverse backgrounds. Statisticians from Bristol University are advisory to the data processing methodology. Neither the lay coinvestigators nor individuals from Bristol University will be determining the purposes or the means of data processing. Outputs, using aggregated data with small numbers suppressed, will be co-produced as a team in order to respect the sensitivity of this topic.

Project plan:

This project aims to answer three questions using routinely collected maternity data:

i) How have the COVID-19 driven modifications to maternity services impacted on maternity outcomes overall, and on the inequality gap in these outcomes?

ii) To what extent has ethnicity contributed to the inequality gap in maternity outcomes before and during the pandemic?

iii) Which units have narrower inequality gaps in maternity outcomes during the pandemic?

How data provided by NHS Digital will be used in the study:

This study will use Hospital Episode Statistics (HES) Admitted Patient Care (APC) data on mother and child provided by NHS Digital to describe national trends and unit-level differences in key maternity outcomes by ethnic and socioeconomic group. The team will then seek to identify maternity units where there is evidence of good practice (a narrowing in inequalities in maternity outcomes) during the pandemic and approach these units to obtain consent to investigate these further through service-level interviews (i.e. interviews with clinicians and women's representatives in order to identify service changes in these units during the pandemic). There has been no engagement with these units prior to this request, as data is required to identify participant units, but preliminary approaches to three units to assess feasibility suggested that being approached as a 'positive deviant' (i.e. a unit where changes in practice during the COVID-19 pandemic narrowed existing gaps in outcomes between women from different ethnic groups, or if these do not exist, a unit where the impact on existing inequalities was as small as possible) would be viewed favourably.

Through use of the HES data from NHS Digital and the subsequent service-level interviews, the project will provide recommendations regarding which service modifications (for example, types of telephone clinics; use of remote blood pressure monitoring) will provide a positive impact on equality in maternity care. These can then inform rapidly implemented change, improve the quality and safety of maternity care and ensure that all women, irrespective of their background or place of residence, have access to safe maternity care. Data from NHS Digital on maternity care and outcomes is not currently published by hospital by ethnic and socioeconomic group and thus pseudonymised data is required in order to generate these totals and enable further investigation. Requesting HES data minimises the data burden on NHS staff by ensuring we use routinely collected data.

Data will be restricted to a cohort for births from 1st January 2018 to 31st March 2021 that is derived from hospital admissions records that contain valid information about either mode of birth or outcome of delivery. The study team estimate that this will be approximately 1.8 million women and their babies (approximately 1.8 million births). All historic admissions episodes from 2000-2017 should be provided for all individuals with a record in this cohort. By looking at women’s previous admissions in HES, it is possible to derive their previous medical and maternity history, as well as use ethnicity as recorded in a previous admission if it is missing from the birth record; these processes have been used by other researchers. Since this is a national project, data from all English NHS trusts is required.

Organisations involved:

The organisations involved in data processing for the study are the Royal College of Obstetricians and Gynaecologists (RCOG), supported by researchers from Queen Mary University of London (QMUL). The project was commissioned by the Health Foundation and The Healthcare Improvement Studies (THIS) Institute to understand the impact of COVID-19 on maternity outcomes and health inequalities. The RCOG is leading and hosting the project and is the sole data controller.

The RCOG has a secure data access environment (hosted by RedCentric PLC) which is where the data will be kept and used by both employees of the RCOG and of Queen Mary (any individuals involved in the data processing who are not substantively employed by the RCOG or by QMUL have an RCOG honorary contract). QMUL is the primary employer of the principal investigator. This project has been co-developed with two lay co-investigators in order to ensure it encompasses the concerns of women and particularly women from ethnic minority groups.

RCOG’s legal bases for processing the requested data are GDPR Article 6(1)(f) - legitimate interests, and Article 9(2)(h)- health care. This project has completed a legitimate interests assessment, and the balancing test shows that the individual’s interests do not override the legitimate interests of RCOG in undertaking the project. Article 9(2)(h) applies because the processing will support the management of health care systems to provide equitable outcomes to women and babies from all ethnic backgrounds. This project supports the need for the healthcare system to reflect upon the impact of service changes made during the pandemic and assess the equity of their impact.

References:

Khalil A, von Dadelszen P, Draycott T et al. Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic. JAMA 2020;324(7):705-706. doi:10.1001/jama.2020.12746

ONS. Provisional births in England and Wales: 2020. 2021. Available from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/articles/provisionalbirthsinenglandandwales/2020andquarter1jantomar2021

Hedermann G, Hedley P, Baekvad-Hansen M et al. Danish premature births during the COVID-19 lockdown. Archives of Disease in Childhood - Fetal and Neonatal Edition 2021;106:93-95.

Knight M, Bunch K, Vousden N et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2107

Public Health England. Beyond the Data: Understanding the impact of COVID-19 on BAME communities. 2020. Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf

The Hospital Episode Statistics (HES) data provided by NHS Digital will enable the following outputs:

(1) Peer-reviewed publications (to be submitted to journals including the British Medical Journal, BJOG: An International Journal of Obstetrics and Gynaecology, PLoS Medicine, PLoS One) supplemented with online resources detailing

(a) national and regional changes to maternity outcomes by ethnic and socioeconomic group during the pandemic: target date late 2021/ early 2022 (aimed at academic and policy audience).

(b) associations between service changes and maternity outcomes by ethnic group: target date March 2022 (aimed at an academic and policy audience).

(2) A list of units to be approached for further qualitative analysis. Units which constitute ‘positive deviants’ (i.e. any units where changes in practice during the COVID-19 pandemic narrowed existing gaps in outcomes between women from different ethnic groups, or if these do not exist, units where the impact on existing inequalities was as small as possible) in their approach to ethnic and socioeconomic inequality during the pandemic will be chosen in consultation with a lay group. Ten such units are anticipated to be identified on the basis of maternity care and outcomes (eg differences in stillbirth, preterm birth, and caesarean section rates).

(3) A final report on service changes associated with adverse outcomes and ethnic inequality to inform policy and guideline changes. This will have a supplementary lay and policy briefing to enable change (aimed at the public and at policymakers).

All outputs will be coproduced with patients and the public (including academic outputs). The report and supplementary lay briefing will be freely available. We will make every effort within funding constraints to enable published papers to be open access.

All published outputs will be aggregated with small number suppression in line with the HES analysis guide.

Note on patient and public involvement (PPI): This project is supported by a Women's Reference Group. This group, which will have 5-6 meetings throughout the year, is made up of 25 women chosen from over 200 who applied, who together represent a diverse range of experience (diversity of ethnicity, socioeconomic group, birth experience, parity, geography) supported by the PPI team at the RCOG and a qualitative researcher. This group will provide direct input into the selection criteria for units identified for qualitative investigation and a framework of lived experience of the pandemic, as well as ensuring that what is important to women is highlighted in the recommendations made. The team also has two lay co-investigators who each lead representative networks of women, who have provided direct input into the conduct of the study, the desired outputs, and the design of the qualitative aspects of the study in which they have expertise.

A wide network of stakeholders has formally committed to the project including the Royal College of Midwives (RCM), NHS England, the Care Quality Commission (CQC), the Governments of the devolved nations of the UK, charities and National Maternity Voices. This network will facilitate bi-directional dissemination, mobilising outputs down to practitioners and end users and up to policy makers. Dissemination of the key findings via social media will enable us to reach women directly, drawing specifically on the RCOG’s Women’s Network and Voices panels.

Yielded Benefits is not a requirement for new applications.