NAME: Akindele Omolara Abiola

STUDENT ID: 209327061

PROGRAM: MSc. Public Health

MODULE CODE: HSSM66

MODULE TITLE: Health Research Methods and Critical Appraisal

MODULE LEADER: Dr Floor Christie

MODULE DELIVERER: Dr Louise Harvey-Golding

ASSESSMENT TITLE: Essay-Research Proposal

RESEARCH TITLE: “Exploring experiences of Black women in Sunderland, UK while

utilizing maternity services during the COVID-19 pandemic”

1
 TABLE OF CONTENT
1. Introduction --------------------------------------------------------------------------------------- 3-4

2. Research Question ------------------------------------------------------------------------------- 5

3. Aim -------------------------------------------------------------------------------------------------5

4. Objectives ----------------------------------------------------------------------------------------- 5

5. Literature review --------------------------------------------------------------------------------- 6-9

6. Methodology ------------------------------------------------------------------------------------- 10-15

7. Budget -------------------------------------------------------------------------------------------- 16

8. Timeline ------------------------------------------------------------------------------------------ 17

9. References ---------------------------------------------------------------------------------------- 18-25

2
 BACKGROUND

Corona Virus Disease (COVID-19) is a potentially critical respiratory disease induced

by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pathogen (Shereen

et al., 2020). It emerged in December 2019 in the Wuhan province of China and proceeded to

swiftly spread across the globe till the World Health Organization (WHO) announced it as a

Public Health Emergency of International Concern (PHEIC) on the 30th of January 2020, and

eventually declared it a pandemic on the 11th of March 2020 (Zhu, Wei & Niu, 2020;

Cucinotta & Vanelli, 2020).

In the wake of the COVID-19 pandemic, healthcare systems globally were immensely

strained (Muralidar et al., 2020; Lal et al., 2021). They were faced with the burden of

managing the widespread infection of vulnerable populations such older populations, people

with underlying illnesses and immunosuppressed people (e.g., pregnant women); and also

dealing with the unforeseen interruption of the fluid delivery of essential healthcare services

(Clark et al., 2020; Roy et al., 2021).

In the UK, people of black and minority ethnicities have been found to be at a greater risk of

infection by COVID-19, constitute a higher percentage of COVID-19 hospital admissions

and to have a higher chance of dying from COVID-19 (Public Health England, 2020; Bambra

et al., 2020; Aldridge et al., 2020). According to the Office for National Statistics (ONS),

mortality rates related to COVID-19 in the UK were highest among people of Black African,

Black Caribbean ethnicities (4.2 times) during the first and second waves of the pandemic

when compared to white ethnic groups (Larsen, Bosworth & Nafilyan, 2021). Public Health

England also goes further to report that as at August 2020, people of black and minority

ethnicities were identified to constitute a perturbingly high percentage of confirmed cases

3
(486 females & 649 males) and critical cases requiring hospitalization (36%) per 100,000

population (Public Health England, 2020).

Several factors are assumed to be at play here, such as the effect of pre-existing inequalities

within the healthcare system, occupational risk, incidence of co-morbidities that increase

vulnerability to COVID-19, social and economic inequalities (Public Health England, 2020).

Seeing as they have also always been disadvantaged in the access to healthcare services in the

UK (Szczepura, 2005), this places them in a precarious position.

Pregnant women of Black and minority ethnicities (BAME) in the UK are especially at risk,

as in the past, due to significant inequalities in the maternal healthcare sector, risk of

mortality during pregnancy was found to be 5 times higher than in other ethnicities (Knight

et al., 2019). More recently, Oxford University in collaboration with the UK Obstetric

Surveillance System for SARS-CoV-2 Infection in Pregnancy Collaborative Group deduced

that of the pregnant women that were admitted into study hospitals due to infection with

COVID-19, 55% of them were of Black and Asian minority ethnicities (Knight et al., 2020)

thereby proving the notion that BAME pregnant women are at a higher risk of COVID-19

infection than other ethnicities.

Due to the COVID-19 pandemic, healthcare systems have had to adapt to new methods of

service delivery. Routine healthcare services such as maternity services have been altered to

follow existing guidelines while facing pressure due to staff shortages, decreased patient

visits, increased infection prevention measures and mandatory lockdown regulations (Kotlar

et al., 2021). The perspectives of patients i.e., pregnant women however, have not yet been

collected in specific areas of the UK (e.g., the Northeast) and as such, it is unclear how these

changes have affected the experiences of Black pregnant women while utilizing maternity

services in these areas. Knowledge on how these changes impacted existing inequalities

4
relating to access and quality of maternity services especially in the North Eastern part of the

UK are also lacking.

Based on the existing gap in knowledge, underpinned by the Grounded Theory (Glasser &

Strauss, 1967; Levers, 2013) and an Interpretivist epistemological approach (Hiller, 2016;

Vasilachis de Gialdino, 2009), this Study aims to fill these gaps in knowledge and ultimately

provide an evidence base for the development of policies that would improve the access to

maternity services by BAME pregnant women.

5
 RESEARCH QUESTION

What are the experiences of Black women in Sunderland, UK while utilizing maternity

services during the COVID-19 pandemic?

AIM

To explore the experiences of Black women in Sunderland, UK while utilizing maternity

services during the COVID-19 pandemic.

OBJECTIVES

1. Identifying changes to maternity service provision during the COVID-19 pandemic

2. Assessing the effects of changes to maternity services on black women in Sunderland,

UK

3. Identifying barriers to maternity healthcare utilization during the COVID-19

pandemic

4. Exploring the experiences of black pregnant women while utilizing maternity services

during the COVID-19 pandemic

5. Devising recommendations based on the experiences of Black pregnant women while

utilizing maternity services during the pandemic.

6
 LITERATURE REVIEW

The COVID-19 pandemic has exposed prevalent inequalities globally especially in the

healthcare sector (Blundell et al., 2020). As the pandemic continues, many researchers have

attempted to assess its impact on healthcare systems.

A systematic review developed by Moynihan et al. (2021), aimed to reveal the nature of

variations in the utilization of healthcare services globally during the COVID-19 pandemic

by comparing data from studies that assessed the utilization of healthcare services such as

healthcare visits, admissions, diagnostic services and therapeutic or preventive interventions

over a period during the COVID-19 pandemic and studies that assessed same but before the

pandemic. The review found that during the pandemic, healthcare consumption reduced by

about one-third, with reductions being greater among persons with less severe diseases.

In the UK specifically, a study carried out by Flynn et al. (2020), analysed epidemiological

and economic secondary data over the span of about 8 months in order to depict the spread of

COVID-19 in the UK and its impact on the economic, business and healthcare systems of the

UK. Results from this study that are pertinent to this literature review include the conclusion

that there was a gross decline in the availability of beds in maternity centres, acute hospitals,

and mental health clinics, a significant increase in number of patients treated by the NHS, a

reduction in daily patient attendance observed in emergency departments, reduction in

hospital admissions, erratic changes in the number of emergency calls received by ambulance

services, reduction in primary care utilization, changes in mode of appointment delivery from

face-to-face to telephone, online or video appointments, and a great impact on overall

treatment waiting times as the numbers shifted from a marginal rise in median waiting times

to a sharp reduction in wait times. These results highlighted the significant resource pressures

7
faced by the healthcare system as well as posed the hypothesis that patients avoided certain

healthcare services due to fears of COVID-19.

Chmielewska et al. (2021), carried out a systematic review and meta-analysis that set out to

assess the impact of the COVID-19 pandemic on maternal and perinatal outcomes. Results

obtained indicated a substantial increase in still births and maternal mortality during the

Covid pandemic in comparison to figures before the pandemic, an indifference in preterm

birth rates, poorer maternal mental health, increase in surgically managed ectopic

pregnancies, and no significant changes observed in other maternal outcomes such as

gestational diabetes, hypertensive disorders, preterm births, labour induction, neonatal death,

low birthweight, etc. with significant differences observed between developed and

undeveloped settings. The researchers opined that the increase in adverse pregnancy

outcomes reduced access to care, reported reduced attendance of healthcare providers to

routine & unscheduled pregnancy care, reduced staffing available for maternity care,

concerns of infection with COVID-19 from hospitals, government policy restricting citizens

to their homes, or unavailability of public transport and day care services during the first and

second lockdowns.

Brislane, Larkin, Jones and Davenport (2020) carried out a quantitative study where they

recruited pregnant women and women who had delivered 6 months prior in order to gain

insight into the quality of healthcare made available to pregnant and postpartum women

during the COVID-19 pandemic. Using an online survey, they collected data from these

women through questions regarding access to obstetric care, modifications to routine

obstetric appointments, their preferences in appointment systems and the overall quality of

prenatal care. The researchers resolved that study participants indeed faced obstructions to

obstetric healthcare; appointment cancellations, suspension of obstetric services as well as the

exclusion of birth partners at delivery had a negative impact on the quality of obstetric

8
services; and recommended that during times such as the COVID-19 pandemic, telemedicine

should be integrated as much as possible and that pregnant and postpartum women should be

duly informed on modifications to services before implementation.

More similarly, Karavadra et al., (2020) championed a nationwide qualitative survey during

May 2020 to explore the perceptions of women who were pregnant or gave birth during the

COVID-19 pandemic on their perceptions of the disease and their healthcare experiences

during the pandemic. After extensive public and patient consultations, a questionnaire was

developed, disseminated via online media and analysed by qualitative thematic analysis.

Antenatal concerns expressed by participants included: The Booking of appointments,

Infection control, partner attendance, virtual antenatal clinics, changing of services,

ultrasound scan concerns and perinatal mental health support. Intrapartum concerns included:

Concerns of ‘catching the virus’, birthing options, birthing pool availability, birthing partner

presence, availability of personal protective equipment and Communication concerns.

Postnatal care concerns included: Breastfeeding support, minimized visits from community

midwives/health visitors, postnatal depression, absence of aid from family and friends due to

movement restrictions and inaccess to certain healthcare professionals. The researchers

thereby concluded that the pandemic indeed had a significant impact on healthcare and

maternity service delivery in the UK and that while the changes are temporary, patients and

their relations should be more involved in the design and implementation of any changes in

service delivery in the future. Although the study appears to be the most similar to the

research at hand, its limitations include the fact that: only 6% of its participants were of

BAME backgrounds and so, it might not stand to give a thorough overview of BAME

women’s views and perceptions; and Only 2.91% of its participants were from the North

East; therefore, there is room to carry out further research in order get deeper insight into the

9
perceptions of pregnant women from the North East. The study at hand aims to fill these gaps

in knowledge.

Currently, the UK has certain policies in place to protect pregnant women of Black and

Minority Ethnicities such as the NHS Long Term Plan which cites efforts to improve

maternity services and reduce health inequalities for pregnant women of Black and minority

ethnicities by 2024, seeing as the rates of maternal/Neonatal mortality and morbidity are

considerably higher in BAME women compared to pregnant women of white ethnicities

(Alderwick & Dixon, 2019).

This study also aims to provide relevant information that will give insight into the

effectiveness of existing policies/guidance that protect pregnant women of Black and

Minority Ethnicities and possibly influence future policies that would make the utilization of

necessary maternity services easier for women in the future.

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 METHODS

 Study Design

This study, being of a Qualitative nature, will adopt the Phenomenology study

design as it aims to describe the experiences of Black women while utilizing

maternity services during the COVID-19 pandemic (Ploeg, 1999). The aim of the

phenomenological approach is to shed light on the topic of focus by identifying trends

in the individual perceptions of the subjects (Groenewald, 2004); It is closely

associated with the interpretivism epistemological approach which is rooted in a

viewpoint of subjectivist ontology and ultimately promotes the importance of

individual perspectives and interpretations (Lester, 1999).

 Study Area

The Area in which this study will be focused is the city of Sunderland which is

located in the North eastern part of the United Kingdom. According to the World

Population Review (2021), 93.6% of the population are White, 3.4% Asian/Asian

British, and 0.7% are Black; although, some wards have higher concentrations of

BAMEs such as St. Peters, Hendon and Barnes (World Population Review, 2021).

 Study Setting

The Redeemed Christian Church of God (RCCG) established in Nigeria in

1952 has been referred to as the UK’s fastest growing Pentecostal church as it grew

from a few churches in 1991 to almost 800 branches spread across 70% of UK towns

as at 2016 (The Guardian, 2016). With a primarily Black congregation, it serves as an

ideal study setting to sample study participants. Officially, there are three RCCG

11
 churches within the Sunderland Area: RCCG Living Praise Sunderland (SR46LR),

RCCG Living Faith Sunderland (SR51AB) and RCCG Saints in Light assembly

(SR12LJ), all of which will be sampled concurrently until saturation.

 Sampling method

Due to the nature of the study, and the inclusion criteria listed above, a

purposive sampling method will be the most fitting method to select participants.

Purposive sampling, also known as judgemental or expert sampling is a type of

nonprobability sampling which involves selecting a sample that is representative of

the targeted study population (Lavrakas, 2008). It is widely used in qualitative

research for the sampling of apt respondents directly related to the research focus

(Palinkas et al., 2015).

 Sample size

This study will adopt the concept of ‘Data Saturation’ which is a widely used

principle for determining sample size of qualitative research (Vasileiou et al., 2018).

Rooted in The Grounded Theory (Glaser & Strauss, 1967), the principle of data

saturation has evolved to be defined as the stage in data collection where there aren’t

any new themes or information observed in the data extracted from further interviews

or cases (Guest et al., 2006; Saunders et al., 2018). Once this stage is reached, data

collection will be discontinued and the sample size at that point will be assumed as

the sample size for the study (Boddy, 2016).

 Study Population

As mentioned earlier in the introduction, pregnant women of Black and minority

ethnicities have been identified to be at a higher risk of COVID-19 infection and

12
 hospitalization (Knight et al., 2020). Seeing as they are also more likely to be

disadvantaged in the access to healthcare services during the pandemic due to pre-

existing health inequalities (Razai et al., 2021), this research would specifically study

women of black ethnicities who utilized maternity services in Sunderland, UK within

the past 1 year in order to explore their experiences while accessing maternity

healthcare services during the COVID-19 pandemic.

 Inclusion criteria

o Women from Black Ethnicities

o Women based in Sunderland, UK

o Women that utilized prenatal, perinatal or postnatal services within the past 1

year

 Exclusion criteria

o Women that are not of black ethnicities

o Women that are not based within the Sunderland Area

o Women that did not utilize prenatal, perinatal or postnatal services within the

past 1 year

 Recruitment

Participants will be recruited from religious communities, specifically the Black

African church called the Redeemed Christian Church of God which is a

concentration of potential participants (Ellard-Gray et al., 2015). Through the head

pastors of the branches, who would act as gatekeepers, announcements would be

made for volunteering of participants that fit the inclusion criteria. Volunteers will be

expected to reach out to the researcher via phone call or email after which an

informed consent document will be sent across to them and informed consent will be

obtained from them before initiation of data collection.

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 Privacy/Confidentiality

In order to ensure utmost confidentiality of participants, this study will adopt the

approach referred to by (Kaiser, 2009) as the ‘Dominant Approach’ which is a multi-

step approach that requires researchers to collect, analyse and report data in such a

way that respondents’ identities are uncompromised.

During data collection, respondents will be ensured that personal identifiable

information such as names, age, addresses, occupations, etc. will not be collected or

included in the research in accordance with the UK Data Protection Act (Data

Protection Act 2018, 2018; The British Psychological Society, 2018).

After data collection, during data analysis and result reporting, the data will be

thoroughly reviewed so that any potential identifiers mentioned during the interviews

that are not particularly relevant to the study will be removed or replaced with a

pseudonym. (Kaiser, 2009).

The research proposal and interview guide will have also gone through ethical

evaluation by a registered Research Ethics Committee (REC) before data collection,

in accordance with the UK Policy Framework for Health and Social Care Research

(NHS Health Research Authority, 2017).

 Gatekeepers

The Head pastors of the churches selected for sampling would be the Gatekeepers of

the study setting (Andoh-Arthur, 2019). They will act as mediators to access the study

setting and potential participants (McFadyen & Rankin, 2016). Appointments would

be set with them and requisite permission will be obtained from them to sample

participants from the congregation.

14
 Data collection Methods

Data will be collected via the Semi-structured Interview method. This is a

method of qualitative data collection whereby there is verbal communication between

the researcher and the respondent in a way that follows a pre-planned order (Fox,

2009). Participants will be expected to give a retrospective account of their

experiences during the COVID-19 pandemic while accessing maternity services. The

interviews will be recorded, transcribed and then analysed (Guion, Diehl &

Mcdonald, 2011)

 Data Analysis

Of all the stages of qualitative research, data analysis has been referred to as

the most complex stage (Thorne, 2000). A widely utilized approach to qualitative

analytic strategies is one known as the “constant comparative analysis”. It is an

approach that is rooted in the grounded theory, and essentially aims to identify or

explain fundamental social processes assumed to be influenced by individual human

behaviour/experience (Thorne, 2000). Examples of methods of data analysis that draw

from the concept of constant comparative analysis include Naturalistic inquiry,

interpretive description and Thematic analysis (Thorne, 2000). This study is going to

utilize the Thematic Analysis method which is essentially a process of extracting,

computing, categorizing, discussing and reporting themes obtained from a dataset

(Braun & Clarke, 2006). The QSR NViVo software will be used to facilitate the

analysis of the data collected (Jones, 2007).

 Ethical considerations

15
 o Participants will be within the ages that allows them to give of legal consent
o Voluntary participation
o Informed Consent to be obtained from respondents
o Confidentiality and Privacy
o The topic conforms to the UoL criteria that avoids sensitive matters and
vulnerable groups
o Ethical approval to be obtained from the University of Sunderland Ethics
Review Board

 Research Outcomes

o Fill Gap in Knowledge

o Provide relevant information on the impact/effectiveness of existing policies

that aim to protect pregnant women of minority ethnicities in the UK

o Devise recommendations based on data collected

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 BUDGET

S/N ITEM COST

1. Transportation 100
2. Internet facilities 100
3. Miscellaneous 200
Total 400 Pounds

17
TIME LINE

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