Infant death and women's health are marked by inequality but outreach workers are now changing prospects, reports Caroline White

Death rates among infants have been falling in most areas of the country. But this trend masks the gap in rates between different income and racial groups, leaving strategic health authorities with a lot of work to do if they are to meet the public service agreement for perinatal mortality: a 10 per cent fall from 1997-99 figures by 2010.

The Department of Health's agreement progress report, published in February, shows that in 1997-99, infant mortality rates for the poorest people were 13 per cent higher than the average. In 2002-04, they were 19 per cent higher.

Rates were twice as high among Pakistanis, and 63 per cent higher among Caribbean people. Over two-thirds of black and minority ethnic people in England live in some of the most deprived areas.

A study in the British Medical Journal of almost 200,000 pregnant women in London, published in April, showed that South Asian women had higher perinatal mortality rates than black or white women, and that the single most important risk factor for stillbirth among them was low birth weight.

Daghni Rajasingam, consultant obstetrician at Guy's and St Thomas' Hospital foundation trust and Royal College of Obstetricians and Gynaecologists spokeswoman, says diet is crucial. Only one in 10 of the women she sees in her clinic takes folic acid, a key nutrient for fetal development.

She is about to begin research on why BME diabetic women do not access maternity services.

'We know it's not just the language barrier,' she says. 'But we need to find them and engage with them much more. They are a hidden group, and we usually only see them when they are about to deliver.'

In Birmingham, where perinatal mortality rates are the highest in Europe, trusts realised they had to do more. Pregnancy outreach workers, trained and employed by community interest company Gateway Family Services, search out the women themselves.

The workers have experience of many of the problems their clients may be going through, such as domestic violence and homelessness. And they speak a variety of languages.

'They work in a very complex environment, for which midwifery training doesn't prepare you,' explains Gateway chief executive officer Vicki Fitzgerald. 'A lot of social support is involved. We know that midwives don't have enough time for that.'

The new role, active since August, has prompted some professional misgivings. But Ms Fitzgerald is convinced the workers will prove their worth: 'Getting women to appointments is critical, and the outreach workers can do that.'

The 2004 Confidential Enquiry into Maternal and Child Health report shows that one in four of the 50 women who died during pregnancy or childbirth booked for maternity care after 22 weeks of pregnancy or had missed more than four antenatal appointments.

Luton primary care trust has also been thinking differently. Delayed weaning in South Asian children, stemming from a belief that rapid weight gain from milk feeds indicated good health, caused feeding problems which led to accident and emergency and hospital admission.

'We needed to get into the community and sensitively change a lifestyle that had lasted many generations,' explains chief operating officer Ian Winstanley. 'But a lot of our health visitors are white and middle class, and the interpreting service is all male.'

A trust nurse consultant, who had worked in Pakistan and spoke Urdu, recruited mothers from the South Asian community to bridge the cultural gap and take health messages back by visiting families in their homes at meal times. These weaning advisers are given Open College Network accredited training competencies, including the ability to make diagnoses.

'The health visitors recognised they didn't have the skills, and local GPs accepted them very quickly, because this seemed to solve a problem. The referrals have come thick and fast,' says Mr Winstanley. 'They do joint work with GPs now, and are a known group. They do feel they work for the NHS.'

The confidential enquiry report also shows that BME women are three times more likely to die in pregnancy and childbirth than white women, while the poorest have death rates 45 per cent higher than the wealthiest.

At Bristol PCT there was no infrastructure to cope with the sudden influx of Somali families, many of whom had fled war zones, and traditional health visiting approaches 'struggled to provide meaningful services,' says health visitor Barbara Potter.

Her Somali clients often didn't understand the appointments system, or that treatment could be preventive; health visitors couldn't fully appreciate the trauma they had experienced, or other sensitive cultural issues, she says.

But employing an outreach bilingual worker, who accompanies Ms Potter on her home visits, has transformed service delivery. 'She has become a bridge between us and them,' she says.

'We have a drop-in session once a week, where people can bring all kinds of concerns that wouldn't be picked up in a 10-minute GP consultation,' she says. 'But this would not have happened if [the worker] hadn't gone into the community and built up trust.'

Sessions on effective workforce planning and embedding race equality in the NHS commissioning cycle are part of the Achieving Race Equality in the NHS conference programme. For more information visit