'It requires something drastic': Interviews with health care leaders about organisational responses to social...

Persisting disparities in maternal and child health outcomes in high income countries require new insights for health service response.

Significant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study.

To explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes.

In-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews.

Health care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; 'clinical risk' versus 'social risk'; and taking steps for system change.

Priority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff.

Achieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.