BACKGROUND:
Digital consultations (telephone and video) became rapidly embedded into UK maternity services during the COVID-19 pandemic. While these approaches offer flexibility and efficiency, they also risk entrenching disparities if equity, language needs, and relationship-based care are not embedded into their design. Concerns persist about exclusion, depersonalisation, and inconsistent implementation across services.

OBJECTIVES:
To explore how digital clinical consultations can be implemented in a clinically safe, appropriate, and acceptable way within maternity care, for whom, in what settings, and for what purposes, while attending to access, communication, and equity.

METHODS:
A realist synthesis was undertaken as part of an NIHR-funded project (NIHR134535). Data sources included 93 research studies, policy and safety documents, and insights from community organisations, women, and maternity staff. Programme theories were developed to explain how different mechanisms and contexts interact to shape outcomes. Stakeholder workshops were held throughout to prioritise questions, validate findings, and inform framework development.

RESULTS:
Digital consultations were acceptable where women experienced clear communication, continuity, and choice. Positive outcomes relied on adaptable systems, responsive staff, and equity-led infrastructure. Barriers included poor connectivity, digital poverty, linguistic mismatch, and limited relational continuity. Stakeholders emphasised that digital delivery alone does not guarantee access or inclusion. The synthesis generated a conceptual framework and four CORE principles: Creating supportive infrastructure, Optimising care to individual needs, Recognising digital and social barriers, and Enabling safety through relational practice.

CONCLUSIONS:
Digital transformation in maternity care must be equity-led, relationship-based, and context-aware. Implementation requires more than technology: it needs co-designed processes, flexible pathways, and inclusive decision-making with women and staff.

KEY MESSAGE:
Digital care is not inherently safe or equitable. Midwives must lead on embedding relational safety, co-design, and justice into digital maternity pathways to ensure no one is left behind. Poster session 4 (Group B)