Racial Bias in NHS Maternity Care.

It has sadly been a long known concern that women of black and Asian ethnic background, and women of mixed ethnic background have different birthing experiences, as well as traumatic outcomes and loss, compared to white women.

This article considers why that is, and why it has not been resolved.

Statistics

The statistics are stark. Black women are four times more likely to die in pregnancy and childbirth, and have severe complications more frequently than their white counterparts. For every 1,000 deliveries by black women, 2.3 are investigated compared with 1.3 for white women. Black babies in England are three times more likely to die than white babies, and also more likely to suffer a brain injury.

In 2021, MBRRACE UK reported that “mortality rates remain exceptionally high for babies of Black and Black British ethnicity”, with stillbirth rates over twice those for white babies and neonatal mortality rates 43% higher. For babies of Asian and Asian British ethnicity, stillbirth and neonatal mortality rates are both around 60% higher than for white babies.

Sadly, these figures aren’t new. Ethnic disparity has been reported for over 20 years and it appears that things have not changed.

Why is there bias?

The 2020 MBRRACE report powerfully outlined how the women who died faced a “constellation of biases”, which prevented them from receiving the care they needed. Multiple overlapping factors were at play such as:

• Being from an ethnic minority group
• Socioeconomic deprivation
• Social services involvement
• Language difficulties
• Mental ill health
• Obesity
• Domestic abuse

These factors combine to increase the impact of the structural and cultural biases women experience in pregnancy.

In 2022, the Race and Health Observatory identified that “women’s experiences of negative interactions, stereotyping, disrespect, discrimination and cultural insensitivity, system-level factors, as well as the attitudes, knowledge and behaviours of healthcare staff, contribute to some ethnic minority women feeling ‘othered’, unwelcome, and poorly cared-for.”

There are a high number of experiences from black, Asian and mixed ethnic background women reporting that their pain during labour is ignored or denied, and even pain relief being withheld due to staff not believing that they were in labour.

Donna Ockenden, who investigated the maternity care at The Shrewsbury and Telford Hospital NHS Trust, is currently leading a review into services at Nottingham University Hospitals NHS Trust. Ms Ockenden has said that expectant mothers are experiencing overtly discriminatory and racist treatment, including having their accents mocked and being refused translators. Black, Asian and minority ethnic women are also more likely than white patients to report being denied adequate pain relief.

Racist stereotypes, including black women’s perceived ability to tolerate pain, and Asian women’s perceived inability to cope with pain, are having a significant impact on women using maternity services. It is astounding that such stereotypes are impacting maternity care, or indeed anywhere. If someone is saying they are in pain, who is anyone else to disregard that? Many women feel at their most vulnerable whilst giving birth, and to be denied pain relief, based on a clinician’s assessment of your pain threshold, is abhorrent.

There are of course additional factors that impact a women’s birth experience. The lack of interpreters where English is not a first language at hospitals, for appointments and during labour, can have a hugely detrimental impact on mums and their birth choices. There may also be a lack of resources such as leaflets in other languages, and antenatal education not being provided in a culturally sensitive way.

It is known that gestational diabetes is more prevalent in certain ethnic groups, and not having a diabetic clinic at a local hospital, which then requires the need for additional transport, demonstrates a further lack of provision for minority ethnic communities.

What is being done to improve racism within maternity services in the NHS?

In 2019, the NHS Long Term Plan set out a goal that “by 2024, three-quarters of pregnant women from Black, Asian and minority ethnic communities will receive care from the same midwife before, during and after they give birth”.

In 2022 NHS Trusts were told they must be able to demonstrate safe staffing levels before proceeding with their planned rollout. Nevertheless, the national commitment to deliver continuity of care for 75% of women from Black, Asian and minority ethnic communities, and from the most deprived groups is restated in the 2021 NHS Core20PLUS5 approach to reduce health inequalities, which includes maternity as one of five clinical areas of focus “requiring accelerated improvement”.

In contrast, the independent NHS Race and Health Observatory, which was established in 2020, has identified maternity and neonatal care as areas requiring urgent attention, and explicitly recognised the need to address systemic racism and discrimination. Their recommendation was that “there needs to be a serious commitment from NHS England and NHS Improvement to tackle racist attitudes and behaviours among healthcare staff, and address structural dimensions of NHS systems that discriminate against ethnic minority women and their babies”.

The Ministerial Maternity Disparities Taskforce which was announced in February 2022 also sets out to tackle disparities in maternity care experienced by women from ethnic minority groups and those living in deprived areas. There was a focus on personalised care and informed decision-making, which are core to rights-respecting care.

Similarly, the Office for Health Improvement and Disparities has a remit covering maternal health, although this focuses on a lifetime approach, preventable risk factors and pre-conception health. These are all crucial factors, but this overlooks the impact of racial discrimination and trauma on health through lifetime ‘weathering’; past experiences leading to a breakdown of trust and affecting interactions with services; and direct discrimination and systemic racism within maternity care.

The Royal College of Midwives have called for improvements in midwifery education so that student midwives are taught how to better assess women and babies with darker skin tones, as part of a motion to ‘decolonise the midwifery curriculum’. This would be a case of leading from the ground up and in educating the student midwives, it is hoped that racism will be eradicated in NHS care.

Whether racism is unconscious or conscious, indirect or direct, intentional or unintentional, fleeting or persistent, the impact is the same. It is well overdue that racism should be eradicated and it will be interesting to see what progress the NHS makes on this important topic.