The impact of racism within NHS maternity care

According to the Care Quality Commission, who in 2022 published their annual assessment of health and social care, mortality rates are considerably higher for women from ethnic minority backgrounds. Their findings also revealed that women from ethnic minority backgrounds are more likely to be re-admitted into hospital following giving birth.

In more recent findings in 2023, the ONS (OFFICE for National Statistics) revealed that black babies stillborn rates are at almost twice the rate of white babies.

Tinuke Awe, the co-founder of Five X More, a campaign group to improve black maternal health, said the figures divulged by the ONS were not a surprise. She said:

“We know that these numbers have been higher for black women and their babies for decades now, that’s why it’s not a surprise to us. The data has been there for a while. It’s just a shame that it’s going up instead of going down”.

Clotilde Rebecca Abe, also a co-founder of Five X More, said the figures highlighted that little was known about the causes of the disparities:

“We need to find the root of the issue. I want to know, in terms of stillbirth, why are black babies dying more? And what are the causes behind it? Are black babies dying from the same thing that white babies are dying from? What are the causes of this? Should we be looking at the mother’s history and the mother as well? Is it because black women aren’t being listened to? So when they say reduced fetal movements and things should be done, is it not getting done on time? Are they having traumatic births? Is it because they are having rushed C-sections? What is the issue that is affecting the child? Is it a condition that the mother had that went undiagnosed during a pregnancy? What exactly is it?”

These concerning 2022-23 findings echo a previous report published by MBRRACE in 2018, which revealed that black women are five times more likely, and Asian women twice as likely, to die in the perinatal period than white women. In a more recent report by MBRRACE in 2022, the organisation divulged that these stark disparities in maternal mortality rates remain.

In response to MBRRACE’s most recent 2022 findings, Birthrights has pleaded for a collective effort to devise a solution that would achieve racial equality. However, the recent move by the Secretary of State for Health & Social Care to scrap the Government’s long-promised white paper on health inequalities, significantly undermines such a vision.

Despite this unfortunate setback, in February 2022, the Minister for Patient Safety and Primary Care amongst others joined forces to formulate a taskforce that intended to explore inequalities in maternity care and identify how the UK Government can improve outcomes for women from ethnic minority communities. Although, it remains to be seen what impact this will have, it has received a positive reception.

For instance, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists (RCOG) supports this new taskforce. He said:

“We strongly welcome this new Maternity Disparities Taskforce, which will aim to tackle the unacceptable inequalities that exist for women from black, Asian and minority ethnic backgrounds when it comes to maternity outcomes.

The colour of someone’s skin should never dictate whether they have a positive or negative birth experience. The RCOG’s Race Equality Taskforce is committed to working with this new taskforce to understand why these disparities exist and create meaningful solutions to improve healthcare experiences and outcomes for all ethnic minority women”.

Commenting, the Royal College of Midwives (RCM) Director for Professional Midwifery, Mary Ross- Davie said;

“The disparities in outcomes and experience of maternity care for black and Asian women and women from other ethnic minority backgrounds are shocking, so the RCM welcomes the creation of the Maternity Disparities Taskforce and is keen to be part of the work in finding solutions. The RCM has long called for more consultant and specialist midwife posts in trusts and health boards to provide better support to women with pre-existing conditions such as increased BMI, high blood pressure, diabetes, and mental health conditions. In many parts of the UK, these midwife roles either do not exist or are very limited, yet they could make a huge difference to black and Asian women in particular.

There is some excellent work being done in some areas, so it would be good to see that experience shared across maternity services. Improvement of outcomes relies on sharing what works and what doesn’t, so that we can bring about effective, consistent change. We look forward to working with colleagues on the taskforce to highlight the current problems and find ways to address them in a positive way.”

To support maternity staff and families further, the NHS is increasing the maternity workforce further with a £95 million recruitment drive to hire 1,200 more midwives and 100 obstetricians.

Nevertheless this is a significant feat, given Birthrights itself produced a report in May 2022 on racial inequalities within NHS maternity care titled “Systemic racism, not broken bodies” which investigated the perspectives of over 300 brown, black and mixed ethnicity women. In doing so, they uncovered some common and utterly unacceptable themes of experiences of women, including:

• a lack of physical and psychological safety;
• being ignored and disbelieved;
• racism by caregivers;
• dehumanisation;
• a lack of choice, consent, and coercion;
• structural barriers;
• workforce representation and culture.

These are findings which are echoed by Five X More, who also in May 2022 published a survey which also explored the experiences of maternity care of more than 1,300 women from ethnic minority backgrounds. Their findings, like Birthrights’s, revealed that a high proportion (43%) of ethnic women felt that their race impacted the care they received.

Moreover, Birthrights also found that stillbirth rates in babies of black and black British ethnicity were more than twice for white babies. These are findings which have been supported by the RCM (Royal College of Midwives) who also are rallying for urgent attention to address the high levels of racism in the NHS.

Further, the report produced by Birthrights details upsetting case studies such as jaundice not being detected in a black baby, resulting in the baby suffering brain damage. Another case involved a baby suffering a brain injury due to hypoglycaemia (low blood sugar), caused by a lack of feeding support and information for a non-English speaking mother; the NHS failed to arrange interpretation services either antenatally or postnatally to ensure the safety of both the mother and her baby.

Indeed, the lack of interpretation services has been reported just this week by HSIB (Health Safety Investigation Branch) for a mother who died at Gloucestershire Royal Hospital in 2021 after suffering a post-partum bleed. Ms Abdelkarim was Sudanese and spoke little English, she did not have the support of an interpreter and suffered from language barriers at her ante natal appointments and didn’t appreciate that she was sent to hospital for induction and did not give proper consent to that procedure.

In the conclusion of its report, Birthrights called on the UK Government and NHS to recognise the role that racism plays in dire outcomes for brown, black and mixed ethnicity women.

Established in 2021, the NHS Race and Health Observatory is an independent body which was created by the NHS to examine ethnic inequalities in the NHS and to provide practical support to the NHS in eradicating those inequalities.

What is their response to racism within NHS maternity care?

The NHS Race and Health Observatory believes that racism within NHS maternity care is a serious issue. It communicates that there is an urgent need for programmes across England which are designed to address, tackle and evaluate maternal inequalities going forward. In its findings published in late 2022, the body itself found the policies currently adopted to focus on addressing ethnic health inequalities across maternity care were lacklustre.

In light of this, the Health Observatory has called for the development of a central data repository to map improvements around reducing poor outcomes in maternal and neonatal healthcare for black, Asian and ethnic minority women (BAME). It also calls for, amongst many other things, better research and data recording and support with post-natal depression for specific ethnic groups and specialist Cultural Liaison Midwives to improve trust with pregnant women.

NHS Race and Health Observatory believes that the proposal of practical recommendations, such as improvements in data collection and support, compiled by maternal experts and those with lived experience, will lead to such racial disparities being closed.

In catalysing such action, the NHS recently made a pledge to improve equity for mothers, babies and race equality for NHS staff. This was made in response to the devastatingly high levels of racial disparity within NHS maternity care as revealed by these studies and also the findings of NHS People Plan, (a body set up to improve working practices within the NHS) who concluded that where an NHS workforce is representative of the community that it serves, patient care and patient experience is more personalised and improves.

With that said, in 2021, as part of this pledge the NHS committed to investing £6.8 million in its bid to support local maternity systems improve equity and equality, whilst also focussing on devising more effective measures to track mortality rates by ethnicity, in furthering its attempts to address racial inequalities within NHS maternity care.

The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional association which works to improve healthcare for women by setting standards, training, and educating doctors, and advocating for women’s health worldwide. Its members include people with and without medical degrees, who work in the field of obstetrics and gynaecology, that is pregnancy, childbirth, and female sexual and reproductive health.

What is their response to racism within NHS maternity care?

RCOG does recognise that racism persists in NHS maternity care. According to its research, pregnancy risks are considerably higher for women from ethnic minority backgrounds, with two to three times higher rates of perinatal deaths and stillbirths compared to white women.

In light of this, RCOG has called for the support of policy makers and healthcare providers to be a facilitator in its initiatives, through its own “Race Equality Taskforce” to help eradicate such wide spreading, unacceptable disparities in racial inequalities.

Its findings (produced in conjunction with the RCM) have also revealed these racial disparities persist largely due to the current pregnancy screening procedures used within NHS maternity care. Therefore it asserts that, if new pregnancy screening technology was to be used, the evidential racial disparities in baby death rates could be immensely decreased.

This appears to be the case, given that in a pilot rollout of this new digital tool across three maternity units in England, results have shown that this new screening algorithm reduces baby deaths amongst mothers from ethnic minority backgrounds by 60% – a significant change.

Therefore, RCOG believes this is something that should be prioritised to help eradicate the racial disparities in baby deaths that remain.

In the wise words of the American black writer James Baldwin, “not everything that is faced can be changed, but nothing can be changed until it is faced”.

With that said, although progress has been made in addressing racism within NHS maternity care, radical action is required. So, it is up to us to also take heed of these concerning revelations, take action that will promote awareness, and incentivise reform. In doing so only then can change be made possible.