Childbirth is a vulnerable time for any woman. Black women have particular cause to be anxious. Their labours are almost twice as likely to be investigated for potential NHS failings, the Guardian revealed this week, with the head of the Royal College of Midwives (RCM), Gill Walton, blaming institutional racism. For every 1,000 deliveries by black women, there were 2.3 investigations, compared with 1.3 for white women.
Black women are up to six times more likely to experience some of the most serious birth complications as their white counterparts and almost four times as likely to die in pregnancy, childbirth or postpartum, while Asian women are almost twice as likely to die. Black babies are almost twice as likely to die as white; Asian babies are also at greater risk.
These shocking statistics point to the confluence of two problems: failings in maternity services, and poorer health outcomes for black, Asian and minority ethnic communities. While the UK has one of the world’s lowest maternal mortality rates, a recent report found around one in three labours are traumatic. The Care Quality Commission has found almost two-thirds of maternity units to be not safe enough.
Factors can include poor record keeping; hierarchical culture which makes it hard for other staff to challenge consultants; mistrust between midwives and doctors; a lack of transparency; pressures on the NHS making it hard to retain experienced staff; and the prioritisation of vaginal births. Though hospitals were told two years ago to scrap targets aimed at limiting caesarean sections, many feel that a preference remains embedded in the culture.
These problems are not easily solved, but might be mitigated if healthcare services were better at listening to women, and providing them with clear information. Instead, England’s patient safety commissioner this month warned that women raising concerns were often fobbed off or dismissed as “difficult” – a trope frequently attached to black women in particular.
Black, Asian and other minority households are more likely to live in the most deprived areas than their white counterparts. But social and economic disadvantage is not an adequate explanation of the poorer outcomes. Donna Ockenden, the maternity expert who is currently leading a review into services at Nottingham University hospitals NHS trust, told the Guardian 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 more likely than white patients to report being denied adequate pain relief.
Broader issues of cultural competence also play in. Medical staff may not be aware that some complications are more prevalent in particular communities, or that symptoms may present differently. Textbooks still treat the white European body as the standard. Even pulse oximeters can be affected by skin pigmentation.
The women and equalities committee warned last year that the government and NHS had underestimated the role played by racism in maternity care failings. The RCM has begun work on decolonising the curriculum, and Labour’s manifesto pledge to set an explicit target to close the black and Asian maternal mortality gap is welcome. Improving maternity services in general is essential. But ensuring that they work for all will require specific measures and a willingness to recognise and tackle racism.
