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You report, without comment (22 April), that the Commons Women and Equalities Committee has accused the maternity care system of racism because of appalling inequality in maternal mortality rates (MMR). Besides quoting scare headlines, the BMJ should also give its readers the facts, and perhaps even suggest how to improve matters.
Disparity in death rates was first suspected in the 1991-93 Report of the Confidential Enquiries into Maternal Deaths in the UK and confirmed in 1998, as soon as we had census data on ethnicity [1]. Since then the gap has reduced slightly but in 2018-20 the MMR among Black women was still 34/100,000 pregnancies compared to an overall rate of 11/100,000 [2]. A higher risk in Black women has been found in all countries where such research has been done. The causes, as the Committee said, “are still not fully understood” but not through lack of effort by epidemiologists. Collaborative work in the USA has led to some improvement [3].
There are, however, lessons to be learned from the past, as detailed in our new book [4]. Social class has long been – and still is – the major cause of disparity in MMRs. In Rochdale in the 1920s the rate was 852/100,000 (a truly “appalling” figure) but in 1931 it was reduced to 176/100,000 by an energetic Medical Officer of Health He ensured that all local women (and their doctors) understood what to expect from good antenatal care.
His campaign was characterised, not by shaming or name-calling, but by a friendly community spirit, using all available methods to reach out to women and their partners. It was led by a doctor, not by a politician. Couldn’t we try this today? Our multi-ethnic medical and midwifery professions should take the initiative in connecting with the UK’s multi-ethnic communities. And the BMJ could help by advocating action rather than simply quoting MPs.
James Drife MD FRCOG
Emeritus professor of obstetrics and gynaecology, University of Leeds
Formerly Clinical Director, UK Confidential Enquiries into Maternal Deaths
References
1. Lewis G, Drife J. Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-96. London: TSO, 1998.
2. Knight M, et al. Saving Lives, Improving Mothers’ Care. Core Report: Lessons learned to improve maternity care from the Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: NPEU 2023. www.npeu.ox.ac.uk/mbrrace-uk/reports
3. Main, EK, Chang SC, Dhurjati R, Cape V, Profit J, Gould JB, Reduction in racial disparities in severe maternal morbidity from hemorrhage in a large-scale quality improvement collaborative. Am J Obstet Gynecol. 2020 July; 223(1): 123.e1–123.e14. doi:10.1016/j.ajog.2020.01.026.
4. Drife JO, Lewis G, Neilson J, Knight M, Cooper G, Cantwell R. Why Mothers Died and How their Lives Are Saved. Cambridge: University Press, 2023.
Re: Government isn’t doing enough to end “shameful” inequality in maternal mortality, MPs say
Dear Editor,
You report, without comment (22 April), that the Commons Women and Equalities Committee has accused the maternity care system of racism because of appalling inequality in maternal mortality rates (MMR). Besides quoting scare headlines, the BMJ should also give its readers the facts, and perhaps even suggest how to improve matters.
Disparity in death rates was first suspected in the 1991-93 Report of the Confidential Enquiries into Maternal Deaths in the UK and confirmed in 1998, as soon as we had census data on ethnicity [1]. Since then the gap has reduced slightly but in 2018-20 the MMR among Black women was still 34/100,000 pregnancies compared to an overall rate of 11/100,000 [2]. A higher risk in Black women has been found in all countries where such research has been done. The causes, as the Committee said, “are still not fully understood” but not through lack of effort by epidemiologists. Collaborative work in the USA has led to some improvement [3].
There are, however, lessons to be learned from the past, as detailed in our new book [4]. Social class has long been – and still is – the major cause of disparity in MMRs. In Rochdale in the 1920s the rate was 852/100,000 (a truly “appalling” figure) but in 1931 it was reduced to 176/100,000 by an energetic Medical Officer of Health He ensured that all local women (and their doctors) understood what to expect from good antenatal care.
His campaign was characterised, not by shaming or name-calling, but by a friendly community spirit, using all available methods to reach out to women and their partners. It was led by a doctor, not by a politician. Couldn’t we try this today? Our multi-ethnic medical and midwifery professions should take the initiative in connecting with the UK’s multi-ethnic communities. And the BMJ could help by advocating action rather than simply quoting MPs.
James Drife MD FRCOG
Emeritus professor of obstetrics and gynaecology, University of Leeds
Formerly Clinical Director, UK Confidential Enquiries into Maternal Deaths
References
1. Lewis G, Drife J. Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-96. London: TSO, 1998.
2. Knight M, et al. Saving Lives, Improving Mothers’ Care. Core Report: Lessons learned to improve maternity care from the Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: NPEU 2023. www.npeu.ox.ac.uk/mbrrace-uk/reports
3. Main, EK, Chang SC, Dhurjati R, Cape V, Profit J, Gould JB, Reduction in racial disparities in severe maternal morbidity from hemorrhage in a large-scale quality improvement collaborative. Am J Obstet Gynecol. 2020 July; 223(1): 123.e1–123.e14. doi:10.1016/j.ajog.2020.01.026.
4. Drife JO, Lewis G, Neilson J, Knight M, Cooper G, Cantwell R. Why Mothers Died and How their Lives Are Saved. Cambridge: University Press, 2023.
Competing interests: No competing interests