Ethnic inequities in maternal health
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1040 (Published 12 May 2023) Cite this as: BMJ 2023;381:p1040
- Abimbola Ayorinde, assistant professor1,
- Oluwaseun B Esan, post-doctoral launching fellow2,
- Rachael Buabeng, director3,
- Beck Taylor, clinical associate professor1,
- Sarah Salway, professor of public health4
- 1NIHR, Applied Research Collaboration West Midlands, Warwick Medical School, University of Warwick, Coventry, UK
- 2NIHR School for Public Health Research, LiLaC, Department of Public Health Policy and Systems, University of Liverpool, Liverpool, UK
- 3Mummy’s Day Out, London, UK
- 4Department of Sociological Studies, University of Sheffield, Sheffield, UK
- Correspondence to: A Ayorinde A.Ayorinde.1{at}warwick.ac.uk
The report on Black maternal health from the UK government’s women and equalities committee, published on 18 April 2023,1 is yet another reminder of the slow progress in tackling serious ethnic inequities in UK maternal health. The risk of maternal death remains almost four times higher for Black women and two times higher for Asian and mixed ethnicity women, than for white women.23 These inequities were the impetus for the report, which critically assessed previous improvement attempts by the government and the NHS and made recommendations for change. Although the report focused on maternal health, the recommendations covered wider ethnic inequalities and overlapping socioeconomic inequalities.
The committee acknowledged that the causes of the ethnic inequalities in mortality are complex and not fully understood. It cautioned against focusing only on physiological and demographic factors, which could erroneously place the blame on women. The report emphasised that the government and NHS leadership have underestimated the contribution of racism to these inequalities. It explicitly highlighted the role of racism in maternity care, showing how it undermines women’s access to treatment and the quality of care received. Evidence comes from various sources, including advocacy organisations Five X More,4 Birthrights,5 and Muslim Women’s Network.6
The report identified poor data quality and missing ethnicity data as limiting our understanding of the factors underlying inequalities in maternal health. This echoes previous work,78 including that commissioned by the NHS Race and Health Observatory, which critically reviewed the evidence on existing policy interventions to tackle ethnic health inequalities in maternal and neonatal health. The observatory review identified only 19 evaluated interventions over 40 years, and methodological limitations created difficulties in assessing their impact.7 Several ongoing initiatives, such as pregnancy circles (group antenatal care targeted at women living in deprived and ethnically diverse parts of England910) are yet to report results.7 Consequently, the effectiveness of most existing interventions remains unclear.
Multifaceted response required
Many risk factors for maternal morbidity and mortality, such as cardiovascular diseases, diabetes, and obesity, exist before pregnancy and are disproportionately experienced by women from ethnic minorities.1112 Most maternal deaths occur in the postnatal period.2 Addressing the “constellation of biases” linked to poor outcomes will require multiple interventions throughout the life course, in the wider community, and beyond the health service.13 However, population level strategy on inequalities is now uncertain after the government abandoned its white paper on health inequalities in 2022.14
One key recommendation from the report was for a cross-government target to eliminate ethnic and socioeconomic inequalities encompassing meaningful, measurable indicators rather than a single numerical target. This approach aligns with expert evidence provided to the committee and international maternal health improvement strategy.15 This should include more upstream targets, such as increasing the number of healthcare workers with the right skillsets and implementing policies to promote non-discriminatory access to maternity services. The Maternity Disparities Taskforce will be responsible for setting targets. However, the taskforce has faced challenges fulfilling its aims so far, and it is not clear how targets will be set and monitored.
A further concern is workforce shortages, which are a major barrier to improving care. The new national three year delivery plan for maternity and neonatal services emphasises the need for safe staffing levels to reduce inequalities.16 Inadequate staffing has already resulted in the removal of the deadline for achieving continuity of maternity care for 75% of ethnic minority women.17 Any new strategy must take full account of the role of ethnicity and racism as highlighted in the Birthrights report on systemic racism.5 There must be emphasis on approaches to tackle racism at every level of society.18
Racism has finally been named; it is now time to start asking how it is operating here, and organising and planning to act.18 Action is required not only from healthcare professionals, policy makers, and researchers but also from ethnic minority women, who are often reluctant to engage with healthcare and research because of mistrust arising from generations of internalised racism.5 Advocates, champions, and peer researchers—including organisations run by and for Black and other ethnic minority women—can bridge this divide and hold the government and health services accountable.
Ethnic and socioeconomic disadvantages are structural, and the NHS is not immune to these problems. The solutions to persistent and deep inequalities in maternal outcomes are complex and multifactorial. Woman centred, adequately resourced, collaborative work is needed urgently. We need better data, evidence, and care. The thousands of women from Black and other ethnic minority groups giving birth in the UK every year should be able to approach pregnancy and birth without fear that they are at increased risk because of their ethnicity. It is time to move beyond repeated reports and policies documenting the problem and put meaningful action in place to tackle these unacceptable inequities.
Acknowledgments
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare no other interests. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Footnotes
Provenance and peer review: Commissioned; not externally peer reviewed.