Amali Lokugamage: Maternal mortality—undoing systemic biases and privileges

The tennis player Serena Williams has spoken in detail about the life-threatening postnatal complications that she experienced after the birth of her daughter. Her symptoms were not initially taken seriously and many media pieces written from a black feminist perspective have suggested that Serena’s story highlights alleged racism in US healthcare. The New York City, 2008–2012, Severe Maternal Morbidity Report, highlights the persistent disparities in maternal outcomes by race and ethnicity, particularly between black and white non-latina women.

According to the report, in the US, black non-latina women are three times as likely to die during pregnancy or childbirth and twice as likely as white non-latina women to experience severe maternal morbidity. The report goes on to say that there are likely many contributors to these disparities, including pre-conception maternal health status, prevalence of obesity and other comorbidities, and access to care. Factors associated with poverty, such as inadequate housing, residential segregation, and lower educational attainment, which disproportionately affect black women in the US, also increase the risks of severe maternal morbidity. However, the report specifically states that racism and its attendant stresses may also contribute to adverse maternal health outcomes

The recent MBRRACE-UK report on maternal mortality, published in 2018, has revealed glaring disparities in maternal mortality between racial groups. The report states “research is urgently needed to understand why black women are five times more likely and Asian women are twice as likely to die from complications of pregnancy and childbirth compared to white women.”

The MBRRACE report does not specifically allude to systemic racism as a cause. It contains a call to action, which states that there is a need to address these disparities for policy makers, service planners, commissioners, service managers, and all health professionals. However, the report does not offer specific guidance.  

The MBRRACE report has led to heated debate on social media, with some suggesting that systemic racism may be a contributing factor, with cross-reference to the similar statistics in the US. Black feminists have raised this situation as an example of “intersectionality.” This is a sociological idea that describes the effect of multiple intersecting forms of oppression: in this case that BAME women can experience and which prevents them from receiving optimal healthcare. There seemed to be a feeling on social media that the release of these figures should have prompted a more urgent national institutional response. The debate was so inflamed that a Maternity Experience Facebook group had to be temporarily shut down due to blistering exchanges on this topic, magnified by a feeling of historic injustice by some opinion holders and frustration that improvements have been very slow.  

In order to address these disparities, we need a better understanding of the causes behind them. We also need to address any unconscious bias in healthcare culture that could contribute to the “intersectional” excess of mortality and we need a new approach to patient care to tackle these inequalities. A nursing model of care called “cultural safety” is used in New Zealand and could be potentially advantageous as an adjunct to medical reflective practice as outlined by the GMC. Cultural safety involves the process of a healthcare professional quickly reflectively “checking” on their own privileges, biases, and any potential power imbalance between them and the patient, before an interaction with the patient. It is a sort of “quick human rights reflective checklist.”

Writing in the Medical Law Review, Richardson et al say  “This concept provides recognition of the indices of power inherent in any interaction and the potential for disparity and inequality within any relationship. Acknowledgment by the healthcare practitioner that imposition of their own cultural beliefs may disadvantage the recipient of healthcare is fundamental to the delivery of culturally safe care.” The first place that I heard about cultural safety was at the Wellcome Collections symposium on Decolonising Health (2018) in relation to midwifery care. It was discussed as a way of addressing healthcare inequality experienced by indigenous New Zealanders. Cultural safety is thought of as part of the decolonising movement in healthcare. So what would this model look like in practice elsewhere in the world and could it be used to address some of the inequities highlighted by the MBRRACE-UK report?

Recently a popular video has emerged on Twitter and has been widely shared on social media. It shows Rupa Marya (associate professor of medicine at the University of California, San Francisco) eloquently discussing a clinical example of cultural safety practice at work. She describes a case where rare, but recurrent symptoms had been dismissed in a black woman presenting to her hospital. She describes how she reflected on her own biases, her own privileges, and the data suggesting that black women presenting to healthcare facilities are sometimes not listened to because of systemic racism in healthcare. This led her to push for further investigations, despite resistance from her colleagues, and to diagnosing a rare cardiac condition. This example demonstrates how the model of cultural safety, if it became part of medical reflective practice, could help to neutralise systemic racism, which in some cases may contribute to these worrying statistics in maternity care outcomes.

If incorporated into medical reflective practice, the cultural safety model could potentially improve situational awareness and professionalism in healthcare professionals, which would be of great benefit to patients. By engaging in this practice, healthcare professionals would be continually checking their privilege in interactions with patients and other members of staff and checking for power imbalances, which would lead to fairer interactions with patients and co-workers. After all, the WHO surgical checklist has been incorporated into surgical environments to improve patient safety, so why not check for power imbalances to seek fairer interactions with patients and co-workers? This practice may have the potential to plant the seeds of cultural change and contribute to the “call to action” triggered by the MBRRACE report.


Amali Lokugamage is a consultant in obstetrics and gynaecology at Whittington Health NHS Trust, London, UK and a deputy lead for clinical and professional practice at UCL Medical School.

Competing interests: AL is on the Board of Directors of the International MotherBaby Childbirth organisation and a Trustee for the Birthlight Charitable Trust. She is a company director of a small publishing company called Docamali Ltd.