By Dr Shohaib Ali
More than one quarter of the 600,000 babies born annually in England and Wales are to mothers from ethnic minority groups. The Confidential Enquiry into Maternal Deaths showed that in 2016-18, compared to their white counterparts, the rate of women dying during up to one year after pregnancy is more than four times higher among black women, and almost double among Asian women. The data is quite clear; ethnic minority mothers are more likely to die during childbirth then their white counterparts in the UK.
As the public becomes more conscious of the ethnic differences in health outcomes, this has become a key health policy area, and one that will only gain more political traction in time. This article will explore the reasons why these differences exist, current policy aimed at addressing this imbalance and future policy recommendations.
Suggested reasons for the disparity
Ethnic disparities are not just isolated to maternal health outcomes. Across almost all health outcomes, ethnic minorities, especially black and south Asian people fare the worst. Those of black ethnicity have a greater risk of detention under the mental health act than their white peers. COVID-19 has disproportionally affected those from ethnic minorities, with 25% of patients who required intensive care support being of black or Asian background. Black or Asian people with COVID-19 had the highest death rate.
This suggests that there are pervasive factors that influence inequalities in health across groups. There is a building evidence base that racism is a fundamental cause and driver of adverse health outcomes in inequities in health. On a societal and individual level this leads to both direct and less obvious effects on an individual’s health.
For instance, the segregation of ethnic minorities in the UK is one key driver in differing health outcomes. Segregation leads to differences in access opportunities at the community level across a range of areas from health, education and employment. In England the most marginalised ethnic groups are over-represented in the most deprived neighbourhoods. Only 9% of white British people live in the most deprived neighbourhoods compared with 31% of Pakistani, 28% of Bangladeshi, 20% of black African and 18% of black Caribbean people. Lack of services and lack of health education compound, leading to worse maternal health outcomes.
Another area that can lead to adverse health outcomes is bias of healthcare professionals. A report in the US found that minority ethnic minority groups routinely received poorer quality care than white groups. White patients were twice as likely to receive pain relief than Hispanic patients, and this bias difference in how ethnic groups are treated in healthcare are found across a range of health outcomes. In the UK 54% of doctors are white, with 60% of consultants being of white ethnicity. There is a clear lack of ethnic diversity in the medical workforce, especially in those at the top of the profession. Having medical professionals who reflect the communities they work in is crucial to allow women to be treated in a way that is culturally appropriate and sensitive.
The effect of these numerous factors has led to the development of the concept of ‘weathering’. This model explores the idea that exposure to discrimination, as well as psychological, physical stressors damages health and increases ageing, and may explain why black women’s health deteriorate at an earlier time then that white women. The difference in maternal mortality is not caused by a single factor, but is the cumulative effect of numerous stressors, with some easier to see then others.
Previous policy responses
The systemic problems that have been highlighted require structural interventions and polices, across all aspects of life including education, housing and criminal justice. Ethnic disparities in maternal healthcare have led to a number of reports and recommendations over the years with seemingly limited change.
Maternity services were a priority for successive NHS forward plans. The first of these forward views in 2015 lead to Better Births: improving outcome of maternity services in England. It has set the agenda for future reports, focusing on enhanced continuity of care as the main health policy recommendation. It did not have any specific findings in relation to maternal mortality rates, nor did it include any specific recommendations for mothers from different ethnic groups.
The NHS long term plan published in 2019 introduced a target to ‘achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025’. Once again there was a lack of clear commitments to reduce ethnic variation in maternal mortality, instead focussing on maternal mortality as a whole.
A review of progress on better birth in 2020, showed that maternal mortality rates remain higher for ethnic minority groups, and set clear targets to roll out continuity of care to BME groups, but once again failed to set a specific target to reduce ethnic maternal mortality disparity.
A key focus of the government’s response to maternal mortality inequality is via an enhanced continuity of carer model, as previously mentioned. This is a midwife-centred initiative that ensures that each pregnant woman builds a relationship with their midwife and ensures the provision of a named midwife. There is a building evidence base in the UK for its use. A Cochrane review of systematic reviews found that, compared to standard care, this model reduced preterm birth and premature death, however there was no reported outcomes on maternal mortality. Further research into the impact of this midwife lead model on maternal mortality is needed, and its impact in reducing ethnic disparities in maternal mortality.
The Government’s Commission on Race and Ethnic Disparities, widely discredited for a lack of awareness of structural issues, signalled a possible attempt to pivot the conversation from the issues highlighted in this article with a new focus of individual and personal factors as the reason for disparities in health outcomes. This approach fails to acknowledge the pervasive factors that should be addressed in order to stop outcomes for BME mothers falling further behind white British mothers.
In conclusion, the government should consider setting explicit targets for reducing the ethnic minority maternal mortality disparity and ask the CQC to specifically consider differential outcomes based on ethnicity.
This blog draws heavily on work initially published by the Young Fabians.
Dr Shohaib Ali is an Obstetrics and Gynaecology academic foundation doctor at Imperial College London.