Inequality of maternal morbidity in a global pandemic; a clear signal for urgent action

Data emerging from the last three months are highlighting that health inequalities prevail even in global pandemics. This appears to be as true regarding morbidity for pregnant women, as it is out-with a pandemic. Alongside the wider debates about COVID-19 and the observed disparity of impact by ethnicity, we should ensure maternal morbidity and mortality is a key part of this conversation.

From previous maternal mortality reports we know that Black women are five times more likely to die in the perinatal period (during pregnancy and up to one year after) than White women1,2. The reports also highlight that Asian women are two times more likely, and women of Mixed ethnicity are three times more likely to die than White counterparts1,2. These are stark figures which since their publication have brought about a drive to improve this inequality in maternity services in England with a specific focus in the Maternity Transformation Programme3.

Maternal mortality surveillance data continues to be collected throughout the pandemic and will report on this period in the next few years, where I am sure this issue will feature along with the continuing risks to maternal morbidity and mortality faced by Black, Asian and Minority Ethnic (BAME) women. This disparity is not unique to the UK; an American study found a significantly higher risk for severe morbidity from post-partum hemorrhage for Black women, with risk of death also five times higher than White women4. (A EBNJ commentary on this paper can be accessed here5).

At the start of the pandemic the UK Obstetric Surveillance System (UKOSS) initiated a hibernating research protocol and were able to rapidly introduce reporting of pregnancy cases hospitalised with confirmed COVID-196. In pregnant women hospitalised with confirmed COV-SARS-2 from 01st March – 14th April 2020, over half (56%) of women were from a Black or other ethnic minority group (233/427). The incidence of hospitalisation for COVID-19 in pregnancy for White ethnic groups was 3.5/1000, for Asian ethnicity four times more (13.9/1000), eight times more in Black ethnic groups (28.5/1000); and twice or more times for Chinese/Other (9.5/1000) and Mixed ethnic groups (6.9 /1000)7. These findings were stark, but sadly not a surprise; in part from what we already know from the previous maternal mortality reports, but also because this inequality had been reported in the non-pregnant populations affected by COVID-19.

Initiating another hibernating protocol, the ISARIC study8 noted those from BAME groups were younger, more likely to be admitted to critical care or undergo invasive mechanical ventilation than White people9. The authors propose a possible link to polymorphisms and biomechanics of disease severity, in particular ACE2 receptor expression and SARS-COV-2 cell entry9. However, they were unable to take into account exposure through occupation, urban residence social and health determinants9.  There has been much praise of the UK’s hibernating research protocols, which indeed have facilitated the rapid acquiring of critical data10. In future pandemic planning it now seems clear that such protocols should also include more detailed collection of data on demographics, occupation, wider social determinants, along with ethnicity captured with sensitive and standardised classification to allow deeper understanding and analysis.

The government’s-initiated review of disparities and the risk and outcomes of COVID-19 led by Public Health England11 was widely criticised for initially not containing recommendations or an action plan12. However, following the publication of the UKOSS data, NHS England’s Chief Midwifery Officer has called for action within maternity services13. In a move welcomed by the Royal College of Midwives14, maternity units in England will be asked to offer enhanced support of pregnant women from a BAME background, to enhance communication about risk and reassurance, consider vitamin D supplementation, to have a lower threshold to review, admit and consider escalation of care, and collect further data13.

It is true that there is much to be learned about SARS-COV-2 and how it functions as a disease. With more time, ongoing scientific research should produce some answers, but we must also remember that just ahead of this pandemic, the Marmot Review: 10 years on15 was published. The report showed little progress in inequalities of life expectancy, and reminded us that health is linked to the conditions in which people are born, grow, live, work and age15. A lack of data on ethnicity was noted to be a contributing factor to the limited understanding and analysis of how ethnicity may intersect with other social determinants, without such data we should caution on drawing conclusions based on assumption.

Now is a pivotal time to start new conversations as the #BlackLivesMatter campaign is driving discussion and debate. We must embark on a period of learning and listening to those that use maternity services. We must seek to understand how racism, discrimination and wider health determinants influence the way in which people access and experience our health and maternity services. We must all be vigilant and only when we see, hear and learn will solutions be apparent and change effective. How maternity services rise to this challenge is yet to be seen, but as the RCM suggest it is time for us to challenge ourselves to do better16.

  1. MBRRACE-UK (2019) Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-2017 can be accessed: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202019%20-%20WEB%20VERSION.pdf
  2. MBRRACE-UK (2018) Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-2016 can be accessed: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202018%20-%20Web%20Version.pdf
  3. NHS England Maternity Transformation Programme https://www.england.nhs.uk/mat-transformation/
  4. Gyamfi-Bannerman C, Srinivas SK, Wright JD, et al. Postpartum haemorrhage outcomes and race. Am J Obstet Gynaecol 2018;219:185.e1-185.e10.
  5. Caldwell CJ, McCullagh L Recent data indicate that black women are at greater risk of severe morbidity and mortality from postpartum haemorrhage, both before and after adjusting for comorbidity. Evidence-Based Nursing 2019;22:57.
  6. National Perinatal Epidemiology Unit UKOSS COVID-19 in pregnancy https://www.npeu.ox.ac.uk/ukoss/current-surveillance/covid-19-in-pregnancy
  7. Knight Marian, Bunch Kathryn, Vousden Nicola, Morris Edward, Simpson Nigel, Gale Chris et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369 :m2107
  8. International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Clinical Characterisation protocol for Severe Emerging Infection – UK https://isaric.tghn.org/UK-CCP/
  9. Harrison et al (2020) Ethnicity and outcomes from COVID-19: the ISARIC CCP-UK prospective observational cohort study of hosptialised patients Manuscript draft available: https://media.tghn.org/articles/The_Lancet_Ethnicity_Study_ISARIC.pdf
  10. Simpson CR, Thomas BD, Challen K, et al. The UK hibernated pandemic influenza research portfolio: triggered for COVID-19. Lancet Infect Dis. 2020;20(7):767-769. doi:10.1016/S1473-3099(20)30398-4
  11. Public Health England (2020) Disparities in the risk and outcomes of COVID-19 available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892085/disparities_review.pdf
  12. Iacobucci G. Covid-19: PHE review has failed ethnic minorities, leaders tell BMJ BMJ 2020; 369 :m2264
  13. NHS England News, NHS boosts support for pregnant black and ethnic minority women available from: https://www.england.nhs.uk/2020/06/nhs-boosts-support-for-pregnant-black-and-ethnic-minority-women/
  14. Royal College of Midwives Media Release: RCM calls for ‘Swift Implementation’ of NHS action plan to support BAME pregnant women available from: https://www.rcm.org.uk/media-releases/2020/june/rcm-calls-for-swift-implementation-of-nhs-england-action-plan-to-support-bame-pregnant-women/
  15. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J (2020) Health equity in England: The Marmot Review 10 years on. London Institute of Health Equity available from: http://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-full-report.pdf
  16. Royal College of Midwives Media Release: RCM says it will challenge itself to do better on race issues as it launched new campaign available from: https://www.rcm.org.uk/media-releases/2020/june/rcm-says-it-will-challenge-itself-to-do-better-on-race-issues-as-it-launches-new-campaign/

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