The last blog in our series to focus on maternal inequalities comes from Kaat De Backer¹ & Dr Nicola Vousden² and provides an overview of some of the evident social drivers of maternal inequality within the UK and how this might begin to be addressed with personalised care.

For more than two decades, the UK Confidential Enquiry into Maternal Deaths has consistently shown that women of Black and Asian ethnicity have a significantly increased risk of dying during pregnancy or within six weeks of the end of pregnancy, when compared with women of White ethnicity. These findings were echoed in a recent report by the All-Party Parliamentary Group on Birth Trauma, highlighting the disparities between the outcomes and experiences of Black and Asian women, and those of their White counterparts [1]. However, ethnicity alone does not explain the full extent of these issues, as it is closely intertwined with other social determinants of health. Repeated confidential enquiries have shown that women living in the most deprived areas are also at greater risk of maternal mortality and morbidity than women living in the least deprived areas. To reduce these health inequalities, national strategies in England such as the Core20plus5 approach prioritised women from Black, Asian and minority ethnic communities and from the most deprived groups for continuity of carer [2]. While implementation of continuity of carer is no longer a key priority in maternity services due to ongoing post-Covid strain on the healthcare service, it still highlights an intersectional approach is needed to address the underlying causes of maternal health inequalities and to improve maternal outcomes.

The complex interactions between social determinants of health on one hand and medical, obstetric and social risk factors on the other has also been described as a ‘constellation of biases’ [3]’. This concept was first introduced in the 2020 MBRRACE-UK report, and aimed to shine a light on the biases that women with multiple problems are experiencing, thus impacting the care they receive. In this blog, we want to zoom in on some of the challenges in regard to this complex issue, in order for women to access holistic, integrated and personalised perinatal care.

Firstly, the profound impact of social adversity is known to affect psycho-social wellbeing as well as physical health. Professional curiosity and routine enquiry about people’s personal circumstances and daily challenges is critical to obtain a holistic picture of the range of issues people are facing, not just in terms of their health conditions, but how these might be compounded or exacerbated by for instance poor housing circumstances, a controlling and coercive partner, or the care for a child with a disability. However, questions about such sensitive issues are often confined to an initial contact, such as a booking appointment. In many cases, professionals rely on women’s disclosure and sharing of sensitive information, in order for them to be signposted or referred to specialist support, for instance for domestic abuse. Yet disclosure requires trust, which is often developed over time, and with continuity of carer. Therefore, honest and meaningful conversations need to happen throughout pregnancy and the postnatal period, to offer opportunities for sharing sensitive and personal information, when women feel ready to do so, and to a healthcare professional they trust and confide in. A one-off tick box approach will not do.

Secondly, the impact of domestic abuse on women’s mental health should never be underestimated. A recent report from the Royal College of Psychiatrists showed that violence and abuse are driving mental illness in women and girls, leading to serious mental health symptoms, such as suicidal ideation and psychotic symptoms. With domestic abuse and coercive control often escalating during pregnancy, routine inquiry is essential to ensure women are receiving appropriate support for their physical, social and mental wellbeing.

Thirdly, disclosing social adverse circumstances can lead to stigma and discrimination, for instance when a pregnant woman discloses alcohol or substance use. In addition, it can lead to diagnostic overshadowing [4] when recognition of severity of symptoms or clinical management of health conditions is delayed or impaired due to a professional’s knowledge of a patient’s psycho-social circumstances. A recent database study highlighted that women with severe mental illness were more likely to experience an obstetric near-miss, such as sepsis, cardiac arrest or pulmonary thrombo-embolism [5]. Healthcare professionals need to be vigilant to avoid misattributing physical symptoms to women’s wider psycho-social circumstances and therefore denying them timely and appropriate care.

Finally, whether or not women disclose sensitive information should not be the make-or-break of their maternity care experience. A recent systematic review on routine discussion of previous trauma in the perinatal period highlighted that not all women will disclose the full extent of the challenges they face, and therefore consideration should be given to all women, regardless of disclosure [6]. The implementation of a robust strategy for trauma-informed maternity care is therefore a priority.

In conclusion, we advocate to continuously work with women through pregnancy and the postnatal period, to help them understand what their own risk factors might be, and find ways to explore this in a sensitive, personalised way. It is better to ask, than not to ask, as long as it is done with sensitivity, compassion and appropriate action.

A series of helpful videos can be found here: https://vimeo.com/showcase/9905864

¹ Department of Women and Children’s Health, School of Life Sciences and Medicine, King’s College London

² National Perinatal Epidemiology Unit, University of Oxford (nicola.vousden@npeu.ox.ac.uk)

1. Thomas K. Listen to Mums: Ending the Postcode Lottery on Perinatal Care. In: Trauma A-PPGoB, editor. London2024.
2. NHS England and Improvement. Core20PLUS5 – An approach to reducing health inequalities London2021. Available from: https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/.
3. Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, et al. Saving Lives, Improving Mothers’ Care Maternal, Newborn and Infant Clinical Outcome Review Programme. Oxford: 2020 9781838367800.
4. Jones S, Howard L, Thornicroft G. ‘Diagnostic overshadowing’: worse physical health care for people with mental illness. Acta Psychiatrica Scandinavica. 2008;118(3):169-71. doi: https://doi.org/10.1111/j.1600-0447.2008.01211.x.
5. Easter A, Sandall J, Howard LM. Obstetric near misses among women with serious mental illness: data linkage cohort study. British Journal of Psychiatry. 2021. doi: 10.1192/bjp.2020.250.
6. Cull J, Thomson G, Downe S, Fine M, Topalidou A. Views from women and maternity care professionals on routine discussion of previous trauma in the perinatal period: A qualitative evidence synthesis. PLoS One. 2023;18(5):e0284119. Epub 20230517. doi: 10.1371/journal.pone.0284119. PubMed PMID: 37195971; PubMed Central PMCID: PMCPMC10191284.

For other blogs in this series please see:

Culturally Appropriate Care In Midwifery Education

Empowering Change: The Association of South Asian Midwives Advocating for Equitable Maternity Care

https://blogs.bmj.com/ebn/2024/05/26/what-is-the-role-of-a-consultant-midwife-lead-for-inclusivity-and-why-is-this-needed/