Guest post: “Black women are five times more likely to die in the perinatal period”

[BojanaMumsnet]

Whilst the majority of outcomes for pregnant women and their babies are positive, the stark truth is that Black, Asian and minority ethnic (BAME) women have a greater chance of suffering a poorer experience or health outcome when compared to white women.

Findings from the MBRRACE-UK 2015-17 report (published in 2019) shocked the nation. This study found that Black women have more than five times the risk of dying in pregnancy or up to six weeks postpartum compared with white women. Furthermore, women of mixed ethnicity have three times the mortality risk and Asian women have almost twice the risk compared to white women.

Addressing health inequalities is a key priority for the Royal College of Obstetricians and Gynaecologists (RCOG) and, therefore, we hosted an International Women’s Day event on 6 March 2020 – entitled ‘We need to talk about race’ – to expand our understanding.

It quickly became clear that the reasons for these stark health inequalities are complex and are not yet fully understood. Reasons may include socio-economic factors, poor access to antenatal care and other women’s health services and a gender and ethnicity data gap in medical research.

A growing body of research in America also shows that disparities in health outcomes clearly exist despite socio-economic factors and other demographic variables.

Implicit racial bias, though often unconscious and unintentional, can also lead to poorer health outcomes and experiences for Black, Asian, and minority ethnic women which can hinder consultations, negatively influence treatment options and can ultimately result in Black, Asian and minority ethnic women avoiding interactions with health services.

Since then, the COVID-19 pandemic hit the world, and this has shone a light on some of the health disparities that exist in maternity care.

A higher proportion of pregnant women from BAME groups have been admitted to hospital with COVID-19 when compared to white pregnant women and current data suggests that BAME men and women have a greater risk of death from coronavirus than white people in England and Wales.

It’s important to remember that an individual woman and her family lies behind every shocking statistic; a woman who has died or suffered a poor health outcome, sometimes along with her baby, which, in some cases, could have been avoided.

This is completely unacceptable. All women, irrespective of location, age, or ethnicity, should be able to access the same high-quality care and we, as clinicians, have a duty to ensure that care is the best it can be for everyone.

Therefore, in July 2020, the College launched a Race Equality Taskforce to tackle racial disparities in women’s healthcare and racism within the obstetrics and gynaecology workforce.

As a Co-Chair of the Taskforce, I am completely committed to tackling these deplorable outcomes for Black, Asian and minority ethnic women. I believe that the solutions to preventing unnecessary harm require a committed collaborative effort between clinicians, Government and women to ensure that the gap in health outcomes is eradicated.

The FiveXMore ‘five steps’ campaign is a useful tool for Black, Asian and minority ethnic women to use in all healthcare settings, not just in maternity care. As the campaign notes, women should speak up if they feel something is not quite right, they should seek a second opinion if they feel the need to and they should always trust their own feelings and seek help if they think something is wrong.

It will not be easy to eliminate inequalities in women’s healthcare services. But the time to act is now, and the RCOG intends to do just that.

Dr Ranee Thakar will respond to some comments next week.

[PatricksRum]

Ah, a guest post! Great!
Will pin to read for later.
Thanks HQ

[tornadoalley]

Have studies been done to find out the specific issues encountered by BAME women to identify where these inequalities lie?

[EchoCardioGran]

We nearly lost a family member in pregnancy a few years ago, and at the time I didn't know where to go for advice. It felt quite lonely fighting a young mum's corner, and I remember one very young doctor at the hospital A and E kept asking me was I "A Matriarch?". I got a bit rude with him.

It's been a long time since I had my own children and I'm shocked at these statistics. I really welcome these campaigns, it's so important to raise awareness.
www.fivexmore.com/6steps
Mums, and family and friends of mum please read up on the fivexmore six steps. Really important for us all to learn about.

[mamanrose]

'Mumsnet' suggests the site is for mothers
have gone through childbirth or are expecting children.

I'm sure the majority of black women are aware of this and are terrified or traumatized by this.

Why does this need to be shared as as guest post on a site for a majority white audience?

How do you think black mothers feel seeing this information shared in this way?

[EchoCardioGran]

I think it's a really good idea. Why shouldn't everyone read it? I don't think it's here to frighten people. Strange perspective.

I never knew anything about gestational diabetes, for example, when I was younger, but it's important to know about.

Building awareness is not frightening people? Any woman can develop it, but it particularly affects women in certain groups. Knowing that you can be screened is a good thing surely?
( just an example)

www.nhs.uk/conditions/gestational-diabetes/
Any woman can develop gestational diabetes during pregnancy, but you're at an increased risk if:

your body mass index (BMI) is above 30 – use the healthy weight calculator to work out your BMI
you previously had a baby who weighed 4.5kg (10lb) or more at birth
you had gestational diabetes in a previous pregnancy
1 of your parents or siblings has diabetes
you are of south Asian, Black, African-Caribbean or Middle Eastern origin (even if you were born in the UK)
If any of these apply to you, you should be offered screening for gestational diabetes during your pregnancy.

Maybe try reading the actual links and seeing what they say.

[FTMF30]

What really gets me about this is that there is no real answer why this is the case. How can you mitigate against something if you don't know the cause. There are assumptions but that is it.

[omega3]

Great initiative.

[Pinktruffle]

Very well put @EchoCardioGran. It's important everyone knows that this inequality exists and unfortunately, the truth is often ugly. @mamanrose white women cam be allies and as @EchoCardioGran pointed also need to be aware of some of the issues that they could also potentially face. Burying your head in the sand and pretending things are all fairies and roses never helped anyone.

[EchoCardioGran]

Thanks Pink
I ended up on Mumsnet a fair while back, because I was engine searching for information as I had care of a new born baby and a toddler 24/7 because mum was so unwell. It's over 40 years since I had babies.
Reading the experiences of many new mums these days really shocked me. Some things to me seem worse rather than better than in my day. Shortage of midwives for a start. Mums still not being listened to. Lack of money. Austerity.
Maternal mortality is a societal problem, not just a medical matter.

As someone said in the links I just followed.

It feels like an (obstetrician) problem, but really, maternal mortality is a broader societal problem," she said. "If everyone pays a little more attention to their piece of the pie, hopefully we can start to move the needle.

[SerenityNowwwww]

Daft Q maybe - but do we know the tunic makeup of midwives and maternity staff in the U.K.?

Maybe it’s because of where I live but when I was having DS all but one of the staff in the maternity clinic and ward were black/Asian.

Does that staff background make a difference? Is is education - mums or staff?

It’s tricky to compare any stats with the US because of the healthcare system there.

[SerenityNowwwww]

Tunic = ethnic. My autocorrect is a bit eccentric.

[BojanaMumsnet]

Hi @mamanrose,

Point taken, and thank you for raising it. It's a really tricky balance (one we've thought about before when covering things such as the risk of serious birth injuries or stillbirths) - of course we don't want to frighten people without being able to share constructive advice but we hope the Five X More messages shared in the OP provides that and will help to empower expectant mothers who are particularly affected by this issue.

[RedRumTheHorse]

@SerenityNowwwww question is important. As well as knowing the ethnic makeup do we know the percentage of were these staff work? As in what percentage work in the hospital and what percentage work in the community? Also geographical location?

I noticed that while I was treated by black/asian staff in the hospital all the midwives treating me in the community were white. One of them when booking me in didn't listen to me which led to my GP, who is asian, having to intervene to ensure I got adequate medical care. I also changed community midwife teams due to her behaviour.

[EchoCardioGran]

The Nursing and Midwifery Council produced this report last year Serenity. Lots of stats here. I haven't had a chance to read thoroughly. But I think Table 4 and 5 are of interest. Sorry, tech is leaving me behind these days, so not sure how I shorten the link, apologies.
www.nmc.org.uk/globalassets/sitedocuments/annual_reports_and_accounts/edi/edi-2018-19-data-tables.pdf

[Gazelda]

I think it's vital that studies such as this are shared and discussed on forum predominantly populated by white mothers.

All aspects of race inequalities should be constantly discussed to ensure awareness and to encourage all mothers to want to fight for better equality.

[StandWitch]

Hi, Dr.

Do you think it is helpful to reduce this to 'Black women' per se?

The MBRRace report you refer to provides:

55 White European women died of direct causes (which as a whole are mostly deaths from thrombosis), and 76 from indirect causes (as a whole mostly cardiac causes)

meanwhile

4 Black African women died of direct causes, and 18 of indirect causes. Just below that it is given that the death figures for women born in Africa (some of whom might be white, of course) were respectively 3 and 16 (the country of birth is missing for 13 and 15 respectively).

4.9% of all births in 2015-2017 were to mothers born in Africa.

So there are far more indirect deaths, presumably cardiac/stroke/epilepsy, than expected, but no more direct deaths.

At the same time 3 Black Caribbean women died of direct causes, and 4 of indirect causes.

Separately 3 & 1 (direct/indirect) women born in the the Caribbean, S & C America are given as having died.

Only 0.5% of babies were born to mothers born in S America, 0.4% born in the Caribbean, and 0.06% to mothers born in C America.

So whereas the expected number of deaths to women born in this region is by random chance 1 & 1 respectively, it was 3 & 1. In absolute terms this is small, in that clearly 30 vs 10 has much more statistically significance than 3 vs 1.

Further, the report notes

. Similar to the previous triennium, overall there was no statistically significant difference in maternal death rate between women born in the UK and those born outside the UK in 2015-17.

I.e. in general women born outside the UK do not suffer worse outcomes than those born in the UK.

The report adds that there were 10 deaths of women born in Nigeria, and adds that Eritrea was another source, though the number is not given.

The 10 figure for Nigeria is very high, but there doesn't seem to be evidence for a generalised extra risk to 'black women' per se, as compared to 'white women' per se. Rather, there is a clear risk of excess maternal mortality for women born in specific countries, and this has been reported in successive Mbrrace reports with the same countries cropping up again.

I believe that Nigeria's maternal mortality rate is 80x higher than the UK, although I am not sure if the figures are exactly comparable (Nigeria might be better or worse than that), but clearly a risk perhaps of two orders of magnitudes higher, and this is repeated across Africa.

Clearly a large part of this is due to poor healthcare in those countries, but it does not seem that we should necessarily conclude from the fact that Nigerian-born women in the UK have worse healthcare outcomes than UK-born women in the UK, but far better than Nigerian-born women in Nigeria, that the reason is likely to be implicit racial bias.

Obviously research should be done, but it does not seem that your pitch here is very accurate about the underlying data, i.e.:

• women born in certain countries at very high risk
  
• black women are not a monolithic group, and don't share a common experience
  
• mothers born in sub-Saharan Africa giving birth in the UK are around 4x more likely to be aged over 45 than mothers born in the UK. Fewer than 1 in 1000 births to mothers born in Poland giving birth in the UK were aged 45+, but for sub-Saharan Africa that rises to 1 in 86. (2017 figures).
  
  It does not seem all that helpful to say 'we must talk about race', when there seem to be much stronger inputs into risk. And suggesting to black women that the NHS is going to put their health at risk does not seem fair either to the NHS, or to black women.
  
  The very high rate of geriatric pregnancy and very specific characteristics of those dying, and the specific deaths as well (cardiac), do not really suggest an institutionally racist health care system so much as fundamental differences between different groups of women, that cannot be reduced to mere skin colour.

[mamanrose]

@BojanaMumsnet

Hi *@mamanrose*,

Point taken, and thank you for raising it. It's a really tricky balance (one we've thought about before when covering things such as the risk of serious birth injuries or stillbirths) - of course we don't want to frighten people without being able to share constructive advice but we hope the Five X More messages shared in the OP provides that and will help to empower expectant mothers who are particularly affected by this issue.

I disagree. The casual discussion of black mortality on a predominantly white forum further adds to the dehumanisation of black people.

[OnceUponAThimble]

Is there a study involved where obesity is ruled out and where sub-par healthcare is ruled out? Pound for pound, is it the same, all things being equal?

[wishcaptainbarnaclewasmyboss]

This is very sad.

I don't really have any right to comment on this, as a white woman, so feel free to ignore me in favour of other more relevant opinions.

I do wonder whether this is partially explained by the way that our system is designed and currently operates. In my experience:

1. the system is underfunded and midwives and junior doctors in particular follow a number of protocols that don't suit all women and SOME of them really don't look at the woman in front of them to determine whether this is appropriate and to tailor to the needs of the individual. Some of my medical care over two pregnancies has been great and some has been very paint by numbers, where it has been clear that those involved have not read my notes and have just applied "the protocol" to me, as patient #234
   
   
2. SOME of those midwives and doctors (often the same ones!) tend to dismiss the view of the labouring/pregnant woman when she tries to speak up. This happened to me (I had to threaten to sue before i was "permitted" to see a consultant - who then agreed with me and prevented serious damage being done. God only knows what would have happened if I hadn't been able to exercise my privilege in being legally trained, white and confident in expressing my views in English)
   
   I imagine that for 1), the system and protocols are tailored to the majority of white women who have an uncomplicated vaginal delivery. If you don't fit the box, you have to rely on a degree of luck that you will get a professional who looks at you as an individual. And for 2), I suspect black woman have to battle a system that dismisses all women more often than it should but in which black women find it even harder to be taken seriously and are more likely to have their opinions dismissed.

[SerenityNowwwww]

We also need to not just look at the ethnicity but also the country of origin/culture too. Are there still some practices around the word that are now deemed here to dangerous/unadvisable/confusing that could cause issues?

Also age of the mother, number of pregnancies, health/ ongoing health issues, religion (could a religious practice get in the way if healthcare - off the top of my head, a refusal to take a blood transfusion), immunisations, language skills, diet, etc etc etc.

Sometimes the high level stats just don’t tell the full story.

[Pheobeasy]

Universities on the whole don't tend to teach how certain conditions present on skin that isn't Caucasian. There are plenty in pregnancy where this is an issue, but thinking about the most widely known in general, most people would know that a rash that doesn't fade under pressure is a warning sign for meningitis. This can be a lot less obvious (but still visible) on other skintones, but no one really knows what it would look like as the education pieces don't show us- so it's not just an issue for HCPs but for everyone. There have been some pledges by some universities to be more inclusive and include this, but it's not enough.

[SerenityNowwwww]

I read recently about a book that was written by a new doctor at student which shows things like rashes on different colour skin because they show differently. I couldn’t believe it didn’t exist already - so obvious!

[SugarSW7]

@SerenityNowwwww

We also need to not just look at the ethnicity but also the country of origin/culture too. Are there still some practices around the word that are now deemed here to dangerous/unadvisable/confusing that could cause issues?

Also age of the mother, number of pregnancies, health/ ongoing health issues, religion (could a religious practice get in the way if healthcare - off the top of my head, a refusal to take a blood transfusion), immunisations, language skills, diet, etc etc etc.

Sometimes the high level stats just don’t tell the full story.

As a Black woman, I know that it wasn't intended, but I find the inference that some of us are possibly practicing things that are "now deemed here dangerous/inadvisable" etc very offensive.
It's this kind of question that if one were to inherently hold whilst being a midwife could lead to unconscious bias in how people are dealt with.

I'm not here to cause an argument, but honestly, I read that out to some family members and a friend who is White and they all gasped.

[SugarSW7]

*some of us could be

[SerenityNowwwww]

I was actually thinking of some of the things my older family in the ME might suggest to be honest. My grandma did nursing during WW2 and my god, the things she would suggest doing for ailments. So no, I’m not thinking black, actually ME and white because this is what I know. These could be things women’s grans could suggest as ‘natural’ or home remedies.