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.

[BojanaMumsnet]

@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.

Hi @SerenityNowwwww

Here's the response from RCOG:

"Thank you for your message. NHS Digital does not include the make-up of maternity staff in their published NHS workforce statistics. However, the RCOG can roughly find out the ethnicity of the obstetric workforce using our own data.

However, implicit racial bias also plays a part in the poorer health outcomes experienced by people of Black, Asian, and other minority ethnic origin. It can, for instance, negatively influence diagnosis and treatment options made by clinicians, including pain management, and indirectly affects medical interactions. To combat this, we believe that a robust training programme should be included in medical school curricula, to recognise the presence and impact of implicitly held biases on patient outcomes and embed positive behaviours."

[BojanaMumsnet]

@SugarSW7

I'm a Black woman that gave birth last year at a SE London birth centre. Throughout my care in pregnancy and for delivery, I had White midwives.
They were impeccable. I couldn't have asked to be more supported, listened to or encouraged. They were fantastic. So, from a personal point of view, I don't support any view that midwives are somehow racist or biased.

However, what I will say is this - much of the practice in the UK is based on research conducted here and in the US, which has been done on samples of majority White, if not all White participants.
As an example, allowing all women to go up to 42 weeks gestation has been shown to be fine for White women and extremely detrimental to Black women.
The outcomes for a Black woman who gives birth prematurely at 35-38 weeks are much more positive than for a White woman who gives birth at the same gestation. Whereas a White woman may be able to carry until 42 weeks, the majority of whom will be OK, but the risk of maternal and infant mortality is high for Black women.
I read this research and after having had five miscarriages, I begged my community midwife to book me in for an induction at 41 weeks, rather than 42. She'd never heard of the research, but took it on once I showed it to her. I didn't need the induction in the end.
My point is, that if care now includes women from different backgrounds, one size fits all doesn't work and this may be a factor in the stats here.
The NHS know that Black women are more likely to have pre-eclampsia, they act on it quickly, they also know about the higher risk of gestational diabetes - we're all sent for tests regardless of BMI and history. I think this is fantastic. The more Black women participate in research, the better the outcomes will be.

Hi @SugarSW7

Here's the response from RCOG:

"Thank you for your message. We agree that it is vital that medical research is inclusive of all women. Understanding how women and marginalised individuals present and respond to different medical conditions and treatments will help to diminish disparities in healthcare outcomes and improve diagnostic rates."

[BojanaMumsnet]

Hi @stickygotstuck,

Here's the response from RCOG to your question:

"Thank you for your message. Yes, barriers to communication can have a negative impact on health outcomes. Language barriers have been explored in several studies which show, for example, that it can lead to women avoiding interactions with healthcare services.

Nevertheless, a growing body of research in America has shown that ethnic disparities in health outcomes exist despite socio-economic factors and other demographic variables. It impacts BAME women from the lowest as well as the highest socio-economic groups. Therefore, this is a complex issue that we definitely need more research to fully understand."

[BojanaMumsnet]

@tornadoalley

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

Hi @tornadoalley

Here's the response from RCOG:

"Thank you for your message. There have been several studies exploring socio-economic factors and their impact on health outcomes. However, a growing body of research in America has shown that ethnic disparities in health outcomes clearly exist despite socio-economic factors and other demographic variables, thus negatively impacting BAME women from the lowest as well as the highest socio-economic groups. We also know that there is a significant data gap in medical research contributing to health disparity outcomes in the UK. It is clear that more research is required that includes the individual experiences of BAME women in the UK."

[SugarSW7]

@Mollscroll from what I know there hasn't been any research as to why, but yes, I think it would be interesting to explore.
I think it definitely sounds physiological. Like you say about Sickle Cell being more prevalent in Black people and Cystic Fibrosis more prevalent in White people, it could just be another one of those differences.
I think there is fear about suggesting that we have different bodies, etc, but I think it's worth exploring because then maybe outcomes can be improved.

[Mollscroll]

That’s so interesting sugar. I did not know that. Has there been any study into why this is ? It sounds physiological rather than social but perhaps that’s hard to investigate without going down a ‘black and white women have different bodies’ route which might be tough to navigate. Obviously they do and we know that (eg sickle cell prevalent in one group and not another) but perhaps there’s fear inhibiting needed research.

[Pheobeasy]

Yes of course it should be, but these stats are nothing new, nothing has changed or has been done before. Raising awareness online is a powerful tool, one that has been the catalyst for many changes. Sad that it's the case, but here we are.

[hoven]

@Pheobeasy

Well yes, unfortunately though for those who have been working tirelessly to get the curriculum amended, raise awareness with HCPs for years and years, it hasn't been enough. The social media campaign is credited for actually causing some universities to include care of black women- ie how different things present on skin, conditions that are more prevelent etc. So yes, it is important to raise awareness imo- if you think it's just a case of training or an email being pinged to midwives and other medical professionals and that's problem solved then that's ridiculously naieve.

Not training or an email. I work at a university myself and recognise the efforts that are put forward to drive change in research and education. Namely, hiring or using diversity consultants, committees and many other 'behind the scenes' efforts. The focus here should be on the organisations themselves rather than internet users.

[imissthesouth]

This needs a full investigation into how to reduce it. Certain ethnicities are more likely to develop diseases (particularly lifestyle related ones eg diabetes and heart disease) lots of research is poured into them so why has antinatal taken so long?

[Pheobeasy]

Well yes, unfortunately though for those who have been working tirelessly to get the curriculum amended, raise awareness with HCPs for years and years, it hasn't been enough. The social media campaign is credited for actually causing some universities to include care of black women- ie how different things present on skin, conditions that are more prevelent etc. So yes, it is important to raise awareness imo- if you think it's just a case of training or an email being pinged to midwives and other medical professionals and that's problem solved then that's ridiculously naieve.

[mamanrose]

@Pheobeasy

I'm suggesting that sharing this on a forum consisting of a majority white audience comes across as 'trauma porn' and is dehumanising to black people.

Or raising awareness which is what we desperately need.

The awareness needs to be raised with healthcare staff through professional training rather than anonymous internet users

[Pheobeasy]

I'm suggesting that sharing this on a forum consisting of a majority white audience comes across as 'trauma porn' and is dehumanising to black people.

Or raising awareness which is what we desperately need.

[mamanrose]

@firsttimemamabear00

I'm suggesting that sharing this on a forum consisting of a majority white audience comes across as 'trauma porn' and is dehumanising to black people.

[firsttimemamabear00]

@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?

@mamanrose - I'm quite confused by your comment. Im a first time expectant mother, and also a black woman, and yes these statistics really do worry me, especially on top of Covid and general concerns all expectant mothers may face. But curious as to why you think the post shouldn't be shared on Mumsnet because it is 'majority white' audience. I had never heard of the campaign mentioned in the post... and may well have never come across it if it wasn't posted on Mumsnet. Are you suggesting that because it is a majority white audience, articles impacting expectant mothers who are non white are not relevant/ important? That's certainly what it seems like. 🤔

[picklemewalnuts]

The statistic is shocking. The underlying causes need to be discussed and investigated. This needs to happen without fear of accusations of racism on either side.
People may have implicit bias, they may have an interesting perspective- shouting 'racist' at the situation doesn't help people learn or change the way they engage, it makes them disengage.

[RedRumTheHorse]

@TheGoldenApplesOfTheSun my partner (white) was terrified when he heard the Covid restrictions as when I was induced the initial staff treating me were all white. They refused to listen to me about anything and only listened when he went to speak to them. He noticed this every single time.

[stickygotstuck]

@SugarSW7

I'm a Black woman that gave birth last year at a SE London birth centre. Throughout my care in pregnancy and for delivery, I had White midwives.
They were impeccable. I couldn't have asked to be more supported, listened to or encouraged. They were fantastic. So, from a personal point of view, I don't support any view that midwives are somehow racist or biased.

However, what I will say is this - much of the practice in the UK is based on research conducted here and in the US, which has been done on samples of majority White, if not all White participants.
As an example, allowing all women to go up to 42 weeks gestation has been shown to be fine for White women and extremely detrimental to Black women.
The outcomes for a Black woman who gives birth prematurely at 35-38 weeks are much more positive than for a White woman who gives birth at the same gestation. Whereas a White woman may be able to carry until 42 weeks, the majority of whom will be OK, but the risk of maternal and infant mortality is high for Black women.
I read this research and after having had five miscarriages, I begged my community midwife to book me in for an induction at 41 weeks, rather than 42. She'd never heard of the research, but took it on once I showed it to her. I didn't need the induction in the end.
My point is, that if care now includes women from different backgrounds, one size fits all doesn't work and this may be a factor in the stats here.
The NHS know that Black women are more likely to have pre-eclampsia, they act on it quickly, they also know about the higher risk of gestational diabetes - we're all sent for tests regardless of BMI and history. I think this is fantastic. The more Black women participate in research, the better the outcomes will be.

These are very important, valid points.

Separately, I wonder if there have been any in-depth studies into language. Does it play a role in this shocking statistic? I'm thinking specifically of pregnant women with English is a second language (although of course, this won't affect all BAME women). Is it possible that some women are not having access to qualified medical interpreters when they should? Specially in those cases where their English seems 'good enough' but may not be up to communicating/fully understanding important stuff during appointments, etc.

If so, I'd expect this not to be one of the major factors, but could it be a contributing factor too?

[TheGoldenApplesOfTheSun]

This is particularly worrying in the light of covid restrictions on birth partners. How can a woman have an advocate to help her if she still isn't allowed a companion until active labour, per my local hospital rules? Even if you can have someone with you, women are now faced with the hard choice of partner or doula, mother or sister. Two birth companions can support each other and take breaks. Only one would have to be a very strong character to keep advocating for her throughout the whole of labour...

[SerenityNowwwww]

My grandma would have had you rubbing butter your stitches (or honey) and steaming a wound does sound familiar.

[SugarSW7]

@SerenityNowwwww I'm so sorry for jumping to conclusions. Thank you for clearing that up, I should have asked first, but I completely see where you're coming from with family advice etc.
It's truly a complex issue. Now that you say it, my mum told me after I had my stitches to steam them as that's what they did in Ghana when she was younger.
Turns out if I'd listened, thankfully I didn't, my stitches would have come undone! So, yes, you're right!

[SugarSW7]

I'm a Black woman that gave birth last year at a SE London birth centre. Throughout my care in pregnancy and for delivery, I had White midwives.
They were impeccable. I couldn't have asked to be more supported, listened to or encouraged. They were fantastic. So, from a personal point of view, I don't support any view that midwives are somehow racist or biased.

However, what I will say is this - much of the practice in the UK is based on research conducted here and in the US, which has been done on samples of majority White, if not all White participants.
As an example, allowing all women to go up to 42 weeks gestation has been shown to be fine for White women and extremely detrimental to Black women.
The outcomes for a Black woman who gives birth prematurely at 35-38 weeks are much more positive than for a White woman who gives birth at the same gestation. Whereas a White woman may be able to carry until 42 weeks, the majority of whom will be OK, but the risk of maternal and infant mortality is high for Black women.
I read this research and after having had five miscarriages, I begged my community midwife to book me in for an induction at 41 weeks, rather than 42. She'd never heard of the research, but took it on once I showed it to her. I didn't need the induction in the end.
My point is, that if care now includes women from different backgrounds, one size fits all doesn't work and this may be a factor in the stats here.
The NHS know that Black women are more likely to have pre-eclampsia, they act on it quickly, they also know about the higher risk of gestational diabetes - we're all sent for tests regardless of BMI and history. I think this is fantastic. The more Black women participate in research, the better the outcomes will 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.

[SugarSW7]

*some of us could be

[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.

[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!