Adverse birth outcomes in England – which include stillborn babies, premature birth, low birth weight and the death of the mother during pregnancy or after birth – are closely linked to inequality.
A report on maternal deaths in the UK has found that in comparison to white women, black women are four times more likely to die when childbearing. Asian women, or women with mixed ethnicity, have twice the risk of dying. Reports from previous years have documented similar outcomes.
Furthermore, a recently published study has found that a mother in England who is black or South Asian has an increased risk of stillbirth, premature birth or low birth weight, as does a mother from a lower socioeconomic background. The risks multiply for a woman who is both poor and black or South Asian. These women are the most likely to experience an adverse birth outcome.
While the largest inequalities were seen in the most socioeconomically deprived black and South Asian women, adjusted data demonstrated that socioeconomic deprivation, smoking and body mass index (BMI) had little effect on outcomes for women from ethnic minorities.
This means that a black or Asian woman who is not poor, does not smoke and does not have a BMI outside the recommended range may still be at a greater risk of an adverse birth outcome than a white woman with a similar economic and health background. This points to racism as a cause.
Evidence of racism
Research by one of us (Sally Pezaro with colleagues) and funded by the Mary Seacole Awards surveyed a sample of 20 midwives in London to explore the care provided by midwives for ethnic minority women with high risk pregnancies. The findings, while specific to a small group of midwives in a single location, do provide evidence of racism and bias.
Black and Asian women were reportedly not listened to or taken seriously. One midwife participant said that if the woman she had been caring for had been listened to earlier, “things could have been different”. Another midwife observed that “there is a lot of stereotyping that black women do not want to take their health seriously”. The study found that some midwives held negative attitudes towards migrant women who were ineligible for free healthcare. In turn these women often felt too scared to access care for fear of being charged for it.
Broader social issues add further complications. One participant in the research suggested that families from minority backgrounds who relied on zero hours contracts or did not have adequate childcare provision would be less able to attend appointments.
Asylum seeking and refugee women face particular difficulties in accessing support when pregnant, as described in a report by one of us (Amanda Firth) which outlines the findings of research also funded by the Mary Seacole Awards. This study looked at mental health care and found that asylum seeking and refugee women had difficulties in communicating, often because they were not offered the use of an interpreter. The difficulty in accessing interpreting services meant that midwives resorted to the use of Google Translate, or prioritised communication about physical rather than mental health.
Looking for solutions
Suggestions for how to remedy the adverse birth outcomes faced by black and Asian women are often too narrowly focused or misguided. One proposed recommendation, for example, held that women from ethnic minority backgrounds should consider having their pregnancy induced (when labour is started artificially) at 39 weeks, because this can reduce the risk of stillbirth.
Proposals like these may lead to racial profiling and the solidifying of bias about women from minority backgrounds and their pregnancies. Instead, an approach to risk management which considers each woman and her pregnancy individually is required.
Evidence shows that continuity of care – when a particular midwife follows women throughout pregnancy, birth and the postnatal period – can make a real difference. This continuity consistently increases positive outcomes for women and babies in socially disadvantaged and ethnic minority groups.
Another recent study found that targeted caseload midwifery, which prioritises continuity of care and includes more and longer appointments, some of which are at home, had a positive impact. In a deprived and diverse inner city population, this model of care reduced premature births and births by Caesarean section.
Ultimately, measures like this can only be part of the solution. Educational interventions as well as fundamental policy and system changes which prioritise anti-racism are required to make sure that all pregnant women receive the care they need.