Most people would assume that maternal deaths in the UK are, although tragic and comparatively rare, a risk faced equally by all mothers. Sadly, research has shown that this is not the case. There appears to be a relationship between maternal death and ethnicity.
The link was highlighted by researchers at Oxford University’s ‘Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries’ (MBRRACE) unit. MBRRACE investigated outcomes from a range of births during 2016-18 and found that maternal death was five times more likely in black women than it was in white women.
The report, published at the end of 2020, came after a year of increased awareness of racial equality, or more accurately, of the frequent lack of racial equality in our society. MBRRACE’s report raised the spectre that, despite decades of progress, racism remains an institutional problem, and not something limited to the far right or ignorant chants on football terraces.
As well as racial disparities in maternity care, other Important findings from the 2020 MBRRACE report include:
- The significant increase in Sudden Unexpected Death in Epilepsy.
- 90% of those that died in the three-year period from 2016-18 had multiple problems suggesting “a constellation of biases are preventing women from receiving the care that they need.”
- Women living in the most deprived areas were almost three times more likely to die than those who lived in the most affluent areas.
Indirect and Direct Causes of Maternal Deaths
According to the MBRRACE report, indirect causes of maternal deaths were:
- Cardiac disease (the highest cause)
- Neurological causes (epilepsy and stroke) are the second most common indirect cause of maternal death, and the third commonest cause of death overall.
- A “statistically significant increase in maternal mortality due to Sudden Unexpected Death in Epilepsy (SUDEP)” was also noted.
With regard to direct causes of maternal deaths, the following points were noted:
- Maternal deaths from direct causes are unchanged with no significant change in the rates between 2013-15 and 2016-18.
- “Thrombosis and thromboembolism remain the leading cause of direct maternal death during or up to six weeks after the end of pregnancy”
- Tragically Maternal suicide remains the leading cause of direct deaths occurring within a year after the end of pregnancy.
Maternity Outcomes for Ethnic Minority Women
The report, using data from England, found that except for Chinese mothers, black and minority mothers had worse maternity outcomes than white women. Death rates during or within six weeks of pregnancy were just eight per 100,000 for white women (and only five per 100,000 for Chinese women). Asian women had a death rate of 15 per 100,000, close to the rate for mixed-race women of 16 per 100,000. However, the rate for black women was, by a wide margin, the largest, at 40 per 100,000. This meant they were not just five times more likely to die than white women, but also two-and-a-half more likely to die than any other ethnic minority.
Figure 2. Disparities in maternal deaths in Black, Asian, and Mixed ethnicity women
Asian or Asian British babies are at the highest risk for neonatal death (73% increased risk compared to White babies). However, between 2015 and 2017 Black or Black British babies had the sharpest rise in neonatal deaths (from 43% to 67% increased risk compared to White babies.
MBRRACE Report Conclusions
MBRRACE did not suggest any reasons for these differences. The unit produces regular reports highlighting problems within maternity care nationwide. While it will produce recommendations, frequently clinical, in this case, the size and nature of its research meant that while it could identify the discrepancies in outcomes, it could not identify the causes. It therefore recommended to policymakers and managers that more work was necessary to understand and address the differences.
The report, however, noted characteristics of the women who died between 2016-18. These included:
Women at severe disadvantage appear to be over-represented amongst the women who die, multiple disadvantages include substance abuse, domestic abuse, refugee or asylum, mental health diagnosis, learning difficulties and female genital mutilation.
2. ‘Medical and Pregnancy-Related Characteristics’
66% of the women who died in 2016-18 were known to have pre-existing medical problems, 11% were known to have pre-existing mental health problems.
Conditions like pre-eclampsia, where the mother suffers from high blood pressure during pregnancy, are more prevalent in black women than other ethnicities. This, in turn, can result in related complications being more prevalent in black women.
3. ‘Other Characteristics of Women who died’
- Inadequate utilisation of antenatal care services – associated with an increased risk of maternal death
- The proportion of women who died who received recommended levels of antenatal care still remains low, 29% of the women that received antenatal care, received the recommended level of care according to NICE antenatal care guidelines (booking at 10 weeks or less and no routine antenatal visits missed).
4. Classification of quality of care’
- Among the women who died 29% were assessed to have received good care, but detailed assessment of notes shows that for another 51% improvements in care may have made a difference to their outcome.
- For 44% improvements to care may not have made a difference to outcome
5. Birth place
26% of the women who died (in the perinatal period, up to six weeks after the birth) between 2016-18 were born outside of the UK, 36% of whom were not UK citizens.
The report indicates that women born in certain countries had a significantly higher risk of death compared to those born in the UK. According to Table 1 in the MBRRACE report the relative risk is higher for those women from India, Bangladesh, China and Nigeria.
Table 1. Maternal mortality rates according to the mother’s country of birth (selected countries ) 2016-18.
In a December 2020 report by Public Health England titled, Maternity high impact area: Reducing the inequality of outcomes for women from Black, Asian and Minority Ethnic (BAME) communities and their babies” the “cause of poorer outcomes for women and babies from BAME communities were noted as multi-factorial and that more research was needed to better understand the contributory factors.
However it was noted that common issues which can exacerbate problems for this population include:
• low socio-economic status or social support
• lack of proficiency in English
• multiple vulnerabilities such as FGM or recent migrant status
• policy of charging undocumented migrants for maternity care
• a ‘one size fits all’ approach to maternity care which does not consider differences in women’s abilities to understand or access care, or serve the most vulnerable appropriately, can result inequalities in healthcare provision, contributing to structural racism
• cultural barriers combined with insufficient training of healthcare professionals in cultural sensitivity and knowledge.”
Racial Disparities in Women’s Healthcare: Going Beyond the MBRRACE Report
To mark International Womens’ Day in 2020, the Royal College of Obstetricians & Gynaecologists (RCOG) released a policy position statement which noted the following key issues:
- BAME women can receive a lower quality of care and experience poorer health outcomes than other women. Results are poorer health outcomes and worse experiences with the NHS as evidenced in the MBRRACE report.
Poor health outcomes are seen in infant birth statistics with Black, Asian, and minority ethnic women are at an increased risk of having a pre-term birth, stillbirth, neonatal death or a baby born with low birth weight.
- Historically this has been attributed to socioeconomic factors – BAME women are more likely to live in areas of high deprivation and have lower incomes and experience language barriers and poorer access to women’s healthcare services.
However Research in America has shown that ethnic disparities in health clearly exist despite socioeconomic factors.
- The reasons for persisting health inequalities include implicit racial bias affecting quality of care BAME women receive and influencing how women interact with health services.
The policy statement noted “It can, for instance, negatively influence diagnosis and treatment options made by clinicians, including pain management and indirectly affects medical interactions through loss of patient centeredness in treatment plans and removal of patient autonomy.”
Implicit racial bias is unconscious and often unintentional, but implicitly held negative stereotypes about race, ethnicity and gender influence interactions with patients and the care they receive.
The policy statement noted: “It is therefore vital that UK governments, the NHS, clinicians and the public better understand and recognise the presence and impact of implicit biases in order to eliminate health disparities in the UK.
US Research on bias in the medical profession. The results of a meta-analysis of 20 years of studies covering many sources of pain in numerous settings found that black/African American patients were 22% less likely than white patients to receive any pain medication.
On the basis of its research the RCOG is calling for more research into disparities for BAME women in healthcare for better understanding of the inequalities and causes in the UK, this generates solutions.
The recommendations include:
- Government action – reporting on racial inequality in maternity care and recommendations
- Ending the gender and ethnicity data gaps in medical research.
“There is a significant data gap in medical research contributing to health disparity outcomes in the UK. Women of all ethnicities are less likely to be invited to, or participate in, medical trials and research17 – despite women comprising 51% of the population.”
“Amplifying the gender disparity further for Black, Asian, and minority ethnic women is the fact that they are less likely to have participated or be included in medical research compared to white people. Lack of understanding and preconceptions about the incidence, prevalence and presentation of common conditions within certain ethnic groups amongst healthcare professionals leads to delays in diagnosis, resulting in a higher risk of morbidity and mortality.”
- The establishment of robust training programmes in medical schools to eradicate implicit racial bias.
The disparities reach into other areas too. The Covid-19 pandemic presented a significant risk for many sections of the population because of their health condition or status. Because the effects of the virus were unknown, pregnant women were included in the ‘clinically vulnerable’ classification as a precaution. What became apparent is that pregnant BAME women were far more likely to require hospital admission than pregnant white women.
One study showed that over half the pregnant women admitted to hospital with Covid-19 were from BAME communities, this is despite them only constituting around one-eighth of the population. While the reasons behind this might be complex, for example reflecting differential infection rates, it further highlights the gap between white and BAME health outcomes.
Pre-Existing Medical Conditions for Pregnant Women: Why Are BAME Women Being Overlooked?
On the topic of pre-existing medical conditions, two serious findings of the 2020 MBRRACE report included:
- Almost 75% of women who died during or up to six weeks after pregnancy in 2016-18 had pre-existing physical or mental health conditions.
- There was little discussion regarding pre-existing mental health conditions despite the fact that 198 of those 566 i.e. 35% of women who died experienced pre-existing mental health conditions.
In a BMJ Report “Disparity in maternal deaths because of ethnicity is “unacceptable”, published January 18 2021, it was noted that disparity in mortality simply because of ethnicity is unacceptable and it is unacceptable for women with pre-existing medical conditions to not receive an appropriate standard of care.
“Marian Knight, lead author for MBRRACE-UK and professor of maternal and child population health at the University of Oxford, said that disparity in maternal mortality simply because of a woman’s ethnicity was recognised as “unacceptable.” She added, “It is equally unacceptable for women with pre-existing medical conditions such as epilepsy to receive a lower standard of care simply because they are pregnant.”
Research has also shown that BAME women appear to be more likely to give birth prematurely. Black women, especially those with a black Caribbean background, are twice as likely as white women to give birth before 37 weeks. Premature birth has been linked to numerous long-term risks to infants; the negative effects of poorer maternity outcomes can last long after birth.
Case study: Serena Williams
Serena Williams may have been a high-profile example of the problem. The Grand Slam winner found herself ignored when she told medical staff she was concerned she had a pulmonary embolism, a potentially fatal blood clot on her lungs. Despite having suffered one before, and with a history of blood clots, Williams’ was at first ignored by a nurse who thought it was confusion caused by pain medication. After she insisted, she was given an ultrasound on her legs, despite stressing the problem was her lungs. When she was finally given a CT scan of her chest, it was discovered that she did, indeed, have clots on her lungs.
Williams’ story sparked a flood of similar stories from black women. And it highlighted that if she struggled to have her voice heard, despite her money and stature, other ethnic minority women are unlikely to have better experiences.
Interview with Dr Christine Ekechi
In an Interview with Dr Christine Ekechi, co-chair RCOG Race Equality taskforce and a consultant obstetrician and gynaecologist at Imperial Healthcare in London, U.K, (published in Medical News Today) – looked into gynaecological healthcare experiences of black women in the United Kingdom. The need to understand the relationship with difficulties in maternity and pre-existing conditions was also noted:
“Black women are more likely to have conditions such as obesity, high blood pressure, [and] diabetes that put them at risk of having poorer outcomes in gynaecological health and subsequent outcomes.”
Dr Ekechi also commented that other perceived factors behind poor health outcomes included language barriers, low trust in the NHS and socio-economic background.
It is likely that there isn’t a single cause for the discrepancy between the experiences of white and ethnic minority women.
While research such as the MBRRACE report have met with concern from ministers and others, there has yet to be any specific move to investigate and address the problems identified, although some measures currently being implemented may help.
- The Chief Midwifery Officer has also made four recommendations, included better data collection, recommending vitamins, and better communication. Crucially, she also recommended that clinicians have lower thresholds when considering admission and escalation in women from non-white backgrounds.
- Unfortunately, the Care Quality Commission, also identifying the disparities, noted that most services had not implemented the four recommendations, and that many improvements that had been made — like the improved continuity of care — were suspended during the Covid-19 pandemic.
- Public Health England have, as part of their ongoing work to improve the health, and health outcomes, of the nation, published a set of resources to support efforts to improve maternity care.
- Split into six high-impact areas, covering topics like planning and preparation, mental health, and smoking and alcohol reduction, the resources are intended to give children the best possible start in life, and to ensure that mothers have as problem-free a pregnancy as possible.
- The sixth high-impact area, however, is perhaps the most wide-ranging. While the other areas focus on specific elements of pregnancy and maternity, the sixth area covers the poorer outcomes women from black and minority ethnic backgrounds (BAME) have in every area of maternity.
Sadly, it is hard to conclude that, despite the concerns of ministers and NHS leaders, there has been significant improvement. And, for black and minority ethnic women giving birth, they will be subject to the postcode lottery, and will have to hope that their concerns are being addressed by the medical profession.
Making a Compensation Claim for Negligent Maternity Care
Pregnancy can be an anxious time for a mother but experiencing poor maternity care is not something any woman should have to face. If mistakes were made by a nurse, midwife, GP or obstetrician or gynaecologist before or during your pregnancy or during childbirth, you could be entitled to claim compensation.
Whilst not all mistakes lead to a compensation claim, if the treatment you received fell below the standards expected from a competent medical professional and you or your baby experienced serious harm, compensation may be available.
The birth injury or negligence could be associated with:
- Inadequate monitoring of the baby or mother
- Misdiagnosing a serious condition eg. preeclampsia
- Mistakes made by a surgeon or anaesthetist eg. bladder, ureter and bowel injuries sustained during Caesarean sections.
- A poor standard of care during the delivery resulting in cuts, bruising, hip and shoulder damage and fractures to a baby
- Failure to treat or adequately treat serious post-birth complications in the mother eg. fissures, negligence associated with birth tears and /or episiotomy, poor stitching
- Failure to identify and treat secondary infections or other infections eg Group B Strep infections
- Brain injuries to a baby associated with mistakes made before, during or after childbirth
- Birth injuries associated with fetal head impaction
- Placenta or parts of the placenta retained
- Mistakes made in reading CTG results on a fetal heart monitor
- Serious birth trauma to mother or baby
- Mistakes made during a breech birth or the failure to plan for a breech delivery,
Contact Devonshires Claims medical negligence solicitors for advice on making your birth injury claim.
We provide a free no-obligation case evaluation as well as a ‘No Win No Fee‘ agreement, so there are no upfront costs to start your claim and nothing to pay if your case is not successful*. To start your free case evaluation, contact our birth injury claims experts today on 0333 900 8787, email email@example.com or complete our online form.