Ethnic disparities in maternal careBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m442 (Published 12 February 2020) Cite this as: BMJ 2020;368:m442
Maternal health—or lack of it—is one of the starkest examples of racial health inequalities in the United Kingdom and in the United States. Work in the UK by University of Oxford researchers found that between 2014 and 2016 the rate of maternal death in pregnancy was 8 in 100 000 white women, compared with 15 in 100 000 Asian women and 40 in 100 000 black women (box 1).1 It’s a similar picture in the US, where African-American, Native American, and Alaska native women die of pregnancy related causes at a rate three times that of white women, according to a May 2019 report by the Centers for Disease Control.2
Problems in maternal care
In 2015-17, 209 women died during or up to six weeks after pregnancy in the UK, from causes associated with their pregnancy, giving a mortality rate of 9.2 women per 100 000
The overall maternal death rate in the UK did not fall significantly between 2012-14 and 2015-17
Assessors judged that 44% of women who died had good care, but that better care might have made a difference to the outcome in 29% of women who died
Thrombosis and thromboembolism were the leading direct causes of death, followed by maternal suicide
Cardiac disease remains the largest single cause of indirect maternal deaths, followed by neurological causes, particularly epilepsy and stroke
Women and health professionals need to be more aware that heart disease can and does affect young women, and that the additional strain that pregnancy places on the heart can reveal cardiac complications for the first time, said doctors from the European Society of Cardiology in a foreword to the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) report. Among the women who died some had symptoms that would have been treated seriously had they occurred in non-pregnant women. Breathlessness when lying flat and chest pain which spreads to the back or arm or fainting during exercise are not normal during pregnancy
Since the MBRRACE report was published in 2018 several research projects have been launched to investigate the underlying reasons for inequality and to identify what can be done to reduce the disparity between women of different ethnic backgrounds. This work is due to be completed in 2020
The NHS Long Term Plan sets a target of halving maternity related deaths, stillbirths, neonatal mortality and serious brain injury by 2025. Its plans include establishing Maternal Medicine Networks to direct women with acute and chronic medical problems to timely access to specialist advice. There is also focus on preventing preterm births with specialist clinics
The American College of Obstetricians and Gynecologists acknowledges that the causes of these differences in maternal health outcomes “include the impact of racism and implicit bias in access and delivery of healthcare to women.”3
Deidre Cooper Owens, a professor in the history of medicine at the University of Nebraska-Lincoln in the United States, says, “Nobody wants to be accused of being racist towards their patients. That’s a really heavy charge. But a lot of what we see now, both in the diagnosis and in the treatment of maternal complications in black women, comes from a time when doctors had essentially been socialised not to respect black people as human beings.”
Christine Ekechi, a consultant obstetrician and gynaecologist at Imperial College Healthcare NHS Trust in London, says that black women in the UK are negatively affected by racial bias in medicine. “People think of racism in an overt, aggressive way. But that’s not always what it is. It’s about biased assumptions—and we doctors have the same biases as anyone else,” she says.
She cites the differences in diagnosis of endometriosis in white and non-white women as an example. Black women are less likely (odds ratio 0.49, 95% confidence interval 0.29 to 0.83) than white women4 to receive a correct diagnosis of the condition. It takes an average of seven years for women overall to get a diagnosis of endometriosis.5
“I think that doctors’ bias affects how women are treated. Female pain is seen as not equal to male pain, and pain in black women is not treated in the same way as in white women,” Ekechi says. “Endometriosis is diagnosed on the basis of symptoms, primarily pain, and the results of a scan and a laparoscopy. But I think the fact that black women more commonly have fibroids means that they are more likely to receive conservative management instead of being investigated for endometriosis, less likely to receive the appropriate investigations, and doctors are less likely to do a laparoscopy.”
Ekechi is part of a taskforce convened by the Royal College of Obstetricians and Gynaecologists to tackle the ethnic disparities in maternal care. In September 2019 she chaired a roundtable of academic researchers, midwives, junior doctors, consultants, and policy makers “to educate ourselves about the issue and more importantly, work on solutions,” she shared on social media.
Solutions are desperately needed. Gurch Randhawa, professor of diversity in public health at the University of Bedfordshire, says that the failure to reflect ethnic minority data throughout medicine stems from a lack of inclusion of black and ethnic minority patients in the research process. He says that unless all ethnic communities are included in research, the medical profession will never be able to develop culturally competent diagnostic tests and services—and therefore can’t deliver true equity in healthcare.
“What I see time and time again is that when research is commissioned, it often excludes diverse groups and adequate numbers of people from ethnic minorities or lower socioeconomic groups. These groups are hugely under represented in research, and studies are not designed with them specifically in mind,” Randhawa told The BMJ. “Therefore any interventions developed from the research by definition won’t be fit for purpose in those groups.”
But Randhawa stops short of calling for the inclusion of ethnically diverse patient groups to be mandated by research grant funding organisations. Instead he urges organisations such as the National Institute for Health Research to pay far more attention to better reflecting the ethnicity of the UK population that the NHS serves. “It’s to do with the whole structure of how research is commissioned. That’s got to be the start of the whole narrative,” he says.
Ekechi is clear that the disparities in maternal care should not go unacknowledged and untackled any longer. “We’re tired of this issue being a talking point,” she says. “We’re now ready for tangible action.”
For more articles in The BMJ’s Racism in Medicine special issue see bmj.com/racism-in-medicine.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not peer reviewed.