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
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Lilian Anekwe draws welcome attention to the large ethnic disparities in maternal care . However, focus on racism in medicine alone fails to acknowledge the impact on migrants of draconian NHS charging policies which may account for some of these. The delayed MBRRACE-UK report on Maternal Deaths and Morbidity 2015-17, suggested that at least 3 women may have died after being deterred from accessing vital maternity care because of fears of large bills and concerns about their immigration status. (1)
Poverty, homelessness, domestic violence and mental ill-health have long been recognised as contributory factors to adverse pregnancy outcomes. (2) The ‘Hostile Environment’, supposedly intended to deter ‘illegal’ immigration, has created a swathe of laws preventing undocumented migrants from working or accessing benefits. (3) This has particularly harmed women, pushing many to become dependent on male partners. Inevitably, some face the stark choice between continuing in an abusive relationship or becoming destitute if they leave, both situations risking physical health and taking a toll on their mental health. (4)
Since 2010 NICE has advocated more intensive maternity care for women ‘with complex social factors’. (2) And yet, government policies that deliberately exclude migrant populations serve to create and exacerbate the very conditions that NICE has been concerned to address for pregnant women. Simultaneously, exorbitant NHS charges for maternity care increase the likelihood that chargeable women (as well as other migrant or minority ethnic women who do not know whether or not they are chargeable) will book late, if at all, or fail to attend necessary appointments. Such responses are not just the effects of racial bias. They are the predictable effect of policies condemned by many, including the BMA and Faculty of Medical Royal Colleges. (5,6)
1. Knight M, Bunch K, Tufnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. 2019, Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford.
2. NICE, 2010, Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. Clinical guideline 110. www.nice.org.uk/guidance/cg110
3. Liberty (ed.), 2019, A Guide to the Hostile Environment. https://www.libertyhumanrights.org.uk/sites/default/files/Hostile%20Envi...
4. Maternity Action, 2018, What Price Safe Motherhood? Charging for NHS maternity care in England and its impact on migrant women. https://maternityaction.org.uk/wp-content/uploads/WhatPriceSafeMotherhoo...
5. British Medical Association, 2019, Delayed, deterred, and distressed: The impact of NHS overseas charging regulations on patients and the doctors who care for them. https://www.patientlibrary.net/tempgen/194115.pdf
6. Academy of Medical Royal Colleges, 2019, NHS charges to overseas visitors regulations: A statement from the Academy of Medical Royal Colleges. https://www.aomrc.org.uk/wp-content/uploads/2019/03/2019-03-14_NHS_charg...
Competing interests: Susan Bewley is a Trustee of Maternity Action
That Asian women have twice the rate of maternal death, and black women have five times the risk of maternal death compared to white woman is truly shocking. After all, we live in one of the wealthiest countries in the world. But it is not just pregnant women of colour that are disadvantaged by their ethnicity.
Pregnant women that identify themselves as Gypsies and Travellers are at increased risk of poor obstetric outcome. The 1997-1999 Confidential Enquiry (1) into maternal death in the United Kingdom found Gypsies and Travellers have "possibly the highest maternal death rate amongst all ethnic groups”. These women also have very high associated infant mortality and perinatal death rates.
At the 2001 census 58,000 people identified themselves as either Gypsies or Travellers. I suspect that as they are from such a small demographic group, inadequate data exists to know the true extent of the problems these women face. As they are at such presumed high risk this cohort of pregnant women must be treated with the utmost of care, respect and attention. And not ignored nor forgotten about.
1 Lewis G, Drife J. Why mothers die 1997-1999: the confidential enquiry into maternal deaths in the United Kingdom. RCOG Press, 2001
Competing interests: No competing interests