The disparity in outcomes in maternity for black, Asian and minority ethnic (BAME) women giving birth in the UK has been recognised for some time (Nair et al, 2016; Knight et al, 2018; Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK ([MBRRACE-UK], 2017). The coronavirus has forced this disparity in health inequalities to be elevated to national attention like never before (Royal College of Obstetricians and Gynaecologists ([RCOG], 2020).
MBRRACE-UK (2019) provided continual evidence that maternal and perinatal mortality rates were significantly higher for black, Asian, mixed race and minority ethnics. The UK Obstetric Surveillance System's (UKOSS) recent report (Knight et al, 2020) provides further indication of the disproportionate impact in relation to mortality with BAME women. It is suggested that this cannot be simply explained by higher incidence in the main geographical areas with known higher proportions of women from the BAME community, as outcomes were seen when women from areas such as London and West Midlands were excluded. The result also remained in spite of adjustment for age, body mass index and co-morbidities.
Therefore, there have to be some difficult conversations and discussions, which can be uncomfortable in a liminal space, facing issues of possible institutional racism or unconscious bias held and carried out within the provision of maternity services.
The Equality Act (2010) states it to be unlawful to discriminate against people because of their protected characteristics, such as race, religion or beliefs. Again, under the Public Sector Equality duty (2011), we as healthcare professionals are supposed to comply with the three aims; to eliminate discrimination, advance equality and opportunity, and to foster good relations with those who we serve, whether they have those protected characteristics or not.
Looking at national initiatives within maternity services to improve outcomes, there is the Department of Health and Social Care's ‘National maternity safety strategy’, to halve stillbirth and pre-term birth (Department of Health, 2017). There is the NHS England ‘Maternity transformation programme’, set out for safer more personalised care, as well as the ‘Saving babies' lives care bundle’ version 2, the RCOG ‘Each baby counts’, National Improvement Programme, the NHS Improvement ‘maternal and neonatal safety collaboration’ and the ‘National maternal and perinatal audit’ (NHS England and NHS Improvement, 2020).
It is evident that there is plenty going on to improve outcomes for mothers and babies under midwives' care. But, strikingly, there seems to be little impact on reducing these health inequalities for BAME client groups. The available data on COVID-19 provides a stark reality check and confirmation that marginalised groups have poorer health outcomes compared to their white counterparts (Lokugamage et al, 2020).
An array of potential explanations for these health disparities has been suggested, from social behaviours to health behaviours, comorbidities and potential genetic influences (Lokugamage et al, 2020).
How healthcare is provided has also been suggested as a factor; however, this argument is particularly targeted at the US. Conversely, the fact that these same health disparities are seen in the UK where there is universally free healthcare access for all, suggests this is not a reason (Knight et al, 2020).
The evidence of the disparities of COVID-19's impact between different population groups is clear. The disparities indicate a higher risk of infection and poorer outcome and death between certain ethnic groups. UKOSS (RCOG, 2020) found that 55% of women admitted to hospital with SARS-CoV-2 were from BAME communities. However, when you appreciate that BAME is stated to represent just 13%, of the UK population, this is highly significant (UK Government, 2020).
From a global health perspective, it is important to have an understanding of the differences between equality and equity, both in theory and in practice, with the concepts of marginalisation, vulnerabilities, resilience, who benefits and who is harmed (Stone et al, 2018). It is suggested that a healthcare practitioner who operates from assumptions and stereotypical opinions impairs healthcare provision, potentially putting people at risk (Papps and Ramsden, 1996). Within the Nursing and Midwifery Council ([NMC[, 2015) code, midwives are told to prioritise people, avoid making assumptions and to recognise diversity upholding human rights, challenging discriminatory attitudes and behaviours.
Personalised care is found throughout the maternity transformation programme, and I believe it does hold huge potential, if utilised truly in risk assessment for positive results driven through continuity.
To review the lack of personalised risk assessment today, two cases can be compared. The first, a 42-year-old Caucasian woman, with an in vitro fertilisation pregnancy, good diet, good lifestyle and physical activity, body mass index of 26 would be automatically categorised in a high-risk group. The second, a young black woman, aged 23 years old, spontaneous conception, poor diet, poor lifestyle, no physical activity, with a body mass index of 33, would be categorised as low risk. This is because risk is not always quantified in the correct manner, irrespective of the knowledge that exists today in relation to ethnicity and risk. Moreover, the present risk assessment tools have not changed fundamentally since the 1960s, utilised on a hugely different population in 2020 (Grandi et al, 2019).
Decolonisation of healthcare acknowledges the legacy that colonial rule has had and that it has penetrated into all facets of life, thus contributing to health inequalities experienced by certain groups today. The frequently proclaimed ‘father of gynaecology’ Marion Sims, credited as such because of his development of the Sim's speculum and surgical repair of vesico-vaginal fistulae, is a prime example, as history often omits his motivation was to return black slave women to work rather than the admirable intention to heal them (History, 2018). These women did not give consent, nor were they provided with any form of analgesia while these experiments took place (Brown, 2017).
Similarly, the Tuskegee syphilis eugenics experiments in the 1930s of untreated syphilis on black males were conducted without informed consent, instead informing the participants that they were being treated for bad blood while being intentionally denied a cure, even once one was identified. The study was projected to be concluded in 6 months, but instead went on for 40 years, into the early 1970s (Centres for Disease Control and Prevention, 2020). These are just two examples of many acts of the dehumanisation of certain ethnic groups.
Those who purport the decolonisation of healthcare argue these truths should be a part of the ethical syllabus within healthcare training, to initiate the dissipation of cultural arrogance where the colonial legacy may operate as an unconscious bias in professional behaviour rather than encouraging cultural humility (Foronda et al, 2016; Lokugamage et al, 2020), addressing the microcosm of inequalities in healthcare provision. Stemming from a social justice perspective, accepting the impact of this legacy of medical heritage, and the advantages of being white and male within a system based on patriarchal power, healthcare is required to reposition itself to address the power imbalances of the past and how they influence care in the present (Gishen and Lokumagamage, 2018). Highlighting the importance of the concept of cultural humility in the provision of medical care (Lokugamage et al, 2020).
Stakeholders within the Public Health England (PHE, 2020) review stated that the root of inequalities was racism, and that discrimination encountered by BAME communities and the stress resulting from such experiences impacts directly on one's resilience, physical and mental health. Some BAME groups stated a lack of trust in NHS services and treatments provided, resulting in hesitancy to obtain care in a timely manner. This often results in BAME users being seen in tertiary care for treatment rather than addressing issues earlier with potentially better outcomes if caught in primary care (PHE, 2020). Efforts to confront racism and discrimination, although a sensitive subject, must be addressed in a sensible manner but with commitment and pace to rebuild trust, reducing structural disadvantages. It can be argued there is both a legal and moral duty to reduce inequalities.
Garcia et al's (2015) scoping review for maternity intervention specific for BAME women concluded there was a lack of rigorous research and practice interventions, specific to maternity aimed to address culturally competent maternity services.
In an effort to confront these issues, midwives as a unit are now incorporating the principles of cultural safety within their mandatory training, taken from the New Zealand nursing model, as an adjunct to reflective practice (Nursing Council of New Zealand, 2011). The cultural safety nursing model – derived as a result of the same health inequalities being seen within the indigenous Maori population within New Zealand – was developed by Maori nurses to improve the Maori people's health status so they are afforded the same level of healthcare as the non-Maori population (Papps and Ramsden, 1996). It aims to assist the practitioner in understanding the dynamics of personal, cultural and professional power, and their impact on the provision of healthcare (Richardson and Carryer, 2005).
The key focus of this model is to deliver care in a manner that the consumer determines to be culturally safe (Nursing Council of New Zealand, 2011). It involves the healthcare practitioner quickly checking their own privileges and potential bias before undertaking a consultation with a client. It acknowledges that culture is complex, as cultural knowledge about particular groups is simply not enough for one to ever claim to be an expert. But by appreciating the historical, social and political influences on health, and the influences on relationships that may either engender trust or suspicion, it is possible to understand that one's own behaviour is formed from sophisticated social, personal events and experiences throughout life. This then impacts on a person's perspective of people, and therefore, often subconsciously, on a healthcare professional's practice. Therefore, it is important to gain an understanding of one's own culture identity, to rebalance power relationships.
Ethnicity goes beyond skin colour or geographical origin. As a matron in my previous role, there was a dispute between a maternity assistant and midwife. The maternity assistant refused to be instructed by the midwife, as the assistant believed her village in Nigeria to be superior to that of the midwife. Both were black Africans from the same country—this is a small example of some of the complexities that exist. Limiting knowledge to customs, rituals, colour or cultural practices of a particular group presumes that by learning these aspects gives one insight to the complexities and diversity of human behaviours and social realities. It does not.
In the need to address this discrepancy in outcomes for the BAME community within maternity, there has been suggestions that all BAME women, as with women over 40 years of age, should be simply classed as high risk. Personally, being a woman of colour, this felt to me as another layer of discrimination. Painting a vastly eclectic group, both culturally and physically, under the same umbrella based upon melanin appears deeply unfair. However, that is my perspective as a woman of mixed heritage and midwife. Nevertheless, that within itself holds some grounds, having an understanding from a frontline perspective and lived experience. With the recent spotlight being shone on the inequalities faced by ethnic minorities, it is paramount that midwives assess all women on an individual basis, recognising uniqueness. It is key that we accept the legitimacy of difference and diversity in human behaviour and social structure (Nursing Council of New Zealand, 2011), lowering our threshold for intervention for BAME groups, while adapting a humanistic approach.
Fundamentally, there is a huge opportunity within personalised care and risk assessment, but cultural safety must be demonstrated. I stand in agreement with the stakeholders involved in the PHE (2020) review, in the fact that COVID-19 has presented an opportunity to implement transformative, structural societal change. Continuity and personalised care provide a pathway for sustainable change to mitigate further impact that includes and goes beyond maternity care provision.