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Risk assessments and ethnicity in maternity care: looking through the wrong end of the telescope?

02 February 2024
Volume 32 · Issue 2


Many Black and brown women are classified as ‘high risk’ and follow obstetric-led pathways. This may be the result of social determinants of health, or over pathologisation as a result of racial bias by healthcare providers and systems. There may be times when social determinants are mistaken for innate physiological differences, leading to iatrogenic harm. There is both over and underdiagnosis resulting from racial bias in midwifery care. Women with intermediate risk factors may benefit from midwifery-led care, especially Black and brown women. Community-based, relational, women-centred midwifery models of care can reduce the problems of pathologisation and redress some social inequalities.

Most research on midwife-led care and birthplace choice takes women already classified as ‘low risk’ as a starting point. Despite the well-documented benefits of midwife-led care (Brocklehurst et al, 2011; National Institute for Health and Care Excellence (NICE), 2017; Cohen et al, 2018; Scarf et al, 2018; Hutton et al, 2019), increasing numbers of women are classified as high risk, and consequently are put on an obstetric-led care pathway, especially in labour and birth. However, the mechanisms of the classification into low and high risk merit scrutiny, as data suggest this disproportionally affects Black and brown women and leads to higher rates of intervention in that population (Weisband et al, 2018; Webster and NMPA Project Team, 2021; Melamed et al, 2022). This article will explore the mechanisms for this, including the use of the white body as the ‘norm’, leading to both under- and over-diagnosis, social determinants of health, misuse of race-based risk algorithms, and falsely locating the cause of poorer outcomes in physiology rather than in social determinants.

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