By Dr Sureka Suriyakumar, Obstetrics & Gynaecology Doctor, London.
I am at that age where I am surrounded by family and friends, educated professional women, who are falling pregnant for the first time in their life. As an Obstetrics and Gynaecology Doctor, I am often surprised about how little they know about pregnancy beforehand and as a second generation South Asian, I am alarmed by their lack of awareness regarding racial inequalities in pregnancy.
During the COVID-19 pandemic and following the Black Lives Matters protests , the topics of racial health inequalities and BAME (Black Asian Minority Ethnic) have become vogue and trendy. This made me wonder what I would want my family and friends belonging to the BAME community to know about racial inequities and their pregnancy outcome, with the aim to educate and create awareness.
I would tell them that:
" If you’re a Black or Asian woman, you are five times
or twice more likely, respectively, to die during your pregnancy in comparison to a White woman. " MBRRACE-UK Report 2018 [1]
Quite a haunting statistic, particularly if you’re a BAME woman, however I should add that fortunately maternal death in the UK remains rare (13 in 100,000 women), which serves as a comforting thought. This shocking statistic was publicised following a UK review into the reasons behind the deaths of 209 pregnant women between 2015 and 2017.
These results were unexpected, and this review did not set out to investigate racial inequalities, hence their study wasn’t able to explain the cause behind this racial inequity. However, they remarked that 96% of the women who died spoke English and 64% were born in the UK, suggesting the source of these inequalities may be more than just language barriers in BAME women.
Ironically, this study raised more questions than answers, particularly regarding the presence of unconscious racism given all these women were part of a society with free healthcare.
I would tell them that:
"Black or Asian babies, in the first month of their life, have a higher chance of dying in comparison to White babies – this was the case throughout the study period (2015-17)"
MBRRACE-UK Report 2018 [1]
Yet again, the MBRRACE report brought to light surprising disparities, between different ethnic communities. The study wasn’t able to connect these results with the women’s socioeconomic status or the babies’ birth weight- the latter is known to be on average lower in BAME babies. They concluded that their results were not able to explain the gap and that further research was needed to evaluate its origins.
The limited data from the MBRRACE report means that, at present, whether these results are due to inequalities in maternity care, general society or both, remains unknown.
I would tell them that:
" If you’re a South Asian woman in the UK you’re up to 70% less likely to undergo prenatal testing for Down’s Syndrome compared with a White woman."
Domandy et Al., 2005 [2]
We’ve known since 1998 that there’s a link between BAME women and lower approval for antenatal screening tests such as for Down’s syndrome [3]. It is also known that South Asian women are significantly less likely than White women to report being offered the screening[4]. Several studies since have highlighted the same trend and some have suggested this was owing to language barriers or negative attitudes towards antenatal screening tests due to their objections to Abortion.
However, a study in 2004 looking at over a thousand pregnant women in the UK and their uptake for Down’s syndrome antenatal screening test revealed poorer knowledge and lower rates of informed choices among the South Asian women when compared to White women . They did notice that women with negative attitudes towards termination also had a more negative attitude towards having the screening test. However, the attitudes towards testing across BAME women were similar to that across White women. Concerningly, the level of knowledge regarding screening tests and the rate of informed choice among pregnant South Asian women was markedly lower than in White women. They suggested that lack of informed choice and knowledge played a significant role in the lower uptake of Asian women in antenatal screening and called for more interventions to increase knowledge in BAME women.
Another study [5] which caught my eye, surveyed Muslim women regarding their antenatal experiences. There is currently a significant lack of research exploring this group of women who actually represent a large collection of women from diverse cultures, ethnicities, and languages. The survey revealed that many Muslim women felt poorly represented in maternity care and that some healthcare professionals were insensitive to their needs due to lack of familiarity with Islamic beliefs and customs. This impacted their confidence in discussing their needs, making them more reluctant to discuss their birth plans and concerns with staff, as they felt these would be overlooked. The women also felt they were less likely to attend antenatal classes due to presence of males or to be given space where they could ask for female staff for examination without judgment.
They stressed the urgent need for cultural training in healthcare staff and better representation of Muslim women in the maternity workforce.
I would tell them that:
"55% of the pregnant women admitted to hospital with COVID-19 were from a BAME background.
Black pregnant women are eight times more likely to be admitted to hospital with COVID-19, while Asian women are four times as likely."
Results from National UK Study on COVID-19 in Pregnant women, May 2020 [6]
As we entered 2020, the COVID-19 pandemic proved to be the latest example of stark racial inequality in maternity care. This national study involved 194 obstetric units across the UK and its findings once more highlighted the inequities in maternity care and mirrored the warnings raised in the 2018 MBRRACE report. They also demanded for urgent action and investigation into the origins of these racial disparities.
Unfortunately, due to the rapidly changing nature of COVID-19 testing and the fact that this report was produced during an ongoing pandemic, they were unable compare ethnicity with severity of disease as they did not have the outcomes for all the women in the study. However, they did comment that the higher incidence of BAME women being hospitalised wasn’t solely due to higher proportions of BAME women in major cities.
These results remained the same even when they excluded women from London, the West Midlands, and the North West of England which consist of the largest cities in England. They also drew parallels to preliminary results from a US COVID-19 study that showed similar racial inequalities in BAME women but the US study attributed this to lack of access to healthcare in the BAME communities. However, the fact that the same patterns have emerged in the UK, which has a free healthcare system suggests the reason behind this inequality may be beyond just lack of access to healthcare.
Why am I telling you this?
Training on cultural diversity has gained growing recognition as an important part of healthcare professional education and there are positive signs of change, such as the introduction of the RCOG (Royal College of Obstetricians and Gynaecologists) Race Equality Taskforce to tackle racial differences in Maternity. However, there is still a remarkable lack of understanding about cultural diversity in the healthcare system which is fuelling existing racial inequalities, ethnocentrism (act of judging another culture from the perspective of one’s own) and unconscious racism that are ultimately leading to poor maternity care and creating a barrier for BAME women during pregnancy.
I feel there is a great need to raise more awareness and transparency regarding these alarming racial disparities among women. I believe this change could be pivotal to breeding a new era where we, healthcare professionals and patients, can work together to understand the roots of these inequalities, creating solutions and enabling women, as millennials would say , to remain woke about their pregnancy care.
Artwork credit: Instagram @melmelanie.art
References
Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. 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 2019. ISBN: 978-0-9956854-8-2. Available from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
Rowe RE, Garcia J, Davidson LL. Social and ethnic inequalities in the offer and uptake of prenatal screening and diagnosis in the UK: a systematic review. Public Health. 2004; 118(3): 177-189. doi: 10.1016/j.puhe.2003.08.004
Ford C, Moore AJ, Jordan PA, et al. The value of screening for Down’s syndrome in a socioeconomically deprived area with a high ethnic population. Br J Obstet Gynaecol. 1998;105(8):855-859. doi: 10.1111/j.1471-0528.1998.tb10229
Hamilton SM, Maresh MJ. Antenatal screening by history taking–a missed opportunity. J Obstet Gynaecol. 1999;19(1):10-14. doi:10.1080/01443619965868
Firdous T, Darwin Z, Hassan SM. Muslim women’s experiences of maternity services in the UK: qualitative systematic review and thematic synthesis. BMC Pregnancy Childbirth. 2020; 20(1): 115. doi: 10.1186/s12884-020-2811-8
Knight M, Bunch K, Vousden N, et al. on behalf of the UK Obstetric Surveillance System SARS-CoV-2 Infection in Pregnancy Collaborative Group. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ. 2020; 369: m2107. doi: 10.1136/bmj.m2107