Black women are five times more likely to die in childbirth, so what can we do?

Black women are five times more likely to die in childbirth than white women.

That was the finding of the MBRRACE-UK: Saving Lives, Improving Mothers’ Care report (Knight et al 2019).

While the statistics change over time, the problem remains. On this page, I discuss some of the reports which have highlighted this problem, and what we can do about it.

The Reports

Black women are five times more likely to die in childbirth than white women.

That was the finding of the MBRRACE-UK: Saving Lives, Improving Mothers’ Care report (Knight et al 2019). That report was published in December 2019. If you’re not familiar with this project, its subtitle should give you a good idea of what it’s about: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015–17.

Just nine months later, in August 2020, MBRRACE-UK released another report. The findings of Maternal, Newborn and Infant Programme: Learning from SARS-CoV-2-related and associated maternal deaths in the UK were sad, but not surprising. At least to those of us who work with woman and families. It showed a similar trend; that many of the women who died from COVID-19 were from Black, Asian or ethnic minority backgrounds. As a result of this and other reviews, the recommendation was made that:

“Women of BAME background, [or with other risk factors such as hypertension, diabetes or raised BMI], should be advised that they may be at higher risk of complications of COVID-19; we advise they seek advice without delay if they are concerned about their health” (RCOG Coronavirus and pregnancy guideline 2020).

Five times more

But the problem existed before the 2019 coronavirus appeared. The pandemic has exacerbated an existing problem, not simply created a new one. If you’ve not seen the summary of the MBRRACE-UK 2019 report, here’s the key finding that I want to discuss today:

“There remains a five-fold difference in maternal mortality rates amongst women from Black ethnic backgrounds and an almost two-fold difference amongst women from Asian ethnic backgrounds compared to white women, emphasising the need for a continued focus on actions to address these disparities.” (Knight et al: iii)

It’s a stark statistic.

Black women are five times more likely to die in childbirth in the UK than white women. And, in this report, the authors are defining childbirth to mean anytime during pregnancy, labour, birth or afterwards, up to six weeks after the baby is born.

Asian women are twice as likely to die in childbirth than white women, and women of mixed ethnicity are three times as likely to die in childbirth than white women.

The bigger picture

It’s important to understand that these figures are also part of a bigger picture about women who experience inequality for a range of reasons. These reasons include race but they may also be more complex than that:

“Nearly a quarter of women who died in 2015-17 (23%) were born outside the UK; 42% of these women were not UK citizens. Overall 10% of the women who died were not UK citizens. Women who died who were born abroad and who were not UK citizens had arrived in the UK a median of 3.5 years before they died (range 3 months to 18 years). Women who died who were born abroad were from Asia (30%, mainly Pakistan, India and China) and Africa (40%, mainly Nigeria, Eritrea and South Africa), Eastern Europe (17%, mostly from the Czech Republic and Romania) with the remainder from other parts of Europe, the Americas and the Caribbean.

However, women born in certain specific countries had a significantly higher risk of death compared to women born in the UK. Of the 20 women who were not UK citizens and were born outside the UK, three were refugees/asylum seekers (15%), four (20%) were recently arrived wives of UK residents, four were EU citizens (20%) and nine (45%) had another or unknown status.

It is also of note that 20% of women who died were known to social services, highlighting further the vulnerability of many women who died.” (Knight et al 2019: 13).

So what can we do about this?

It’s really clear than we need some deeper analysis of why this is and what happens in maternity care. Why black women are five times more likely to die. Some of that analysis is underway. As you can see above, reports are regularly published. Plans and actions are apparently in place. But we can’t wait for it. And goodness knows there are enough recommendations out there already. If recommendations made a difference, there would be no need for blog posts like this one.

And I’m going to argue that we don’t need to wait. I think it’s really clear, not just from this report but from every other report that I’ve ever seen from around the world, that there are some key things that we can all do more of that can make a difference. No matter who you are or how you work with woman and families.

The authors of this report stress this as well:

“[T]here are actions we can take as individuals now. Continued awareness of these inequalities within our own services and questioning whether the way we deliver care before, during and after pregnancy unconsciously disadvantages different groups of women, whether on the basis of their ethnicity, socioeconomic status or pre-existing social, mental health or physical health problems is an important immediate first step we can all take.” (Knight et al 2019: vii)

In other words:

Be aware.

Think.

Listen.

Be Aware. Think. Listen.

These are really simple things that we can all do.

There are some fabulous Black and Brown people out there offering courses and resources which will help you increase your knowledge awareness. Go on those and pay them for their work.

Think about the issues. Educate yourself about cultural differences and nuances which may affect people’s behaviour. Understand cultural safety. Understand what “structural racism” really means. (Loads of people have written lists of resources. Search. If you’re British, I recommend Reni Eddo Lodge’s “Why I’m no longer talking to white people about race.” but there are loads of others too.)

Reflect on situations where things didn’t go as you thought they would in your own area of work or practice, and ask what you could have done differently. Don’t focus only on blaming others.

Study history and culture

Go and find out about history; about how Black and Brown women’s bodies were enslaved and tortured in the development of obstetric and gynaecological practice.

Think about the wider structural issues. I often write about the problems brought about by standardisation and pathways, for example. They are the inevitable consequence of living in a bureaucratic world where maternity care is a system. But, as I often point out, guidelines are just that – a guide – and individuals can say no. Except that that’s not always as straightforward as it sounds. Because, in order to say no, individuals need to (a) know that they can say no, (b) have the confidence to say ‘no’ and (c) get heard and have their ‘no’ respected if and when they do say ‘no’. And that’s a big problem in a culture which is structurally racist. Where Black and Brown people don’t grow up having their voices heard. In some cases, they learn to actively suppress their voices for fear of recrimination. On top of that, we have the power structures of institutions such as maternity care, which in some ways aren’t really that different from those of organisations such as the police. If the most privileged can’t always get their ‘no’ heard, what do you think it looks and feels like for those whose voices are less respected?

We need to really listen

So we need to really listen. Listen to women. Ask questions, and then really listen to the answers.

If you’re not sure exactly what is being said, or meant, then ask for clarification.

“Listen” with more than your ears. Be observant; and not just of what might be happening physically.

Get back to basics and observe other signs. Educate yourself about how things present in people who have different skin tones. Bear in mind that textbooks and teaching aids often use white skin as ‘the norm’; even calling it ‘flesh’ as if it’s the representation of all flesh. This is an embedded form of racism which white people may not even see unless/until it is pointed out to us. Yet it can be very harmful to people who don’t have white skin. Things may present differently, or you may need to look for other signs. Vitamin K deficiency bleeding is an example of this in maternity care.

Watch people’s body language; be aware of what might be happening socially. But don’t assume that gestures, looks or any other sign means the same in someone else’s culture as it does in yours.

Use services such as interpreters where they will enhance your care and help you listen better. Don’t fall prey to the (often implicit) suggestion that these are expensive and cost the NHS too much. (I have found the line, “Mmm yes, but they are a lot cheaper than an enquiry or investigation because we’ve missed something and got it wrong,” to be quite effective. Feel free to borrow.)

Put your ego away and accept that, thanks to structural racism, your education is far from complete. No matter who you are or where you fit in the birth world; this isn’t only about midwives, obstetricians and other health care professionals getting it wrong.

Believe women.

Listen to colleagues too

Listen to Black and Brown colleagues too. Discuss the issues with all colleagues. Call out inappropriate behaviour. Look for examples of how NHS culture can undermine anti-racist work. Understand that so much of what we call structural racism can’t be seen in overt behaviours. It’s subtle stuff. Such as having assumptions that you don’t even realise are there. Not taking care to learn to pronounce a colleague’s name correctly. It’s a million other microaggressions too. I am only scratching the surface in this post and I want to acknowledge that I get it wrong as much as any other white person. What’s important is that we cultivate a desire to listen, to think and to learn.

Listen harder

Listen for the ‘no’ that’s whispered. The plea for help uttered in the form of a prayer rather than a direct request. The request for more help that isn’t worded as loudly as it would be from somebody with privilege. The ‘yes’ that isn’t informed consent as much as it is a desperate desire to tell you what the person thinks you want to hear so that you will treat them kindly, or not set social services or another authority on them. Get down on the same level, and show that you really care.

Empathy and outrage aren’t enough.

We need to be aware, we need to think and we need to listen to women.

And then listen some more.

2021 Update

MBRRACE-UK have published the latest report from their United Kingdom’s Confidential Enquiry into Maternal Deaths programme and it shows that Black women are still far more likely to die in childbirth than white women.

Those of mixed race and Asian heritage are also more likely to die than those of white descent. About three times and two times more likely, respectively, although you can see the exact data here.

The 2020 report looks at the outcomes for those giving birth in the United Kingdom between 2016 and 2018.

“In 2016-18, 217 women died during or up to six weeks after pregnancy, from causes associated with their pregnancy, among 2,235,159 women giving birth in the UK. 9.7 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy.”

As the report’s authors note, it’s important to remember that maternal mortality is rare.

“Many women have found these figures very worrying and it is important always to qualify such stark statistics with absolute numbers – in 2016-18 in the UK 34 Black women died among every 100,000 giving birth, 15 Asian women died among every 100,000 giving birth, and 8 white women died among every 100,000 giving birth.” (Knight et al 2020: 1)

But race is still a key issue, and the figures relating to the disparity are “fundamentally unchanged from those documented in the 2019 report.” (Knight et al 2020: 1) Maternal mortality STILL affects Black, mixed race and Asian women and families disproportionately more than it affects white women and families.

What are the findings of the 2020 report?

As is the norm for such reports, the research team have focused on identifying the indirect and direct causes of maternal deaths, so let’s look at their overall findings first.

“Cardiac disease remains the largest single cause of indirect maternal deaths. Neurological causes (epilepsy and stroke) are the second most common indirect cause of maternal death, and the third commonest cause of death overall. There has been a statistically significant increase in maternal mortality due to Sudden Unexpected Death in Epilepsy (SUDEP).” (Knight et al 2020: 13)

As I have noted, they identify continuing disparities between different groups, and here are a few key findings.

“Outcomes for women are not equal. There remain gaps in mortality rates between women from different areas, women of different ages and women from different ethnic groups. This year’s report shows a continued gap between the mortality rates for women from Black, Asian, mixed and white ethnic groups.” (Knight et al 2020: 1)

“These figures [on race disparities] are fundamentally unchanged from those documented in the 2019 report.” (Knight et al 2020: 1)

“This represents a non-significant reduction from the five-fold difference reported last year,” while “an overall tendency showing the inequality gap is increasing.” (Knight et al 2020: 13)

The report shows that other inequalities are growing as well.

“Women living in the most deprived areas are almost three times more likely to die than those who live in the most affluent areas. The number of women who are known to be experiencing multiple disadvantages when they die has increased by a third since the last report, from 6% to 8%. Women in these situations will often face mental ill-health, domestic abuse and/or misuse substances. However these and other issues are poorly recorded, so these figures should be treated as a minimum estimate and warrant urgent further enquiry.” (Knight et al 2020: 13)

A few questions and things to consider

I want to offer just a few notes, particularly for those who won’t be reading the report in full, or who want to read the report but would like a bit of a guide as to how to interpret and think about the data it contains.

The report does shows that, in 2016-2018 that Black women were 4.35 times as likely to die than white women. But, as I have noted above, this figure is “fundamentally unchanged” from the previous report (Knight et al 2020: 1) The report authors have stressed this, as I have noted above. The previous MBRRACE-UK: Saving Lives, Improving Mothers’ Care report (Knight et al 2019) showed that Black women were five times more likely to die in childbirth than white women. The 2020 report shows that this figure has gone down to 4.35. But the reports’ authors found this to be a “non significant difference”. What does that mean? Well, when you’re working with what are thankfully relatively rare events amongst large numbers of people, the addition (or subtraction) of just one or two incidences of something can make the numbers look quite different when actually they’re not.

This report doesn’t include the data on what has happened during the pandemic. We know that the pandemic has disproportionately affected Black and Brown people. See here for more on COVID, pregnancy and birth. The 2020 report also can’t tell us about the effect of recent changes, or whether recent campaigns have made any difference, because it reports on data relating to births that happened between 2016 and 2018. It always takes a while to collect, analyse and write about data. So, while it is positive that we recognise an increased awareness and the changes that have been made, as the authors note, this is something that we are going to need to pay attention to for a good few years yet. Settle in for a long ride.

Dig into the data

We need to remain aware that the way in which race is classified in these reports has changed over the years. And that research like this is based on medical and maternity records. That’s important, because records are only as accurate as those who record (or don’t record) things on the day. Mistakes are inevitable. This is by no means intended as a slight against midwives, doctors and other caregivers. It’s just reality. In the real world, especially when things are busy, data sometimes get entered incorrectly.

Don’t be afraid to ask questions of reports, and to dig into the data. One thing that I will be looking more into is a note on table 2.11 on page 15 of the report. This is the table that gives the figures for the relative differences between groups. It shows that, if someone’s ethnic group wasn’t known, they were classed as white. From a statistical perspective, I can understand why that was done. But if the outcomes of a number of Black, Asian or mixed race women were put into that group because data were lacking in their notes, the difference between white women and women from other backgrounds might be even greater than the current figures suggest.

The researchers aren’t the problem either, by the way. They can only work with the data that’s in people’s notes, and with the standards that are in place. There’s no conspiracy in the data here. Just things to be aware of as we work together to try to understand and change this problem.

The researchers themselves highlight this very point in their summary.

“There is an overall tendency suggesting that the inequality gap is increasing with a number of the RRR increasing from the comparison between 2012-14 and 2015-17 presented in last year’s report (Figure 2.6). As noted in 2018 and 2019, further research is needed to fully understand the reasons for these disparities and hence to develop actions to address them.” (Knight et al 2020: 13)

Indeed.

A better way

I want to make one last point. The outcomes of the Albany midwifery practice demonstrate that poorer outcomes for Black and Brown people are not an inevitability. In research into the Albany model, 57% of the women whose data were included in this study were from Black, Asian and Minority Ethnic communities, and the data from this study shows that good midwifery care can make even more of a difference to these women. But this will require the commitment and change from a government that has, thus far, done very little to help those experiencing inequality.

The report and summaries can be downloaded here.

 

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