Why race is still a factor in antenatal care

The coro­n­avirus pan­dem­ic has placed racial health inequal­i­ties under a sharp spot­light. A research team at Uni­ver­si­ty Col­lege Lon­don showed mor­tal­i­ty is almost three times high­er than expect­ed among Black women, 2.4 times high­er in Asian women and 1.6 times in white women. Yet racial dis­par­i­ties in health­care are noth­ing new and nowhere are the dif­fer­ences more strik­ing than in ante­na­tal care.

In Novem­ber 2018, a report into mater­nal mor­bid­i­ty in the UK was released by researchers at Oxford Uni­ver­si­ty, cit­ing that Black women are five times more like­ly to die in preg­nan­cy, child­birth or in the post­par­tum peri­od, com­pared with their white coun­ter­parts. Asian women were twice as like­ly to die com­pared to white women.

This stag­ger­ing imbal­ance isn’t exclu­sive to the UK. The mater­nal mor­tal­i­ty is sim­i­lar­ly high in the Unit­ed States with Black and indige­nous Amer­i­cans being two to three times as like­ly to die of preg­nan­cy-relat­ed caus­es, accord­ing to offi­cial fig­ures.

While over­all mater­nal mor­tal­i­ty in the UK remains rel­a­tive­ly small at 7 per 100,000, it is 38 per 100,000 for Black women, which is sim­i­lar to that of Egypt, a coun­try whose health­care spend­ing per capi­ta is one sev­enth of the UK’s.

What do racial disparities in healthcare look like?

In March, Five x More, a com­mu­ni­ty organ­i­sa­tion, launched a gov­ern­ment peti­tion to raise aware­ness on the dis­par­i­ties in ante­na­tal care and the post­par­tum peri­od; cur­rent­ly the peti­tion has more than 185,000 sig­na­to­ries and is await­ing par­lia­men­tary debate.

Racial dis­par­i­ties are like­ly to be mul­ti­fac­to­r­i­al, per­haps due to a greater preva­lence of con­di­tions such as pre-eclamp­sia, obe­si­ty and high blood pres­sure among Black women.

How­ev­er, health­care providers must also acknowl­edge that the way care is deliv­ered may uncon­scious­ly dis­ad­van­tage some groups based on their eth­nic­i­ty, socio-eco­nom­ic sta­tus or pre-exist­ing health prob­lems. So how far does racial dis­crim­i­na­tion impact patient care?

Dr Chris­tine Ekechi, a Lon­don-based obste­tri­cian and co-chair of the Roy­al Col­lege of Obste­tri­cians and Gynae­col­o­gists’ (RCOG) racial equal­i­ty task­force, describes how a con­ver­sa­tion with a white col­league encour­aged her to tack­le the issue.

“My col­league looked at me and said, ‘You know Chris­tine, if any oth­er per­son had a five-times greater risk of dying due to a con­di­tion, we would place a health warn­ing on that con­di­tion, wouldn’t we? So what are we going to do for Black women?’” says Ekechi, who is the RCOG’s spokesper­son on racial equal­i­ty.

Poor care has repercussions beyond pregnancy

Since then, it has become Ekechi’s mis­sion to tack­le racial dis­par­i­ties among patients and also the attain­ment gap among doc­tors work­ing with­in obstet­rics. She says that if we are going to address the health dis­par­i­ties in mater­ni­ty care, we must start to look at how these inequal­i­ties exist across the entire repro­duc­tive cycle.

For exam­ple, research pub­lished by the Amer­i­can Pub­lic Health Asso­ci­a­tion has found, com­pared with white women, Black women are more like­ly to under­go a hys­terec­to­my and also receive diag­no­sis of gynae­co­log­i­cal can­cers at a much lat­er stage.

She recalls an unfor­tu­nate inci­dent when a Black woman had under­gone surgery for a fibroid, a benign, mus­cu­lar growth of the womb lin­ing thought to be three to fives time more com­mon in Black patients.

“She went home think­ing she had a myomec­to­my [removal of a fibroid], was expe­ri­enc­ing abdom­i­nal pain and was wor­ried about a com­pli­ca­tion,” says Ekechi. “Only for me to read her notes and realise they had opened her up and closed her again because they deemed the myomec­to­my too dif­fi­cult. Which is clin­i­cal­ly fine, yes, but obvi­ous­ly this had not been com­mu­ni­cat­ed to her at all.”

Ekechi was left both upset and embar­rassed by the expe­ri­ence, hav­ing to explain to the woman that she had not had the myomec­to­my that was nec­es­sary to improve her chances of con­ceiv­ing. The cam­paign­ing obste­tri­cian is emphat­ic that the patient was not giv­en “the val­ue she deserved” because of her skin colour; the patient was a well-edu­cat­ed, mid­dle-class woman who would have under­stood if the infor­ma­tion was relayed to her.

How ingrained prejudices damage antenatal care

Four years ago, San­dra Igwe estab­lished the Moth­er­hood Group, a social enter­prise that deliv­ers events and edu­ca­tion to Black moth­ers, fol­low­ing her own dif­fi­cult expe­ri­ences of ante­na­tal care and child­birth. She feels health pro­fes­sion­als did not seem to know how to inter­act with her and believes Black women are often mis­judged as hav­ing an “atti­tude”.

“I was scream­ing in pain and I was being told by the mid­wife, ‘Why are you scream­ing now? You are not sup­posed to be scream­ing now.’ Appar­ent­ly, I was only sup­posed to be scream­ing dur­ing the con­trac­tions, but I was in pain through­out and she didn’t even check if I was OK,” says Igwe.

A study pub­lished last year in Obstet­rics & Gyne­col­o­gy revealed that non-white patients in the Unit­ed States are less like­ly to receive pain relief despite expe­ri­enc­ing more pain dur­ing deliv­ery. In the first 24 hours after birth, white women were asked about their pain lev­els an aver­age of 10.2 times, in com­par­i­son with 8.4 to 9.5 assess­ments for all oth­er moth­ers.

While Igwe’s hus­band was present, she feels it is often dif­fi­cult for birthing part­ners to know how to nav­i­gate the med­ical sys­tem and advo­cate for their spouse. By start­ing the Black Mum’s Sup­port Fund, she is cam­paign­ing for greater access to birth advo­cates and bet­ter access to coun­selling for soon-to-be moth­ers.

Igwe also believes the poor expe­ri­ence of child­birth could have trig­gered her post-natal depres­sion (PND). Research pub­lished by Springer has shown that being a moth­er from an eth­nic minor­i­ty back­ground sig­nif­i­cant­ly increas­es the risk of devel­op­ing PND. But there have been very few stud­ies explor­ing the fac­tors that con­tribute to poor men­tal health and even few­er study­ing the Black com­mu­ni­ty in par­tic­u­lar.

Her expe­ri­ences meant she did not feel com­fort­able reach­ing out to med­ical pro­fes­sion­als to access sup­port and she con­tin­ued to strug­gle with her men­tal health on her own. She believes that many oth­er women may dis­en­gage from care due to neg­a­tive encoun­ters with pro­fes­sion­als ear­ly on in preg­nan­cy.

Improving antenatal care is a life or death matter

My Mid­wives Ini­tia­tive was found­ed by Geor­gia Allan and Sheri­dan Thomas, inde­pen­dent mid­wives who have under­gone addi­tion­al train­ing to become pro­fes­sion­al mid­wifery advo­cates to encour­age reflec­tive prac­tice among mid­wives. Allan says: “To pro­vide cul­tur­al­ly safe care, we need to have an under­stand­ing of the lived expe­ri­ence of the peo­ple we care for and how this has impact­ed on a woman’s mater­ni­ty jour­ney.”

We need to not be more like­ly to die, to not have as much post-natal depres­sion, and to start hav­ing more pos­i­tive expe­ri­ences

Despite the large gaps in care that remain, Igwe is opti­mistic the effects of racial dis­crim­i­na­tion with­in the health­care sys­tem can be reduced. “We need to not be more like­ly to die, for us to not have as much post-natal depres­sion, to bring that per­cent­age down to as low as pos­si­ble, and for us to start hav­ing more pos­i­tive expe­ri­ences with child­birth and encoun­ters with health­care pro­fes­sion­als. For us to be able to real­ly say we were not treat­ed dif­fer­ent­ly sim­ply because of the colour of our skin,” she con­cludes.