When the MBRACE-UK report for 2019-2021 was published showing a four-fold increase in risk of mortality for pregnant people from Black ethnic groups[1], the medical establishment reacted promptly and with horror to investigate and tackle this statistic. The death of any pregnant person is a tragedy, but the fact that people from Black ethnic backgrounds are dying at four times the rate of their White counterparts is completely unacceptable. It is clear however, that the problem is both longstanding and complex and will not be solved overnight – the same report revealed that women from Asian ethnic backgrounds were two times as likely to die during pregnancy, as were those from the most deprived areas. It is also true that these disparities showed up in the 2018 data, and many people had for years been trying to raise awareness of the problem. Years of systemic health inequalities and intersectional disadvantage are revealing themselves in these shocking numbers.
Understandably, many of the programs of work set up in the wake of these findings focussed first on the downstream elements of maternal health care including clinical decision-making tools and procedures and safe staffing levels on maternity and labour wards. In hospital trusts across the country, many teams have worked tirelessly to achieve huge progress on these elements in a short space of time and this is to be applauded. Unfortunately, taking a public health approach to the problem informs us that this alone is unlikely to be sufficient to combat the widespread, systemic inequalities that are taking their toll on differential mortality statistics.
It’s not just birthing parents who are at risk either. Babies from Black ethnic groups are also significantly more likely to be the victims of still birth or neonatal death, and this inequality is widening rather than narrowing.[2]
So, where do we go from here? Unfortunately, the oft-voiced idea that complex problems can have simple solutions is more often than not simply wrong, and that is likely the case here. What is becoming clear though is that the problem will not be solved without the voices of Black women and communities themselves being properly heard and listened to. Local Maternity and Neonatal Systems (LMNS) are the maternity and neonatal arm of the Integrated Care Systems (ICS). In recognition of the importance of hearing the patient and community voices, most LMNS boards will now include representatives from the local Maternity and Neonatal Voices Partnerships (MNVP) who are commissioned by the ICS to help put service user voices at the heart of decision making.
This ambition is clearly articulated in the NHS three-year plan for maternity and neonatal services; the first theme of which is ‘Listening to and working with women and families with compassion’. This document builds on the findings of the Ockenden Report and Better Births both of which highlighted that women wanted to be listened to, and taken seriously when raising concerns.[3]
Appropriately, the 2024 theme for Black History Month is ‘reclaiming narratives’. Stories are powerful tools to effect change and shape how we see and understand the world. ‘Reclaiming Narratives’ recognises that for many years, the stories and histories of Black communities have either been misinterpreted through the lens of those who have not experienced them or overlooked and ignored altogether.[4] With communication factors often being cited in analysis of serious incidents across healthcare, and particularly in maternity, it’s no coincidence that a population who continually feel that their voices have been misheard, misunderstood or ignored altogether have persistently experienced worse outcomes than their White counterparts.
Locally in Leicester, Leicestershire and Rutland, academic partners have been undertaking a detailed piece of work talking to women and communities and exploring the historic experiences of Black motherhood in the city and have now partnered with the local hospital trust’s equity partnership, public health departments and the ICB to expand and take the work forwards. There are many lessons to be learned here for the system, but we have to learn to listen in the correct way.
These plans and ambitions are certainly positive and will work towards tackling inequalities in maternal health, however, there is still something missing without which the problem cannot be fully explored. Listening is one thing, but to paraphrase the words of the 2020 Royal College of Obstetricians Gynaecologists conference, we also need to learn to talk about race. One criticism of the MBRRACE-UK reports has been that they do not explicitly cite racism as a contributing factor to the stark differences in outcomes for Black mothers and babies, but instead refer more vaguely to systemic factors. Listening to the eloquent descriptions of experiences of discrimination recounted by Black women, some of whom are themselves healthcare professionals, make it clear that this is exactly what is being experienced. Those of us working within the healthcare sector not only need to get comfortable with confronting our own subconscious biases but also with recognising and calling out discrimination when we see it. Active bystander training, offered by the NHS and other employing organisations, is just one of the ways we can all commit to feeling more empowered to challenge these behaviours.
The nebulous idea of ‘cultural competence’ has been around for some time, but the most up to date thinking in health equity now recognises that what is actually needed are up to four slightly more distinct aspects to medical practice: cultural competence, cultural safety, cultural sensitivity and cultural humility.[5],[6] These terms can feel intimidatingly complex, but are referring in general to a reframing of the problem as ‘the impact of the patient’s race on their health’ to ‘the impact of the systems treatment of the patient’s race on their health’ i.e. systemic racism and disadvantage.[7] They are also not a ‘one size fits all’ approach but teach that each person must be considered in the context of their surroundings, culture, history and beliefs. eLearning for Health, the NHS England e-learning platform, now has a module for NHS staff on this topic. The Cultural Competence and Cultural Safety E-learning tool has been developed by Health Education England in partnership with the Royal College of Midwives and is made up of three 20-30-minute sessions designed to help you reflect and review your own understanding and practice. More information can be found at: Cultural Competence and Cultural Safety – elearning for healthcare (e-lfh.org.uk).
Black History Month 2024 represents an opportunity for us all to pause and reflect on our own practice, as well as striving for real change in the system. We cannot and should not continue to accept findings like those of the MBRRACE-UK report, and the time for change is now.
Written by Dr Laura French, Consultant in Public Health at Leicester City Council
[1] Knight M, Bunch K, Felker A, Patel R, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Core Report – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2023.
[2] MBRRACE-UK Perinatal Mortality Surveillance Report 2021 available online via Perinatal Mortality Surveillance: UK perinatal deaths of babies born in 2021 | MBRRACE-UK | NPEU (ox.ac.uk)
[3] NHS Three Year Delivery Plan for Maternity and Neonatal Services NHS England » Three year delivery plan for maternity and neonatal services
[4] ‘Reclaiming Narratives: The Inspiring Theme for Black History Month 2024’ Reclaiming Narratives: The Inspiring Theme for Black History Month 2024 – Black History Month 2024
[5] Lokugamage AU, Rix E, Fleming T, et alTranslating Cultural Safety to the UKJournal of Medical Ethics 2023;49:244-251
[6] Write-up of RCOG 2020 conference ‘We Need to Talk about Race’: A reflection on the RCOG’s International Women’s Day conference | All4Maternity
[7] Curtis, E., Jones, R., Tipene-Leach, D. et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 18, 174 (2019). https://doi.org/10.1186/s12939-019-1082-3
