'Not So NICE' Inequality and Bias in Maternal Care

It’s hard to accept or believe that healthcare systems around the world and including the NHS have implicit bias, conscious or unconscious. It’s uncomfortable to suggest that there is systemic racism or inequality of care. But the care we receive and the outcomes we experience in pregnancy and birthing are not a level playing-field.

According to the 2019 MBRRACE-UK report, in the UK today Black women are 5X as likely to die during childbirth as white women. Mixed ethnicity women 3X, Asian women 2x as likely.

Discussion and treatment of mental health issues are also directly affected. Black African and African Caribbean and Asian women are less likely to be asked about their current and past emotional and mental health or offered treatment. (Redshaw and Henderson, 2016).

The same report from BMC Psychiatry concluded that non-white women, those living in more deprived areas, and those who had received less education were less likely to be asked about their mental health, to be offered treatment, and to receive support. … the inverse care law is operating in relation to this aspect of maternity care. Those women most likely to be in need of support and treatment, are least likely to be offered it and may be at risk of serious adverse outcomes’

These discrepancies are shameful. First we must acknowledge they exist and acknowledge why: systemic racial prejudice that determines how, and if, women are listened to, treated, or treated in a timely manner. Then we must challenge and address the discrepancies, and only then can they begin to change.

Medical textbooks still in print state that Black people feel pain differently or not at all, and this racial bias in pain assessment prevails. Teaching diagnoses of rashes and other potentially dangerous signs of underlying issues are only shown as they would appear on white skin. Advancements in gynaecological understanding were achieved brutally on the bodies of Black women because they ‘did not feel pain’. Many of these myths prevail today.

Just this year, NICE announced guidelines that induction at 39 weeks pregnancy is to be recommended for black and brown skinned women. This is pregnancy medical intervention based on skin colour. It is pathologizing skin colour with zero evidence that induction will address the higher incidence of complications.

Complications with tragic consequences are more likely to happen to black and brown bodied women, as are pregnancy health complications. But melanin is not a biological indicator of risk. It is possible you’re thinking ‘But… education… lifestyle… diet… genetics…’ It’s here we must check our bias and check our facts. Because that’s not why. Serena Williams’ and others’ experiences confirm that oversimplified references to socio-economic circumstances don’t hold true either.

We know the healthcare system under-serves BAME women for postpartum mental health and depression. So where ‘broken families’ or ‘absent fathers’ are used to dismiss their childrens’ over-representation in the care system and other consequences, then again check?bias, check facts, because they’re not.

What Does Systemic Bias Look and Sound Like?

Bias may not be your own experience, which may be why you don’t think it exists. It’s not mine. I had very traumatic births and would be classified a ‘maternal near miss’. But I’m a white, cis gendered, able-bodied woman and there were no extra layers. Layers of Black or Brown, layers of prejudice or assumption. I was heard, my husband was heard. That we would not be heard or cared for, was never a consideration.

The stories we hear over and over are of Black and Brown skinned women not being listened to, their concerns and pain disregarded or ignored. They are not graced with the time or attention given to white women, and are often dismissed as hysterical, angry or ‘confused’ (the conclusion of Serena’s Doctors).

The result is missed signs, delayed care, preventable intervention, neglect, disregard or disrespect. And the result of that, is those statistics. 5X as likely to die.

In a care setting this implicit bias may sound like:

“She’s a strong Black woman. She’s doesn’t need pain relief’

‘They breastfeed in their culture, she won’t need support’

‘Only Black babies get sickle cell / Mongolian Blue Spot…’

Midwives and Doulas say they have heard colleagues and peers refer to ‘that angry Black Woman’ or ‘the Asian Princess’ when talking about patients and their concerns.

The fact that it’s not your personal life experience, doesn't mean it doesn’t exist. A pregnant Black person carries a lifetime of that experience with her to her very first antenatal appointment. She already knows to be extra polite, to smile, not to be too assertive, to expect and tolerate the loaded questions, judgments and assumptions.

The fact that it’s not your personal life experience, doesn't mean you don’t have to do or say anything. When we stay silent - with our colleagues, online, with our friends or family - we are complicit.

Our culture, education and health system have a long way to go to address implicit inequalities in maternal health care. We must challenge the bias when we see or hear it, call it out and demand change. Don’t wait for or expect Black and Brown people to teach or justify the existence of a problem. White folks don’t get to declare ourselves ‘Ally’ or ‘not part of the problem’. It’s right there, in the reports and links above just as a start. Follow Abuela Doula, FiveXMore, NotSoNICE, Alicia Burnett, and most of all, listen and learn before we talk, justify or ‘explain away’.

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What’s your experience? As caregiver, medical professional, birthing person or birthing partner? Please share.

MUTU is the inclusive and medically recommended women’s health app approved in 2020 by NHSD Assessors ORCHA with a 91% score. Founder Wendy Powell was selected as a Fellow of the NHS Innovation Accelerator (NIA) in 2021. MUTU is founded on the belief that every woman deserves the dignity and pleasure of a body that works. We are working to scale MUTU in the NHS to ensure that every woman has access to the pelvic health education and treatment she deserves.