A long read by Professor Hora Soltani from Sheffield Hallam University, on behalf of the UK Network of Professors in Midwifery and Maternal and Newborn Health
Mothers and babies from Black and Asian minority ethnic groups and those from socio-economically deprived areas have a much higher risk of death and serious complications in pregnancy, birth and the postnatal period. Alarmingly, this information on maternal and neonatal health disparities have been known for many years. Maternal deaths in the UK have increased with persistent disparities over the past two decades. In the latest national report, Black women were nearly 3 times and Asian women almost 2 times more likely to die during pregnancy, birth and in the postnatal period, compared to their White British counterparts. Mortality for women living in the most deprived areas was 2 times higher than those leaving in the least deprived areas. Similarly, stillbirth or neonatal death were significantly higher in Black and Asian babies, or in those from the most deprived areas.
Most migrants are from ethnic minority backgrounds but not all ethnic minority women are migrants. Evidence from Western countries indicate there is a “healthy migrant effect” which means migrant populations are often in good health when arriving at the host country and their health status deteriorates over the time, although this may depend on their country of origin, age and immigration journey. Reasons for this include changing lifestyle behaviours, a lack of familiarity with the health and social care systems in the host country, poor quality of care, communication issues, isolation as well as overt and covert racial discrimination.
Knowing the magnitude of maternal and infant health disparities, the first step to tackling such inequalities, is to understand the exact nature and the reasons behind them. Deep understanding of health disparities and their determinants are essential prerequisites to create appropriate and targeted interventions. It is well known that ethnicity and deprivation are the two major determinants of health, however the mechanism through which these disparities have been exerted is not very clear. Research has demonstrated that high quality care and better system approaches could have prevented at least half of observed perinatal complications and deaths experiences associated with racial, ethnic and poverty related disparities. Appropriate interventions are needed to be urgently co-developed with the targeted communities to ensure they are sensitive to the needs of those experiencing most inequalities.
Health disparities including hypertension, diabetes and mental ill health have been attributed to genetic predisposition, environmental exposures and changing lifestyle factors such as diet and physical activity. Another contributing feature is suggested to be a lack of training for healthcare providers to be competent in culturally sensitive care, and also in clinical assessment of mothers and babies from diverse communities. Other argue that unconscious bias and/or systematic racism is endemic in NHS health care provision, and that this is a major influence on poor outcomes.
While it is important, the prevailing emphasis on poor outcomes often ignores positive aspects of Black, Asian and impoverished communities. This is particularly illustrated in large cohort data analyses looking at intergenerational differences in lifestyle behaviours amongst migrant populations in which second generation migrants (of mainly Pakistani origin from Born in Bradford (BiB) cohort) seem to adapt unhealthier practices such as having higher smoking and lower breastfeeding rates compared to the their first generation counterparts. Exploring such variations and key contributing factors to scope strengths and values against prospective opportunities are important in co-creating roadmaps for improvement. There is potential to build on community assets by engaging with families to understand the challenges and the opportunities for making a difference collectively. The value of working closely with communities and building on common understandings and values between various stakeholders, investigators, policy makers and service providers in a true sense of collaboration, is gradually being realised. A joined-up approach can help in mapping existing knowledge against where the strengths and gaps are to inform development of strategies for a way forward.
In the case of migrant pregnant women and families, providing bespoke information and support including enhancing health literacy and providing community peer support may be helpful in enhancing quality of care. Additionally, education and appropriate training for health care professionals during undergraduate and post-qualification in practice, is imperative to embed a greater understanding of cultural safety and upskilling staff in providing trauma aware, culturally sensitive and compassionate care for mothers and families in vulnerable situations.
In summary, knowing what we know, it is a moral imperative that national policy makers and service providers collaborate with researchers and communities to co-design and provide practical solutions for such important maternity challenges.
The recent £50m funding call, “NIHR Challenge: Maternity Inequalities funding call”, announced as part of the Department for Health and Social Care’s (DHSC) women’s health priorities, is one key step in recognising this urgent need. This call is aimed to “bring together a diverse consortium, funding research and capacity building in the field to increase the evidence base to address maternity inequalities, facilitating a multidisciplinary whole systems approach to address uncertainties across research, innovation and implementation”.
This highly ambitious and timely initiative draws upon ongoing and recent activities and supports development of high quality, robust and innovative large-scale research to drive measurable improvements in health and social care priority areas. Recognising the value of appropriate care in the first one thousand days of life and even before that, bringing a wide range of expertise and disciplines together with “community engagement” at the heart of it, provides a great opportunity to “join the dots” and formulate a strategic vision and programme to tackle health inequalities for mothers and babies through innovative and collaborative research and capacity building. If this NIHR ambition implemented as it is intended, there are promising outcomes with a long-lasting impact for all.
Professor Hora Soltani (On behalf of the UK Network of Professors in Midwifery and Maternal and Newborn Health)
Professor of Maternal and Infant Health
Sheffield Hallam University