You've likely seen the horrifying statistics around the reality of childbirth for Black women in this country. But, to reiterate: Black women in the UK are five times more than likely to die in labour than their white counterparts; Black pregnant women are eight times more likely to be admitted to hospital with COVID-19 and Black babies have a 121% increased risk of being stillborn, with a 50% increased risk of dying within 28 days of birth, when compared with white babies.
In the midst of this, one writer, Nadine White, asks a question that should be required of no one: 'Is it safe for me to have a baby?'
Correction: a version of this feature, published in the Dec/ Jan 2020 issue of Women's Health, misattributed research conducted by publication Black Ballad, which surveyed 2,500 Black mothers about their birth experiences. Women's Health would like to clarify that it was Black Ballad who compiled this research.
'Auntie Dine!’ The voice of my 11-year-old niece, TT, jerks me out of my thought spiral. It’s a rainy Saturday afternoon and I have a troupe of my siblings’ children at my South London flat. We’ve been making cupcakes; my clothes are covered in flour and two members of the brood are sugar-hyped from the leftover cake mix I let them enjoy straight out of the bowl (because what are aunties for?). Now, TT points at the tub of butter, rapidly melting on the hob, while two-year-old Azzy giggles from the sidelines.
The laughter, the organised chaos – it’s how I imagined my life would wind up. I’d long hoped to have two of my own – a boy and a girl. I often fantasised about the delicious meals I’d cook for them, how I’d teach them about global Black history and crochet cute jumpers. I could even picture them charging around my Nana’s house as I once did, utterly at home in the bosom of our big, effervescent and loving Jamaican family.
Having reached my late twenties with a great husband and a job I adored as a news reporter, I counted myself lucky that my life was shaping up to make that dream a very real possibility.
And yet, as I scrubbed butter off the hob that day, my heart felt heavy. Because at precisely the moment when motherhood was becoming an imminent prospect, I found myself confronted with one of the most shocking statistics I’ve ever heard. Black mothers in Britain are five times as likely as white women to die during pregnancy, childbirth or as a result of complications up to six weeks after the birth. I suspect it’s not the first time you’ve heard this statistic, but it’s no less shocking every time.
The report that launched it into the public discourse was first published in 2018. MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries across the UK), a group formed by the National Perinatal Epidemiology Unit at the University of Oxford, found that, of the 209 women who lost their lives this way in the UK between 2015 and 2017, Black women made up a disproportionate number.
Only 4% of the women who gave birth during these years were Black, but Black women made up 18% of the deaths, from things like heart disease, blood clots, strokes and sepsis. The findings led two Black mothers, Tinuke Awe and Clotilde Rebecca Abe, to launch an awareness campaign, Five X More, and when the second MBRRACE-UK report was published a year later, with the same bleak statistic, it made headlines.
So I wasn’t the only one paying close attention when a global pandemic started disproportionately killing those from Black, Asian and minority ethnic (BAME) communities, expectant mothers included; in the UK, 55% of all pregnant women admitted to hospital with Covid-19 came from BAME backgrounds, and ethnic minority mothers accounted for the majority of deaths among pregnant women. Women like Mary Agyeiwaa Agyapong, a 28-year-old nurse, whose death in April, shortly after her son was delivered, I reported on.
Then, in May, a Minneapolis policeman knelt on George Floyd’s neck, leading to his death and igniting conversations about race that forced everyone to confront the idea that racism is entrenched within the structures of British society – even that most prized and venerated of institutions, the NHS.
The following month, the Royal College of Obstetricians and Gynaecologists (RCOG) launched its Race Equality Taskforce to tackle racial disparities in women’s healthcare and racism within the profession. People with power were listening, from lawmakers to health chiefs and newsroom bosses.
From the day I started reporting on this story, I vowed to use my small slice of influence to shine a spotlight on the issue; to give a voice to Black mothers and platform perspectives that might help to close this gap. But while I’m a reporter, I’m first and foremost a Black woman; I hope I’ll be able to reconcile what this statistic means for me on an emotional level, too.
But first, I want to understand what the data indicates about what’s going on at a medical level. I put in a call to Marian Knight, a professor of maternal and child population health at the University of Oxford, and the lead author of the MBRRACE-UK reports. She reassures me that having a child in the UK is safe, with fewer than 10 in every 100,000 pregnant women dying in pregnancy or around childbirth, before addressing the reasons for the racial disparities she’s been highlighting in her research for over a decade.
‘People used to assume there was a simple answer to do with Black women being more susceptible to certain conditions, but that’s not the case,’ she explains. ‘There’s no real difference in the types of conditions that Black women are dying from – in pregnancy and more generally. It’s that more Black women, relatively, are dying from these conditions.’ The most common complications – stroke, sepsis, heart attacks – can arise outside of pregnancy, but the risk of developing them is far higher when a woman is expecting. ‘The heart has to work 50% harder when you’re pregnant, so it’s under much greater strain,’ she explains.
‘This is why pregnancy can often reveal heart disease for the first time in people who might never have thought they’d be at risk.’ Many of the women whose deaths were reviewed had symptoms that, if they’d occurred in a non-pregnant person, would have indicated a serious cardiac issue, but were instead dismissed as pregnancy-related – with fatal consequences.
While pregnancy is inherently a risky time, Black African or Caribbean communities tend to have poorer health outcomes throughout their lives, including a higher chance of developing high blood pressure or having a stroke.
Dr Christine Ekechi, consultant obstetrician and gynaecologist at Imperial College Healthcare NHS Trust and co-chair of the RCOG’s Race Equality Taskforce, tells me a person’s individual disease risk is influenced by both genetic and social factors. ‘We know that, on average, Black and Asian people are more likely to be in lower social classes, with less money and living in poorer housing,’ she says. It follows, then, that the maternal mortality gap only applies to women from lower socio-economic backgrounds. Only, it doesn’t.
The Centers for Disease Control and Prevention in the US found that Black women with a college degree were five times more likely to die as a result of pregnancy or birth complications than a white woman of a similar education level. And in the UK, the maternal mortality gap exposed by the MBRRACE-UK report persists between Black and white women, even when you factor in education and income levels.
Research like this seems to suggest, overwhelmingly, that this is a race issue; that racism has roots in the healthcare system, as it does in every other institution. To find out how deeply it’s embedded, I call Dr Annabel Sowemimo, a sexual and reproductive health doctor in the NHS.
She’s the founder of Decolonising Contraception, an advocacy group addressing barriers that some groups face when accessing sexual and reproductive healthcare, who writes extensively about race and health. ‘Colonialists held the belief that the African anatomy was different from that of Europeans; that it was inferior and animalistic,’ she says.
She shares how Black people were routinely subjected to experimentation and dehumanisation. She tells me about Dr James Marion Sims, the so-called ‘father of modern gynaecology’, who performed experimental surgeries during the 1840s on Black female slaves in the American South without anaesthesia as he perfected his clinical techniques. ‘As far as many at the time were concerned, Black people didn’t feel pain in the same way as people of European descent, and we don’t really question how much this opinion is still very much endemic within our medical structures today,’ adds Dr Sowemimo.
One way in which racial bias has been demonstrated is in the administering of pain medication. In a 2016 study, researchers at Boston University found that Black patients were half as likely to receive pain medication as white patients for non-definitive conditions, including abdominal pain. Another study published that year linked racial bias in pain management with practitioners’ lingering false beliefs about biological differences between Black and white people.
Then there’s the mounting body of research indicating that women’s pain is taken less seriously than men’s; a University of Pennsylvania study showed women who report having acute pain in A&E are less likely to be prescribed strong painkillers, while a Swedish study found that women waited longer in A&E and were less likely than men to be seen as an urgent case.
Speaking with Dr Sowemimo, I feel a creeping sense of recognition. I was 20 and recovering from emergency gall bladder surgery when I found myself begging for pain relief. The pain was excruciating, but it wasn’t until I was on my hands and knees on my hospital bed that the nurses and consultants believed it was real. My chest feels tight as I imagine being on the receiving end of those microaggressions during labour or in those vulnerable hours after giving birth.
Sandra Igwe, a 31-year-old mum-of-two from London, doesn’t need to imagine. During the birth of her second daughter in 2018, doctors repeatedly dismissed her pain – even denying her an epidural. ‘The midwife kept asking me, “Why are you screaming now? You’re not supposed to be screaming now.” Apparently, I was only meant to scream when I had contractions, but I had pain throughout, and she didn’t check what might be causing it.’
The more visibly annoyed the midwife became, the more Sandra began to question the sensations in her own body. ‘I felt gaslighted and, at one point, I even asked myself: am I exaggerating my pain?’
To this day, Sandra still doesn’t know what caused her pain, but counts herself lucky that it wasn’t symptomatic of a life-threatening condition.
For Patricia Anthony, a 34-year-old receptionist from Manchester, negative stereotypes about Black motherhood shaped her entire experience of maternity care. ‘I was judged for being a single parent, with midwives asking probing questions about the absence of my child’s father and interrogating me about whether English was my first language,’ she recalls. ‘At a time when I needed to feel strong and supported, I felt ashamed, which made it extremely difficult for me to speak up and advocate for myself at crucial moments, such as when discussing my birth plan. I was worried about being stereotyped as an angry Black woman if I spoke up for myself.’
Perhaps these stories call to mind your own interactions with our overstretched, underfunded NHS; perhaps you think that race doesn’t come into it. The most recent data on inpatient satisfaction, published by the Care Quality Commission in September, suggests that Black patients were actually the most satisfied of all ethnic groups. And yet, of the 72,500 respondents, only 6% weren’t from a white background. This data also tells a vastly different story from the one I’ve been told.
Over the summer, as part of a collaboration between my employer, HuffPost, and UK lifestyle publication Black Ballad, which surveyed 2,500 Black mothers about their birth experiences, I read accounts of substandard care, discrimination and microaggressions hundreds of times over. From the wrong dosage of medications being administered to jibes from healthcare practitioners about their ability to speak English, Black women revealed deeply harrowing experiences of being abused and placed at risk during pregnancy. And while data proves that the repercussions can be fatal, they don’t have to cost lives to have a devastating impact on the women who are at their most vulnerable.
‘Whether the bias is explicit, such as blatantly insensitive remarks, or unconscious microaggressions, this can hinder medical consultations, restrict treatment options and ultimately cause Black, Asian and minority ethnic women to avoid interactions with the health service,’ explains Dr Ekechi.
Indeed, Sandra puts the severe anxiety she experienced in the postnatal period down to a traumatic birth experience where she not only felt ignored, but deliberately discriminated against. Rather than re-engage with the NHS, she established a peer support organisation, The Motherhood Group, to help Black and ethnic minority women talk about parenting, mental health and maternity care challenges. Through her work, Sandra has observed a ‘fundamental, widespread distrust’ of healthcare and government from Black women; most of those she works with see the health service as ‘a white system for white people’
They’re not alone: in a report commissioned by Parliament, published in September, 78% of Black women agreed that the NHS does less to help them than their white peers. That statistic has a confronting implication for anyone, like me, who loves the NHS – and has a mammoth question at its core: is the NHS institutionally racist? Multiple articles published in The BMJ point to things like fewer ethnic minority doctors rising to the top echelons of medicine and increased likelihood of disciplinary procedures against ethnic minority doctors.
Dr Ekechi chooses her words carefully when I put this to her. ‘I don’t think that’s the question here,’ she replies. ‘It’s more about looking at our society, and thinking: how do we treat people of different races? And how can that manifest when people come into hospital?’
She refers back to our discussion about risk factors for certain diseases, explaining how these issues manifest outside of the hospital setting; how the disparity in health outcomes for Black women – mothers and non-mothers – would be improved by providing equal opportunities in things like education and housing. Healthcare, in other words, doesn’t exist in a vacuum.
While the public anti-racist vows made by medical bodies such as the Royal College of Psychiatrists and the Royal College of Emergency Medicine are welcome, all the experts I’ve spoken to while reporting on this issue believe change is needed on a more practical, meaningful level. Dr Ekechi is calling for the dismantling of racism within her field, Professor Knight for maternity services to be more individualised to adequately serve the varying needs of expectant mothers in Britain today, while Dr Sowemimo is calling for healthcare to be ‘decolonised’.
That’s shorthand for stripping the system of racist practices and assumptions; pushing for clinical trials to include Black women as participants and focusing on issues that predominantly affect them, like fibroids – so the latest scientific findings might be relevant to them – and agitating for words and actions that move beyond the well-intentioned-but-tokenistic place she believes they’re at now.
Shortly before I submitted this piece, an NHS spokesperson affirmed the organisation’s commitment to closing the maternal mortality gap, aiming to provide 75% of women from Black, Asian and ethnic minority backgrounds with the same midwife before, during and after they give birth by 2024. It’s the same target offered by the Department of Health when I call them for an update in October; a spokesperson assures me that they’ll be tracking, progressing and delivering ‘evidence-based actions’.
I resent that any mention of racism has been glossed over in the government’s response. And I’m not reassured that its deadline for improvement is three years away. But I find comfort in the knowledge that someone as smart and deliberate as Dr Ekechi is leading the charge at the RCOG taskforce; that medics as unflinching as Dr Sowemimo aren’t going to let this conversation be stifled, sugar-coated or whitewashed. And I’m heartened that Black women are connecting with one another on this topic, providing support and the sort of back-up you need in order to truly feel like you don’t need to be superhumanly strong at all times.
I finish this piece confident that the to-my-bones urge to have my own family is still there, present and correct. And, while reporting this story has been wearing, it’s reinforced upon me the importance of advocating for myself if – and hopefully when – I become a mother. I find peace once again in daydreams of noisy kitchens cluttered with baking utensils and unconditional love. I hope for better.
If you're pregnant now...
Here’s how Tinuke Awe and Clotilde Rebecca Abe, of the Five X More campaign, recommend that Black women advocate for themselves in maternity care.
1. Speak up
No one knows your body better than you, and gut feelings are almost always right. So, if you feel like something isn’t right, trust your gut, then make sure you speak to a medical professional; don’t stay silent.
2. Find an advocate
This could be your partner, a family member or a friend – someone you can rely on for support during appointments and who will speak on your behalf, if necessary.
3. Get a second opinion
You’re allowed to ask for a second opinion from another medical professional if you feel you need to.
4. Do your research
5. Document everything
Make sure any treatment or medication you are given – or refused – is written down in your maternity notes by your doctor or midwife, stating their name and reason why. Go a step further and keep your own personal journal in which you write down all of this information, so you can cross-reference.
To find out more about the campaign, visit Five X More
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