Thousands of Adverse Pregnancy Outcomes Linked to Poverty and Ethnic Inequality

·6-min read
Photo credit: JGI/Tom Grill - Getty Images
Photo credit: JGI/Tom Grill - Getty Images

*Content warning: stillbirth and miscarriage*

  • A stark new study has revealed that, due to systemic inequalities, a person's ethnic and socioeconomic background hugely impact their chances of a pregnancy ending in stillbirth or a baby with fetal growth restriction

  • The women at the sharpest end of this inquality are the most financially deprived South Asian and Black women

  • Pollution, racism, poor housing, social isolation, limited access to maternity and health care, insecure employment, poor working conditions, and stressful life events could all be factors in this tragic reality

  • 'These women are being let down by a healthcare system that is supposed to protect them,' said Dr Christine Ekechi, consultant obstetrician and gynaecologist and Co-Chair of the Race Equality Taskforce at the Royal College of Obstetricians and Gynaecologists

A new study has revealed that, due to 'alarming' systemic inequalities, your ethnic background, how much money you have and where you live have huge implications for the outcome of any pregnancy you have.

While these factors were already known to add risk to a pregnancy, the 'heartbreaking' scale of the problem has now been brought to light. The study's findings are leading to calls for urgent action from experts, with some saying that addressing this issue must be a 'national priority.'

The research, which is published in health journal The Lancet, draws data from over a million NHS births from 2015 and 2017 in England. It reveals that, tragically, socioeconomic inequalities, such as not having enough money and living in a deprived area, account for a quarter of stillbirths, a fifth of preterm births, and a third of births with fetal growth restriction (FGR), in which a baby is born smaller than expected.

It also shows that pregnancy complications disproportionately affect Black and minority ethnic women. Twelve percent of all stillbirths, 1% of preterm births and 17% of births with FGR were shown to be a result of ethnic inequality.

Which women are at the greatest risk of inequality?

The people who deal with the greatest excess risk of stillbirth and FGR are Black and South Asian women who are the most socioeconomically disadvantaged. The study shows, for example, that more than half of stillbirths and three-quarters of births with FGR among the most deprived South Asian women could be attributed to socioeconomic and ethnic inequalities – which, horrendously, means that they could have been avoided.

When the study's authors adjusted for socioeconomic deprivation, smoking in pregnancy and BMI, there was little impact on the association between ethnicity and pregnancy outcomes, which indicates that factors relating to racism and discrimination are at the root of this disparity.

The NHS has set a target of halving stillbirth and neonatal death rates and reducing levels of preterm birth by 25% by 2025. However, experts are warning that current national programmes, which hone in on reducing a woman's individual risk and their antenatal care, will not be enough. Instead, health professionals and politicians must work together to reduce social and economic disadvantage and ethnic inequalities.

Why does your ethnic background and financial status have this impact?

'There are many possible reasons for these disparities,' explained co-lead author Professor Jan van der Meulen from the London School of Hygiene & Tropical Medicine. 'Women from deprived neighbourhoods and Black and minority ethnic groups may be at a disadvantage because of their environment, for example, because of pollution, poor housing, social isolation, limited access to maternity and health care, insecure employment, poor working conditions, and stressful life events.

'National targets to make pregnancy safer will only be achieved if there is a concerted effort by midwives, obstetricians, public health professionals, and politicians to tackle the broader socioeconomic and ethnic inequalities.'

'The stark reality is that across England, women's socioeconomic and ethnic background are still strongly related to their likelihood of experiencing serious adverse outcomes for their baby. I think that people will be shocked to see that these inequalities are still responsible for a substantial proportion of adverse pregnancy outcomes in England,' said co-lead author Dr Jennifer Jardine from the Royal College of Obstetrics and Gynaecologists, UK.

'Over the past few decades, efforts to close the gap in birth outcomes focusing primarily on improving maternity care and targeting individual behaviours have not been successful. Birth outcomes don't only represent a woman's health during pregnancy but also reflect her health and wellbeing across her entire life.

'While we must continue to encourage healthy behaviours during pregnancy, we also need public health professionals and politicians to strengthen efforts to address the lifelong, cumulative impact of racism and social and economic inequalities on the health of women, families, and communities.'

Dr Christine Ekechi, consultant obstetrician and gynaecologist and Co-Chair of the Race Equality Taskforce at the Royal College of Obstetricians and Gynaecologists, said: 'We already know that Black women are four times more likely to die in childbirth compared with white women, and this research shows that the largest maternal inequalities exist for the most deprived South Asian and Black women – which is heart breaking. These women are being let down by a healthcare system that is supposed to protect them.

'Reducing the occurrence of potentially avoidable adverse pregnancy outcomes needs to be a national priority, with maternity services and healthcare professionals working with policy makers and the government to urgently address these inequalities. It is not enough to target interventions at the individual if we do not acknowledge and address the social circumstances which significantly influences the health outcomes for themselves and their families.

'What happens in a woman’s life and home plays as significant a role in her pregnancy, as does occur when she interacts with the health system. We must do better at recognising this fact.

'All women should feel listened to, both within and outside the healthcare system, and we must continue to push for significant progress in improving maternal and obstetric care for those most at risk of adverse outcomes.'

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: 'The findings of this study are alarming but sadly they come as no surprise. They provide more evidence that poverty, racism and discrimination can affect women throughout their lives and ultimately lead to devastating incidences of pregnancy complications and baby loss.

'The fact this study attributes 24 percent of stillbirths to socioeconomic inequality and 12 percent to ethnic inequality demands the strongest possible action from across government to address the wider factors that influence the health of women and their babies.

'These disparities are something we as healthcare leaders also have a duty to address and we are committed to providing innovative clinical solutions. All women should have equal access to high-quality antenatal care and support, regardless of their background, but the current pregnancy risk assessment is more than 50 years old. As a result, some women receive unnecessary care and others, too little too late, widening rather than reducing health inequalities.

What are the study's authors suggesting we do now?

The study's authors are proposing three action points to help to reduce these inequalities. These are:

  • Improving antenatal care for high risk women, such as monitoring fetal growth more precisely and frequently, and offering to induce labour when stillbirth risk is increased, as well as clinical intervention during pregnancies, like help with stopping smoking and courses in nutrition

  • Public health strategies such focusing on helping people to eat nutritious diets, help with mental health issues and drink and drug problems and support with regards to high stress levels

  • Comprehensive policies to address the root causes of inequality, such as income, education and employment.

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