There has long been evidence of the stark health inequalities faced by ethnic minority people in England and elsewhere. Despite this, there has been no significant change. One major area of concern is around pregnant and new mothers, in particular where discriminatory or racist treatment can affect their mental and physical health as well as the development of their children. Research from our Centre featured on this blog has already shown that racism towards mothers can have deep-seated and long-lasting negative effects. Now a recent review of ethnic inequalities in healthcare and within the NHS workforce has raised a number of key concerns about the care provided to mothers and babies from ethnic minority backgrounds. The report’s authors Dr Dharmi Kapadia (Centre on Dynamics of Ethnicity (CoDE), University of Manchester) and Professor Sarah Salway (University of Sheffield) discuss the findings.
Our rapid review into ethnic inequalities in healthcare has revealed vast inequalities across a range of health services. Some of the largest of those inequalities were found for mental healthcare where treatment for people from Black ethnic groups was particularly poor. We also found a lack of research into specific areas including how outcomes may differ for ethnic minority babies in neonatal healthcare settings, where we found just one study that had looked into health inequalities in the care of ethnic minority new-born babies.
Our stock take of more than 13,000 research papers covering 10 years’ of academic research shows that women’s relationships with care-providers, particularly midwives and health visitors, during pregnancy and beyond are absolutely key. Sadly, while some mothers do experience positive relationships, this is far from the norm for many ethnic minority women.
A common and prevalent issue identified by our report was poor communication between women and those with responsibility for caring for them during pregnancy and after giving birth. The lack of accessible and high quality interpreting services was certainly a common issue, but this was not the only barrier to quality care as we saw that poor communication was also commonly an issue for British-born ethnic minority women, and migrant women who could speak English. Communication problems were compounded by a lack of trust, insensitive behaviour, failure to listen and to bridge cultural differences. Further, reports of negative interactions, stereotyping, disrespect, discrimination and cultural insensitivity were also common.
The workings of NHS systems, as well as the attitudes, knowledge and behaviours of healthcare staff, made some ethnic minority women feel ‘othered’, unwelcome, and poorly cared-for. These factors appeared to undermine trust and feed fear, negatively affecting ethnic minority women’s willingness to seek healthcare and ultimately the level of care they received.
Navigating unfamiliar services and getting to grips with NHS information, processes and procedures was particularly challenging for women who had recently migrated to the UK , for whom access to and engagement with services was often poor.
Studies describing the personal experiences of ethnic minority women made it clear that they felt underserved by community-based services offering support to pregnant women and new parents.
We also found research highlighting how other aspects of social disadvantage exacerbate ethnic inequalities, compromising women’s access to, and positive experiences of, maternity care. Groups of women who were particularly disadvantaged included Roma, Gypsy and Traveller women, those seeking asylum or with recent refugee status, those with mental health conditions, and teenage women and young mothers.
What needs to change?
Our report makes a clear set of recommendations. In respect of further research, we need both qualitative and quantitative research of maternity care and outcomes across a wider range of ethnic groups. We especially need to identify inequalities in care that contribute to differential perinatal and infant outcomes by ethnicity.
Specifically, research needs to:
- Engage closely with women and families (especially those in very vulnerable circumstances) to understand their perspectives and experiences
- Be co-produced to develop interventions and make services appropriate to their needs.
- Determine how positive relationships between healthcare providers and ethnic minority women can be achieved consistently.
Crucially, attention must also be paid to institutional and system-level barriers, particularly racism, and how these structures, procedures and cultures undermine good quality care, and how these can be recognised, resisted and transformed.
We also make some clear recommendations for policy and practice:
- Routine NHS maternity and neonatal datasets should be linked to allow analyses of patient journeys and outcomes, across mothers and their babies, and across service areas. Recording of ethnicity needs to be complete and accurate.
- Systems for the routine collection of data especially on experiences of racism and discrimination need to be developed.
- There should be renewed and serious efforts to secure high quality interpreting services, translations of and audio health promotion materials.
- A serious commitment from the NHS to tackle racist attitudes and behaviours among healthcare staff, and address structural dimensions of NHS systems that discriminate against ethnic minority women and their babies.
Solid evidence base
For too many years, the health of ethnic minority people has been negatively impacted by a lack of high-quality ethnic monitoring data recorded in NHS systems; lack of appropriate interpreting services for people who do not speak English confidently and delays in, or avoidance of, seeking help for health problems due to fear of racist treatment from NHS healthcare professionals.
Our review confirmed that all of these issues are still to be tackled by the NHS. The evidence on the poor healthcare outcomes for many ethnic minority groups across a range of services is overwhelming and convincing. This solid evidence base now needs to be put into action to address ethnic inequalities at both practical and policy levels.
All women who are expecting babies or caring for newborn children should receive the same service and level of care from maternity and neonatal NHS services. There can be no more excuses for inaction on ethnic inequalities – the time for change is now.