Maternity mortality watchdog, MBRRACE-UK, has published two new reports comparing the care received by women whose babies died during or soon after birth. The stillbirths and neonatal deaths all took place between July and December 2019. The aim of the reports was to identify differences in the maternity care given to the Black or Asian mothers, compared with mothers who are White. MBRRACE-UK has reported on the deaths of mothers and their newborn babies in the UK since 2013 and has repeatedly found disproportionately high rates of stillbirth and neonatal deaths for mothers and babies of Black and Asian ethnicity. Their latest comparison reports reveal the findings of a multi-disciplinary panel of experts who reviewed patient medical records and hospital reviews gathered by the Perinatal Confidential Enquiry, which investigates all stillborn and newborn babies’ deaths. The panel assessed the quality of care against national guidance from Royal College of Obstetricians and Gynaecologists (RCOG), National Institute for Health and Care Excellence (NICE), and other organisations, including the baby loss charity, Sands. The reports focus only on specific areas of maternity and neonatal care which differed significantly between women from the three ethnic groups and were not intended to identify other factors, such as behaviour of healthcare staff or systemic racism, which are not evident from the reviews or patients’ medical notes. MBRRACE-UK’s findings on differences in Black, Asian and White bereaved mothers’ maternity care The reports showed that women and babies from all three groups received an alarmingly high level of substandard care during their maternity and neonatal care pathway. The expert panel identified that the outcomes for nearly half (49%) of the White women, 42% of the Black women and a quarter (26%) of the Asian women could have been different with better care. The mothers’ own outcomes would also have been improved for 69% of White women, 61% of Black women and 59% of Asian women if they had received better care. Major or significant issues were found in the antenatal care given to 69% of White women, 73% of Asian women and 83% of Black women. In addition, major or significant issues were identified in the postnatal or bereavement care of 54% of White women, 44% of Asian women and 33% of Black women; in relation to pathology issues for 67% of Black women, 46% of White women and 27% of Asian women; and at follow up or review for 75% of Black parents, 66% of White parents and 65% of Asian parents. The panel found a lack of personalised, kind and compassionate care across all groups. Whilst these statistics indicating widespread substandard care are a serious cause for concern, MBRRACE-UK advise caution in relying on the headline statistics, which in some cases were based on gradings for a single aspect of the women’s care. The reports’ deeper dive into the way individual ‘vulnerabilities’ were handled more accurately shows how women (and their babies) with different risk factors, ethnicity and cultural backgrounds are disproportionately affected by failings in maternity care. Lack of understanding of the importance of women’s backgrounds Citizenship and ethnicity were inaccurately and inconsistently recorded in the medical records, with inappropriate blending of concepts including nationality, country of birth, citizenship status and religion. MBRRACE-UK note that this reflects a lack of understanding of the importance of women’s backgrounds which affects the ability to assess the woman’s needs and provide personalised care planning. Language barriers reduce women’s ability to make informed choices about their care Language difficulties were a key vulnerability amongst the Asian women, with more than a third (38%) not speaking English as their first language. The panel found that significant or major language issues probably or almost certainly affected the outcome for five Asian women, three Black women and two White Eastern European women, but identifying and responding to language needs was inadequate across all ethnic groups. National guidelines mandate that professional, independent interpretation services are offered to women with language barriers during maternity care conversations. Instead, MBRRACE-UK found that family members and healthcare professionals were often used as interpreters which, along with failure to assess the women’s understanding, may have affected their ability to make informed choices about their care. For example, the panel questioned whether lack of information, understanding or translation may explain why more than a third (35%) of Asian women declined screening for chromosomal (genetic) conditions compared with 6% of White women. Black women more often experienced barriers to accessing specific types of care or advice. This led to some women not taking prescribed medicines, discharging themselves against medical advice, and not attending specialist appointments. Social risk factors A disproportionate number of the women who had experienced stillbirth or neonatal death had social risk factors. Social deprivation was less common for the Black women in this group but was the most common vulnerability amongst the White women, who were more likely to have multiple disadvantage, mental health issues and social services involvement. The panel found that many complex social risk factors were not properly recorded. Significant or major issues with safeguarding and complex social needs probably or almost certainly affected the outcome for 14% of the women. Cultural factors There were some cultural factors which more commonly affected women and babies from Black or Asian ethnic backgrounds. Ten Asian women’s babies died from congenital abnormalities (compared to four babies with White mothers). Three of these Asian women were married to close relatives and already had previous children with genetic disorders. Two more Asian women were partnered with more distant relatives. The panel also identified instances where female genital mutilation (FGM) was not identified or responded to correctly. FGM is more commonly found in Black populations. Whilst this did not directly affect the outcomes for these women, national guidance requires health professionals to safeguard and support women affected by FGM. Differences in specific aspects of maternity care MBRRACE-UK’s panel found differences in specific aspects of the maternity care given to White, Black and Asian women, which may have affected the outcomes for their babies. Significantly fewer eligible Black and Asian women than White women were offered oral glucose tolerance tests. Screening for gestational diabetes was inconsistent and did not follow national guidance. High blood pressure (hypertension) increases the risk of stillbirth and early neonatal death. National guidelines set out the management of hypertension in pregnancy, including escalation to senior medical staff to plan how the mother’s blood pressure will be managed. No White women in this group had hypertension but the panel found that poor management of high blood pressure affected the outcomes for three Black women. Pre-eclampsia is a dangerous pregnancy-related condition which requires careful management for the safety of the mother and baby. NICE guidance recommends that pregnant women who are at high risk of pre-eclampsia should be offered daily Aspirin, from 12 weeks of pregnancy until the birth of their baby. The panel found that this guidance was not followed for nearly two thirds (63%) of eligible Black women and 71% of eligible White women. They also found widespread failure to offer vitamin D to eligible women of all three ethnicities in accordance with guidance that was in place at that time. Whilst proportionally more eligible White women were not offered vitamin D during their antenatal care, the impact was far greater for Black women and significantly greater for Asian women who needed higher doses of vitamin D, compared with only a small proportion of White women. Reduced fetal movements are a danger sign for the unborn baby, so mothers should receive written information before 24 weeks of pregnancy advising them to contact their maternity team if they are worried about reduced fetal movements. The panel found that only 47% of Black women were properly advised about reduced fetal movements compared with 58% White women. In general, MBRRACE-UK found that women of all three ethnic groups received similar levels of poor care during labour and birth. Partogram charts (used by midwives to chart key aspects of labour) were not completed for 64% Black women and 36% White women. Where the mother asked for pain relief during labour, 27% of Black women and 35% of White women did not receive it within 15 minutes. MBRRACE-UK noted previous research highlighting unacceptable and inhumane care given to Black people caused by incorrect assumptions that they have a higher pain threshold than people from other ethnic backgrounds. The standard of neonatal care provision was proportionately similar for Asian, Black and White babies. As with previous reports, common concerns related to medical care, including resuscitation, thermal care, and delays in starting antibiotic treatment for suspected sepsis. In some cases, escalation or team leadership failures contributed significantly to the outcome for the baby. The panel noted that Black women less commonly had consultants present at the birth or joint obstetric and neonatal follow-up. Hospital reviews after stillbirth and neonatal death MBRRACE-UK identified failings in the way hospitals reviewed their own care after the stillbirth or death of a newborn baby. They found that regardless of ethnicity, no parents with identified language barriers put questions or concerns about their care to the local review team, suggesting lack of available interpretation services. This was also reflected in the lower proportion of Asian parents who asked questions or expressed concerns about their care. Reviews often failed to answer the parents’ questions or concerns, or identify failure to respond to the mother’s vulnerabilities or follow guidelines relating to specific aspects of care. The panel found that the overall grading during local hospitals’ reviews of their own care was not affected by ethnicity, but often graded more positively than the confidential enquiry panels. Learning from MBRRACE-UK’s findings on ethnicity differences in maternity care Ethnicity disparities in outcomes from NHS maternity care are unacceptable but require fearless impartiality if their causes are to be identified and addressed. It is widely acknowledged that there is no simple solution to what is both a historic and persistent inequality, with related factors ranging from systemic racism and White skin bias, and a disproportionate overlap with social deprivation, to inhumane or negligent care. MBRRACE-UK acknowledge the limitations to their analysis and reports which are based on patient medical records and hospitals’ review data, but despite those limitations, their expert panel members found largescale evidence of poor care given to the mothers who lost their babies, across White, Black and Asian ethnic backgrounds. The panels used national guidance and standard maternity practice as their benchmark. There were no unreasonable expectations or unfair marking criteria here. But in many cases, if guidelines relating to the individual mother’s circumstances had been followed, that alone would have avoided the deaths of these babies. MBRRACE-UK’s surveillance reports regularly identify the connections between poor maternity care and the avoidable deaths of mothers and babies. However, their latest comparison reports highlight that the difference in outcomes for Black or Asian women is often the layering of basic care errors with missed opportunities to recognise the disproportionate impact that individual risk factors could have on their pregnancy. The compounding effect is best highlighted by the example of a non-English-speaking Black African woman who was found and taken to hospital towards the end of her pregnancy. She was in obvious distress, with shortness of breath, but her hypertension was not documented, pre-eclampsia was not ruled out and no CTG was undertaken. A few days later she suffered an abruption and intrauterine death. She had been given a leaflet about reduced fetal movements but, without interpretation, the panel believed she had probably not understood the information. Mothers from all racial, cultural and social backgrounds have different needs and vulnerabilities, which must be anticipated, discussed with the mother, and documented to inform and underline the need for vigilant care. National guidelines, if followed, already provide a basic framework for safe maternity care. Whilst urgent improvement is needed at national, local and individual levels and from multiple perspectives to address all inequalities in healthcare experienced by Black and Asian mothers and babies, MBRRACE-UK’s comparison reports highlight that in many cases, needless deaths would have been avoided if the mothers simply had received an acceptable standard of maternity care. If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
