Kirstin Webster discusses the latest report by the National Maternity and Perinatal Audit looking at differences in maternity outcomes for women, and their babies, from different ethnic groups and those who live in deprived areas in Great Britain.
Only last week a study in The Lancet, co-lead by Dr Jennifer Jardine from the RCOG, found that thousands of babies in England are being born preterm, smaller than expected, or stillborn because of socio-economic and racial inequalities across the country.
The findings of this study are alarming but sadly they come as no surprise.
Approaching the sprint audit report
As an advanced neonatal nurse practitioner (ANNP), I have cared for preterm babies and those born at term who require extra support at/after birth.
I’ve been very aware at times of the impact disparities in healthcare can have on mothers, babies and families.
Wider inequalities in healthcare and the effects of social determinants of health are well reported by, amongst others, the World Health Organisation[1] and Sir Michael Marmot[2],[3] with inequalities in mortality rates for women and birthing people and their babies reported by MBRRACE-UK[4],[5].
Using the NMPA dataset, the Ethnic and Socio-economic Inequalities in NHS Maternity and Perinatal Care for Women and their Babies report describes inequalities in maternity and perinatal care in Great Britain for over 1.37 million women and their babies. The results are presented according to the ethnic group and level of socio-economic deprivation of the mothers.
The data only tells us so much however, and it was important to also enlist the help of an advisory group comprised of professionals and women with diverse experience of accessing maternity care.
Key findings show inequalities
Whilst many working in clinical practice know from experience, it is still stark to see the extent of the inequalities presented in the results of the sprint audit.
The findings show that Black women had higher rates of caesarean birth, planned and emergency (and both combined) and were more likely to experience a major postpartum haemorrhage ≥1500 ml when compared to white women. Rates of postpartum haemorrhage ≥1500 ml were highest for women in the least deprived areas with a decreasing trend across deprivation quintiles to lowest rates for those in the most deprived areas.
Babies born to Black women had higher rates of having an Apgar score (an assessment of the baby’s condition at birth) of less than 7 at 5 minutes and higher rates of admission to a neonatal unit at term when compared to babies born to women from all other ethnic groups. Babies born to women from South Asian ethnic groups had lower rates of having an Apgar score less than 7 at 5 minutes but higher rates of term neonatal unit admission when compared to those born to white women.
We also look at the characteristics of those included in the report so that we can start to ask questions about the reasons for the differences we observe. For example, women from South Asian and Black ethnic groups and those from the most deprived areas had higher rates of pre-existing hypertension and pre-pregnancy diabetes when compared to women from white ethnic groups and those in the least deprived areas. Rates of having a BMI of 30kg/m2 or above were higher for women from Black ethnic groups compared to those form all other ethnic groups, and for those living in the most deprived areas.
Previous NMPA reports have adjusted for these factors when looking at outcomes, however making these adjustments can mask the full extent of inequalities and thus this report does not provide adjusted results.
Our recommendations
We emphasise in the report that differences in clinical practice are relatively small, and therefore unlikely to explain the difference in outcomes described in the report.
For this reason, we have made recommendations that target health improvements in a life course approach by:
- Supporting all people to improve their health prior to a pregnancy.
- For those who are pregnant to be offered maternity care that is tailored to their individual circumstances.
- For an improvement in the quality of information made available about choices during pregnancy and labour to enable people to self-advocate for the birth experience they want.
We hope the findings of this report can be used to start discussions between women, their families and care providers to enable people to advocate for the birth experience they would like, and to call to action changes in wider healthcare to address these inequalities.
Kirstin Webster is an NMPA Clinical Fellow and Lead Author.
For media enquiries please contact the RCOG press office on +44 (0)7740 175342 or email pressoffice@rcog.org.uk
Notes
[1] World Health Organization. Evidence and Resources to Act on Health Inequities, Social Determinants and Meet the SDGs. Copenhagen: World Health Organization Regional Office for Europe; 2019 [www.euro.who.int/__data/assets/pdf_file/0009/397899/20190218-h1740-sdg-resource-pack-2.pdf (PDF)]
[2] Marmot M, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives: The Marmot Review. London: Institute of Health Equity; 2010 [www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review]
[3] Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On. London: Institute of Health Equity; 2020 [www.instituteofhealthequity.org/the-marmot-review-10-years-on]
[4] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ, on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care 2020: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2020 [www.npeu.ox.ac.uk/mbrrace-uk/reports]
[5] Draper ES, Gallimore ID, Smith LK, Fenton AC, Kurinczuk JJ, Smith PW, Boby T, Manktelow BN, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance Report: UK Perinatal Deaths for Births from January to December 2019. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester. 2021 [http://www.npeu.ox.ac.uk/mbrrace-uk/reports]