Introduction
Last month a new report called “Systemic Racism, Not Broken Bodies” by maternity charity Birthrights was released. Widely covered by the media and others, it cited evidence that black women are five times as likely to die than white women during pregnancy and childbirth, whilst Asian women are twice as likely. A panel chaired by Shaheen Rahman QC, a barrister specialising in clinical negligence, interviewed over 500 people on “racial injustice in a maternity setting”. The report says that the disparity has previously been explained by looking at “Black and Brown bodies as the problem – regarding them as ‘defective’, ‘other’, and a risk to be managed” when it was “systemic racism” to blame. But is this true?
What does the report say?
The report begins by saying that the “starting point for our year-long inquiry was that systemic racism exists in the UK and in public services”. The authors spoke to women and to “birthing people”, with 244 responses to the written call for evidence; 11 focus groups, reaching 50 women and 5 midwives; 14 in-depth interviews, with 3 LGBTQ+ birthing people/partners, 2 women, 1 midwife and 8 clinical negligence solicitors or barristers; as well as a poll conducted by Survation to “to compare the experiences of 1,069 women who gave birth in the last 5 years – 556 white and 513 Black, Asian and Mixed ethnicity”.
Amongst the focus groups were the African Community Centre, Swansea Women’s Asylum Seeker and Refugee Group, Raham Project, Latin American Association, Happy Baby Community (Kurdish, Arabic, Yoruba, Urdu, Mandarin), Leeds NHS Maternity Voices Partnership, and Healthcare professionals. Some of these groups were very small however; the Happy Baby Community Kurdish group only involved three women for instance.
The most common experience in the testimony was “feeling unsafe”, with examples including a nurse failing to recognise jaundice on a black baby, a Ghanaian woman who was discharged despite being in distress as a result of what they later found was a blood clot, and an African woman whose sepsis was only noticed by a South Asian doctor. Other issues included feeling ignored, examples of racism, cases where the patients felt dehumanised, occasions when patients felt that consent wasn’t properly obtained, and examples of structural barriers such as a lack of translators in hospital.
Citing the Human Rights Act and the Equality Act 2010, the report ends with a call to decolonise the maternity curriculum, commit maternal care to being actively anti-racist, dismantle structural barriers to racial equity, create inclusive workplace cultures, and let black and brown women be decision-markers in their own care.
This would involve “mandatory” anti-racism training, an “organisation-wide racial equity action plan”, a review of training to ensure that “ the white body is not centred as the norm” and stop “pathologizing Black and Brown bodies”, setting targets for recruiting more diverse staff to senior positions (justified under the “positive action” of the Equality Act), assessments to feature situations dealing with racial stereotypes or microaggressions, “trauma-informed teams of ‘Link Lecturers’ for Black and Brown students” in institutions, “ongoing therapeutic supervision for all frontline staff”, the ending of all “NHS charging for maternity care” (which only really applies to illegal immigrants and overseas visitors), and a commitment to end the ethnicity gap in maternal deaths by 2030.
What’s wrong with the report?
Although the report claims systemic racism is responsible, no attempt is made to prove it, beyond pointing out the disparity in deaths. Looking at the MBRRACE data, it is true that certain minorities are more likely to die: 8 in every 100,000 white women but 15 for Asians and 40 for black women. However the report ignores that the same data also shows that women of Chinese/others ethnicity were the least likely to die, with only 5.32 in every 100,000 doing so. If (white) systemic racism really was the cause of higher rates of death then that shouldn’t be the case.
Maternal mortality also varies substantially within race by country of origin. Pakistani origin women were twice as likely to die than Indian women, whilst Eritrean women were almost three times more likely to die than Nigerian women. This suggests that race is not the primary factor leading to higher rates of maternal deaths.
In fact the leading causes of death are blood clots and suicide, with the former largely being a result of being obese or overweight, something stated on the very first page of the document the report links to when citing the higher maternal death rates of some minorities. Research has explained this as a result of “gestational diabetes during their current pregnancy, medical comorbidities, previous pregnancy problems and inadequate use of antenatal care”.
Issues the report focuses on, like sepsis, lead to only 1 in 100,000 deaths. In total, “66% of the increased risk of maternal death in the UK could be attributed to medical comorbidities” whilst “two-thirds (68%) of the women who died in 2014-16 were known to have pre-existing medical problems”. In particular, 37% of women who died were obese and 20% were overweight, 12% were substance users, and 16% were known to social services. It’s not that non-white bodies are “broken” therefore, but rather that poor personal choices make them less healthy, leading to more risk of death.
Within the year after birth, suicide rises to become the main cause of death, with 86% of those suicides being white and only 10% from ethnic minorities (4% of the data is missing). This clear racial disparity is never cited nor discussed in the report.
Comment
Although the report raises many harrowing stories and is correct that healthcare has improvements to make when dealing with darker skin tones, the very data which it links to disproves its own claim that systemic racism is to blame for higher rates of maternal deaths. Whilst the report rejects the “broken bodies” claim, it is largely pre-existing health issues which are to blame for the inequality. By blaming racism, they put these minority women at greater risk, by encouraging them to blame a scapegoat rather than choose to live more healthily. Saving lives requires pushing them to lose weight, quit substance abuse, and attend antenatal appointments regularly.
Similarly, although many of the experiences relayed are terrible, it isn’t clear in many of them that racism is to blame. Poor treatment on the NHS is not confined to ethnic minorities alone and examples such as being moved from bay to bay will be familiar to people of all races. Nor is any attempt made to verify these stories.
The policies fixes suggested involve devolving power over training, staffing and human resources to a highly politicised ideology, summed up in the petty decision to capitalise “Black” and “Brown” throughout the report whilst leaving “white” in lowercase. Some suggestions, such as implementing “positive action”, will inevitably end up penalising white people for being the wrong race. Improving the NHS instead requires focusing on investment.
Although Birthrights is a charity, of their £347,327 in income only £45,960 came from grants under £5,000 (as well as £11,875 in gifts in kind). The rest was provided by a variety of large foundations, with the money for this report provided by the Joseph Rowntree Charitable Trust and John Ellerman Foundation. A grant from the National Lottery Community Fund, which is defined as a government grant, was also used to pay for “anti-racism training for staff and trustees”. Once again, this demonstrates how charities with little grassroots support lobby for policy change on the basis of poor data and ideologically motivated reasoning.