Abstract
Background: Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. Methods: National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009-18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received, and describe any structural or cultural biases or discrimination identified. Findings: There were no major differences in assessed quality of care, nor in causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). Interpretation: This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. Funding: NIHR Policy Research Programme Declaration of Interests: All authors have completed the ICMJE disclosure form and declare: Marian Knight, Sara Kenyon and Jennifer Kurinczuk received grants from the NIHR PRP in relation to the submitted work. Kathryn Bunch, Nicola Vousden, Anita Banerjee, Philippa Cox, Fiona Cross-Sudworth, Mandish K. Dhanjal, Jenny Douglas, Joanna Girling, Rohit Kotnis, Roshni R. Patel, Judy Shakespeare, Derek Tuffnell and Meg Wilkinson have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. No authors have other relationships or activities that could appear to have influenced the submitted work. Ethics Approval Statement: Identifiable MBRRACE-UK data were collected in England and Wales without consent with approval of the Secretary of State for Health and Social Care under Section 251 of the NHS Act 2006 (15/CAG/0119). Data were collected in Scotland without consent with approval from the Public Benefit and Privacy Panel for Health and Social Care (1920-0131). Identifiable information was not provided from Northern Ireland. The legal basis for this activity is Article 6 (1)(e) and Article 9 (2)(i) under the General Data Protection Regulation.
Highlights
Racial and ethnic disparities in maternal mortality have been documented in both high[1] and low resource settings.[2,3] Disparities were first documented in the UK in the early 2000s but are known to be widening.[4]
Surveillance and maternal death review is conducted in accordance with WHO Maternal Death Surveillance and Response (MDSR) technical guidance,[16] and a database of all maternal deaths occurring since 2009, cross-checked with linked vital statistics records has been maintained.[17]
In total 1894 women died in the UK between 2009 and 2018 during or up to a year after the end of pregnancy, 1538 were in the White aggregated group (81%), 140 in the Black aggregated group (7%), 165 in the Asian aggregated group (9%), 21 in the Mixed aggregated group (1%) and 30 in the Chinese or Other aggregated group (2%)
Summary
Racial and ethnic disparities in maternal mortality have been documented in both high[1] and low resource settings.[2,3] Disparities were first documented in the UK in the early 2000s but are known to be widening.[4]. In the United States (US), a substantial part of the disparity in maternal morbidity and mortality is attributed to healthcare insurance status and consequent differential access to high quality maternity care.[8] In the UK a delayed first antenatal visit, or fewer antenatal visits than recommended, have been shown to be associated with observed differences in mortality rates between ethnic groups,[9] but do not account for all the observed difference. Overall the causes of maternal death in the US are similar to the UK, different causal patterns of maternal deaths amongst different racial and ethnic groups have been reported.[8] In the UK, whilst pre-existing medical morbidities, gestational diabetes and obstetric history are known to be associated with maternal death,[9] varying cause of death by ethnicity has not been described. Adopting the framework of Kilbourne et al,[10] further research is needed at the ‘understanding’ phase before actions can be designed to reduce the observed disparities
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