Abstract
SummaryBackgroundEthnic 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.MethodsNational surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 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. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified.FindingsThere were no major differences 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).InterpretationThis confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted.FundingThis research is funded by the 10.13039/501100000272National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217–21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the 10.13039/501100000272National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
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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