birthrights

Notes on: Birthrights (ND) . Systemic racism, not broken bodies. An inquiry into racial injustice and human rights in UK maternity care. Avaialble from https://www.birthrights.org.uk/campaigns-research/racial-injustice/

Dave Harris

The foreword by the inquiry co-chair relates that black and brown women do not feel safe when accessing maternity care and that this cannot be understood without grasping racism and bias in the healthcare system, which had 'a massive impact on my journey… I was stereotyped and felt like I had to suffer in silence after repeatedly raising concerns then being ignored'. The other inquiry co-chair says in her foreword that the usual explanations mention socio-economic deprivation and comorbidities but these should be seen as added factors affecting the training of staff, really just the straw that broke the camel's back.

The report drew upon 'hundreds of black, brown and mixed ethnicity women, birthing people and healthcare professionals'. They also ran focus groups and interviews with midwives and health care professionals. They had an initial scoping and evidence review, then some interviews with LGBTQ + birthing people. They rooted this work in 'antiracist principles and practice. They work widely with other organisations and foundations including legal ones.

In 2018, the MBRRACE report found that black women were five times and Asian women twice more likely to die in the perinatal period than white women. These trends continued for decades. They are also more likely to experience baby loss, become seriously ill and have worse experiences of care. Black and brown bodies have often been seen as the problem 'regarding them as "defective", "other", and a risk' (9). They insist instead that 'systemic racism exists in the UK and in public services'and set out to see how it manifested itself and how to end it. They heard testimony from women, birthing people, professionals and lawyers and focused on systemic racism in individual interactions, workforce culture, curriculums and policies. An expert panel brought together this lived experience, maternity care and legal knowledge. They had 'in-depth testimony from over 300 people' following an online call for evidence, focus groups and interviews, from professional clinical bodies, experts and various women and other birthing people.

The common themes that emerged were: 'lack of physical and psychological safety; being ignored and disbelieved; racism by caregivers; dehumanisation; lack of choice, consent and coercion; structural barriers; workforce representation and culture' (10) [spelled-out later]. Calls for action follow: the maternity system should 'commit to be an antiracist organisation; decolonising maternity curriculums and guidance; make black and brown women and birthing people decision-makers in their care; create a safe inclusive workforce cultures; dismantle structural barriers to racial equality through national policy change'. Definitions follow, referring to inclusive language, hence 'birthing people', defining the various ethnic categories using the same definitions on the census, but also calling for evidence from people that are not specified in census categories 'e.g. Somali, Thai, Vietnamese, mixed black and Asian; and from people who may identify primarily by their faith e.g.: black, Asian and Arab Muslims'(11). Somalis are promptly included in black, however brown include Asians and Latin Americans.

They used the MacPherson definition of institutional racism — the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. They want to broaden it to refer to systemic racism because they have gathered evidence to show that racism goes beyond single institutions 'and infects national systems, policies and attitudes' (13). We need to understand the 'long history of dehumanisation of black and brown people in the UK… People who have been perceived by white societies being subhuman… Black women specifically'. They were subject to particular forms of abuse in healthcare settings, medical experimentation without consent and forced sterilisation, and '"the medical model that exists in maternity care today was built on this patriarchal, white supremacist framework"' (quoting Roberts 1997) [bold assertion]. This persists in treating black and brown people as outside the normal where normal is whiteness. This affects, for example, access to and provision of healthcare. It affects maternity care in ways which threaten basic human rights to 'safety dignity and autonomy and equality'.

Systemic racism is found in four categories:

Individual interactions — being ignored and disbelieved, experiencing stereotypes and micro-aggressions, being dehumanised, denied pain relief.

Education and training — white bodies as the normal default, failure to recognise conditions like jaundice or sepsis, lack of cultural understanding

Policies and frameworks — ethnicity as grounds for induction within policies, high risk pathways based on ethnicity alone, lack of representation in clinical evidence and committees, NHS charging regime and failures to provide interpreting services

Workforce — lack of senior representation, higher rates of disciplinary action, bullying and toxic culture

The remedies in each case is a commitment to be an antiracist organisation, making black and brown women decision-makers, decolonising maternity curriculums and dismantling structural barriers [charging regimes and interpreting] while creating workplace cultures that are safe. (14)

This follows from applying the Human Rights Act [not really CRT then] and human rights law [which already apparently means that 'the person giving birth is the primary decision-maker in their care' (15)] [further implications from articles and humans rights legislations follow].

The existing evidence already shows persistent racial inequalities in birth outcomes and experiences in the UK. The panel also reviewed US data. Statistical research informed the use of qualitative methodology 'to gather the stories behind the statistics and address gaps in the evidence'(17).

There are consistently higher death rates for black brown and mixed ethnicity women compared to white women. Overall death rates in pregnancy and childbirth are relatively low in the UK 'fewer than one in 10,000 pregnancies' but there are persistent and significant racial inequalities. The most recent MBRRACE Report in 2021 shows a continued gap between mortality rates, with black ethnic groups four times more likely to die than women from white groups, Asian and mixed ethnicity groups twice as likely. The slight drop in maternal mortality rate for black women 'was not statistically significant' and the picture is not changing over 10 years. Further inequalities arose between women born outside the UK and those born in the UK. Women born in Nigeria had the highest maternal mortality rate. Heart disease was the leading cause of death, followed by epilepsy and/, sepsis, and blood clots during or up to 6 weeks after the end of pregnancy.

[This is an interesting cause of death -- the factors mentioned below attributed to lack of care cover things like jaundice {for kids}, blood clots and sepsis but do not even mention heart disease]

The women who died 'faced a "constellation of biases" which prevented them from receiving the care they needed'. There were overlapping factors — 'being from an ethnic minority group, socio-economic deprivation, social services involvement, language difficulties, mental ill-health, obesity, domestic abuse' which increased the impact of 'the structural and cultural biases women experience in pregnancy' (17) [but from whom? Men in their own cultures? MBRRACE doesn't seem to blame the NHS].

Similar racial inequalities exist with infant birth outcomes in 2021 — '"exceptionally high for babies of black and black British ethnicity"' (MBRRACE), stillbirth rates over twice those who are white babies, neonatal mortality rates 43% higher. Asian and Asian British stillbirth and neonatal mortality rates 60% higher than for white babies. The overall stillbirth rates have been reduced between 2013 and 2018, but are falling more slowly and an ethnic minority babies compared to white babies so 'initiatives to reduce baby loss are "failing to reach many women from higher risk ethnicities"' [again not exactly blaming racism in the NHS, is it?] (18).

There are further inequalities. Infant mortality rate was highest among babies with Pakistani ethnicity, and one study (2009) showed that Pakistani infants of Pakistani born mothers have a lower risk of neonatal and infant death than those born to UK born Pakistani mothers [that is odd]. Caribbean and Pakistani babies were more than twice as likely than white British babies to die before the age of one and the multiple complex factors cited by the study included 'the impact of systemic racism... On both health outcomes and maternity care experiences', although it noted that 'empirical work on the impact of racism… Is lacking' despite a number of US studies reporting positive association between perceived racism and both preterm delivery and low birthweight'.

Black and Asian women are at higher risk of illness during pregnancy, and the pandemic has exposed and exacerbated these tendencies — black pregnant women eight times and Asian women four times more likely to be admitted to hospital with covid compared to white women in 2020. Again this is attributed by Public Health England to a combination of 'structural racism, socio-economic disadvantage, housing challenges and occupation (frontline care, retail, transport)' (19). The Royal College of Midwives notes that 'socio-economic disadvantage and being from a BAME background are closely associated with higher prevalence of obesity, diabetes, hypertension and cardio metabolic complications' which increase the risks of both Covid and pregnancy, although an MBRRACE review doubted those links, and other studies have also concluded that poverty does not explain maternal health inequalities between ethnic groups, nor does age and socio-economic status. Reduced access to or delays in care 'are all the more concerning' given that we do know there is a relation between some conditions and specific ethnic communities, such as sickle cell anaemia or thalassaemia.

Postnatal depression and anxiety are higher in black Asian and mixed ethnicity women, while rates of access to perinatal mental health services are lower in women and birthing people from those groups. (19).

There are studies reporting that women in all minority ethnic groups had a poorer experience of maternity services than white women, with more worries about labour and birth, related to pain, uncertainty about duration and possible medical interventions. A 2010 survey of 24,300 women found significant differences in care, relating 'directly to basic human rights' (20). Black and brown women face more barriers to access and choice and were treated with less dignity and respect. They were less likely to be involved in decisions to give birth at home or in a birth centre or to receive pain relief and were more likely to be offered emergency cesarean. MBRRACE found they faced delayed or reduced access to care and this played a role in maternal deaths — nine out of 10 Nigerian women who died received antenatal care but only one at the recommended level. In another report maternity care was variable and many had minimal or delayed inputs. American studies show that racism directly impacts through stereotyping which influences diagnosis and treatment options including pain management and communication gaps affecting medical history details and monitoring. This 'creates a cycle where black and brown people avoid interactions with healthcare professionals through fear of potential prejudice and discrimination' or fear of being stereotyped, and are less likely to share information or follow advice.

American literature also points to the historical roots of gynaecology in the experimentation and forced procedures on enslaved black women [Dr J Marion Sims is mentioned, although he has recently been defended]. Racist views about black people in pain still persist in 2016 among white medical students attributing them to biological differences, although, 'there is far less UK research on racism within healthcare'. Nevertheless the Royal College of Obstetricians and Gynaecologists said in 2020 that racial bias can hinder consultations affect treatment options and result in black Asian and minority ethnic women avoiding interactions, and the Race and Health Observatory noted women's experiences of 'negative interactions, stereotyping, disrespect, discrimination and cultural insensitivity'which led to some ethnic minority women feeling othered, unwelcome and poorly cared for. Another report in 2020 described racism and stereotyping in NHS maternity care, reporting 'a common midwifery and obstetric perspective that '"Asian women have a shorter perineum"' assuming the anatomy as compared to some "white norm"', and reporting that some 'non-BAME maternity staff… [act]… On the mistaken belief that black women have a higher pain threshold than other women [this seems to be drawn from the experiences of ethnic minority NHS staff in maternity services]. There are other UK studies finding that 'midwives stereotypically view Asian women as needing less support, being generally well supported by their families, having a lower pain threshold in labour and a tendency to "make a fuss about nothing", and being too demanding '(22).

There are other compounding factors including age, disability, language and migrant status. For example NHS charging rules can deter undocumented migrant women from accessing care. In America, perceptions of race and mental capacity intersect to reduce black and brown women's autonomy — in one case a woman was forced to have a cesarean against her will and racism was alleged to be a factor. Religious discrimination might be a factor for Moslem women who also can face stereotypical and discriminatory behaviour, lack of awareness and understanding of Islam and with visible clothing which opens them to discrimination. Muslim Somali women have reported that 'they are repeatedly asked if they have experienced female genital mutilation… Which can be insensitive, intrusive and re-traumatising' (23) [but still relevant?]

Gender identity is still underresearched and we don't know how many deaths include trans men and non-binary people. Trans men do experience some of the greatest health disparities and unequal treatment when accessing healthcare in general, and '"trans-phobia and racism in perinatal care intersect"' to affect 'trans and non-binary birthing parents of colour"' (23).

National initiatives addressing racial inequalities have had little impact because mostly they have overlooked the role of systematic racism or have perpetuated the view that black and brown bodies of the problem. For example they are focused on the roll-out of continuity of care but not on antiracism and cultural safety training. They have focused on equity, but have not set targets to reduce disparities for black women, or identify the sources of 'oppressions in maternity care experiences and outcomes' (25). Most of the recommendations face on obvious 'preconceptions of health or pre-existing conditions' like smoking or diabetes, and although this is welcome, it still risks blaming black and brown bodies. What is still missing is 'reference to the important concept of "weathering" — the lifetime impact of every day racial trauma and discrimination on health, including on pre-existing conditions' (25). This can lead to a breakdown of trust and poor interactions with services.

There is apparently an independent NHS Race and Health Observatory which has recommended tackling racist attitudes and behaviours among healthcare staff. The Royal College of Midwives has also called for improvements in midwifery education so that midwives are better able to assess darker skin tones as part of a move to decolonise the curriculum. But there are wider structural issues, including chronic underfunding and staff shortages, which themselves have 'led to preventable deaths of women and babies' (28) a particular report focusing on the experiences of black brown and mixed ethnicity maternity staff said they felt particularly scared anxious and worried about their own health, did not feel safe or supported at work, or supported by management, face the lack of personal protective equipment and acknowledgement of psychological impact and 'did not feel they were able to raise concerns for fear of retribution'(28). This looks like systemic dysfunction which is likely to have a disproportionate impact on marginalised groups again.

The panel adopted a qualitative methodology for evidence gathering 'rooted in the trauma informed approach' [for focus groups]. They held three oral evidence sessions, advised by 'Nova Reid (31) the acclaimed writer, speaker and antiracism expert'. There is also a poll with a sample of 1069 respondents, comparing the experiences of minority ethnic and white women. The findings appear in the form of anonymous quotes from respondents to the call for evidence or participants in focus groups and interviews. Over 300 people replied, with 14 in-depth interviews, including three LGBTQ+ birthing people. The sample of people giving evidence were dominated by black African, black Caribbean, and the healthcare professionals likewise. White people on their own do not appear as a separate category at all in those giving evidence, and but are 24% of the healthcare professionals [there are some mixed white and black Caribbean, white and black African, white and Asian together making up 15% of the people giving evidence, and a further 19% of health professionals].

The oral evidence sessions were closed and detailed transcripts were not published. The main evidence was summarised and rendered in the form of anonymous quotes produced [selected?] by members of the expert panel. Nova Reid and others ensured 'we applied an antiracist framework to discussions and conclusions' (35).

Six case studies werer considered from a range of ethnicities. The emerging themes were 'racial micro aggressions and stereotypings, failure to recognise serious medical conditions due to skin colour, lack of respect for culture and religion, breaches of consent, and trauma'. Panel members also shared their own experiences. They highlighted that the case study showed that '"the system was not built to support black and brown people"' (36). Apparently there was also discussion of colourism, having darker skin led to the worst experiences, blame culture which included fear of retribution for speaking out, defensiveness and denial, and examples of how exemptions set out in NHS trusts are often not applied in relation to violence or destitution — patients were not often notified about them, or information about violence is not always shared with overseas visitor managers, nor is the option to write off debts or to avoid charges for treatment. Racial profiling was discussed, so that black women were subject to particular scrutiny in a maternity unit close to an airport. Charging was applied differently according to regional and age variation, and there were no checks to prevent discrimination against certain nationalities. Particular findings from LGBTQ+ people emerge that showed they were not being particularly listened to, dismissed, treated with lack of compassion, often a black pregnant person being treated less seriously than a white partner. People said they were 'racialised by the nature and focus of questions asked by caregivers'. They had a 'deep and persistent fear of death related to "knowing and not knowing" the maternal mortality statistics"' and the lack of knowledge of healthcare professionals, and time pressures which impacted on their personal care. Interviewees did not feel comfortable disclosing they were queer. They did feel more positive about surviving birth, having a healthy baby, being treated well by midwives and having a continuity of care, however. The depth of fear was particularly noticeable [rather odd – it seems to be related to the need to build up some sort of relationship between staff and patients, although some said they were reprimanded for spending too long on this]. Some felt that it was necessary to have 'a vital antidote to the level of fear… Celebrating black and brown birth… "The amazingness of growing and nurturing our families"'.

[Are non-white people more likely than white people to experience fear? Everyone is pretty scared, surely?]

The text for many from healthcare professional bodies and focus groups underlined themes like the NHS culture of blame and fear, lack of senior representation, witnessing or experiencing overt racism. The Royal College of Obstetricians and Gynaecologists presented their work on training and inclusivity and national audits. They revealed that black and minority ethnic doctors in their field have a significantly lower pass rate compared to white peers. They welcomed the explicit focus on racism, but emphasised action not just research, disseminating urgent mandates on how jaundice and sepsis can be diagnosed in darker skin, engaging people who do not express interest in antiracism, a common approach to the medical curriculum, appointing more black and Asian lay examiners, focusing on racism and microaggressions. The Royal College of Midwives has shared intelligence from other mixed ethnicity midwives and support workers that they were more likely to be disciplined work and receive harsher outcomes, more likely to experience bullying and undermining behaviours and less likely to be promoted. They asked to ensure that antiracism trainers are really experts 'not just a group of passionate black and brown members' (40). For them, cultural safety was crucial not just cultural sensitivity, and the need to support staff who were reporting bullying or harassment. The Nursing and Midwifery Council highlighted person centred care, human rights safety and health. They pointed to lower acceptance rates onto education courses for black and Asian students, especially for overseas professionals and recommended more research, improvements to data, changes to overseas registration and revalidation. The panel itself recommended more emphasis on microaggressions and stereotypes, mandateory antiracism training especially for midwives, diverse imagery and specific language, but not BAME, leadership targets, high-profile examples of members who were 'not sufficiently held to account for racist behaviour' (41). They also published a specific case where a person had made racially abusive comments about colleagues and the original nursing and midwifery Council panel agreed a suspension although she was subsequently struck off.

The oral evidence sessions provided witnesses from various places like the National Institute for Health and Clinical excellence (NICE) and MBRRACE. They review the NHS equity and equality guidelines for maternity systems. Nice address their own guidelines especially those that had singled out black Asian and minority ethnic women for particular induction programmes, which they had finally dropped, following reaction that it was 'racist and discriminatory' (42). The panel discussed how it had arisen and how the trust might be rebuilt. MBRRACE presented their report [as above] identified cardiovascular disease as the leading cause of death in all ethnic groups, and 'identified multiple microaggressions experienced by women who died'. These included '… Not being listened to… Agitation in women who did not speak English… Attributed mental health problems… A low pain threshold… Being called difficult when hypoxic… Descriptions of women's ethnic group in origins from generic terms such as Afro-Caribbean to detailed country of birth… Quality of interpretation and continued reliance on interpretation by family members… Assumptions around symptoms made on the basis of language ability and/or ethnic group' (42 – 43) [so lots of these are actually language or translation problems that would affect any foreign women? Or foreign men?]. Microaggressions occurred in all ethnic groups most commonly in Asian women. Lack of individual care was notable among black women who died. There were research limitations and how there might have been problems on identification of microaggressions following limitations with 'representation among the coinvestigator group' [unrepresentative white women?] (43). Numbers were too small to compare nuances between ethnic groups, and they were aggregated. They could work only with medical records and on the care of women who died. They also thought that '"defensive writing"' in healthcare notes, and missing or amended information raised suspicion that other microaggressions or racist views and behaviours 'are not being recorded'. Nevertheless, this analysis 'is powerful and correlates with the findings on microaggressions in this inquiry's evidence'.

Poll findings from 556 white respondents, 513 black, 227 Asian, 141 mixed ethnicity. 26% of nonwhite respondents said English was not their first language, 10% of white women.

[Quite a lot of people who might have difficulties with English then?]

Those who gave birth in London were overrepresented. 38 respondents said their gender was not the same as the sex they were assigned at birth. 'On the whole the majority of both groups reported experiencing respect for maternity care' (NB) (44). However these findings still 'underline the inquiry's evidence in relation to choice, informed decision-making, cultural needs and the direct impact of race on care'.

Nonwhite women were more likely to report that they felt uncomfortable when 'communicating their cultural preferences or requests [more so if English was not their first language?]… [and] asking questions because they didn't want their midwife or doctor to think they were being difficult. Making decisions about their care because they felt uneasy disagreeing with the care options… recommended. Choosing where to give birth as they were not given enough information to make a decision'. One third of nonwhite women who reported that they were treated poorly 'felt that this was because of their race or ethnicity', four times more likely to say this was the reason compared to white women, and twice as likely to feel it was because of their cultural background and language [again differences if English was not their first language?].

'Throughout the inquiry' black and brown people did not feel safe. There were many stories 'that depicted experiences of women feeling deeply fearful'[more so than white people?] [A summary findings says that this was the most prominent theme with two thirds of people who shared their stories describing not feeling safe 'some or all of the time' and saying that 'racism and racial discrimination had a direct impact on their sense of safety' they claim that 'existing research shows that black Asian and mixed ethnicity women experienced far higher rates of unsafe outcomes including death… [But]… Many black and brown people do not feel safe during their care regardless of clinical outcome' [so much of it is irrational?]. Evidence was provided of serious risks and actual harm as in the case studies below. Concerns were not taken seriously, life-threatening symptoms not spotted. Race was never explicitly referenced, but many were left thinking whether they 'they would have encountered the same treatment had they been white'.

Case studies. One describes a Ghanaian person who was discharged despite pain in the chest. It turned out to be a blood clot in the lung. They complained but their pain wasn't taken seriously. Another African person describes a horrible birth experience where a midwife minimised the concerns, carried on with the paperwork and did not recognise the symptoms of sepsis in the skin because she was a black woman — her husband had to go and find some blankets, severe pain was ignored until a South Asian doctor noticed that her skin was pale and she was eventually put on antibiotics and gave birth just in time to treat her suspected septicaemia. She thought that a white woman would have been given pain relief but that the nurse thought she was either strong enough or was exaggerating (47).

There are multiple examples where jaundice had been missed, 'which highlights how centring the "white norm" in education and training directly impacts on the safety of black and brown [people], jeopardising their human rights.' One case study shows her premature baby developed jaundice that the health visitor could not see it until she tested the levels and even then insisted the machine was wrong, and the doctor agreed because he could see nothing wrong despite a reading — 'the white staff did not recognise jaundice in a black baby' (48). There were other reports of birth injuries, tears, stitches, infections, haemorrhage and long-term incontinence, just under 1/3 had neonatal complications risking the baby's life and involving intensive care. 12 testimonies described baby loss. Solicitors and barristers testified on the devastating consequences. Others talked about negligent care and its effects on babies outcomes. One Afghani woman was denied pain relief and she ultimately had a stillbirth. A British woman of African descent had poor care and again a stillbirth. A black woman was denied her choice of cesarean and she and her baby nearly died — in each case lawyers were involved in these cases and 'felt that race was a contributing factor to the mismanagement of these women's care'.

Psychological safety is also critical, and again fear can lead to long-term trauma. It can also lead to feeling unable to raise concerns. One person felt that they were going to be just another black statistic. Others were shouted at or threatened with reprisals if complaints were made. Fear and lack of control 'are strongly associated with PTSD' (49). A patient felt that the doctor did not provide informed consent and shouted at them during an examination resulting in anxiety about the intentions of staff and wanting to be discharged as soon as possible.

Over half of the respondents [overall?] gave an example of being ignored or disbelieved and many reported concerns about the provision of care. In particular 'that their pain was dismissed or minimised… There was evidence that the failure to listen to black and brown [people] was at least in part a consequence of racism'. (52) 'in some examples… The racial element was explicit and the role of racist stereotypes in creating a culture… Was obvious'. One midwife spoke about racist stereotypes in a belief that Asian women can't handle pain and make a fuss so did not receive pain relief. Another midwife swapped stories with other ethnic minority parents about lacking pain relief. A Sikh woman was ignored asking about their baby feeding properly and felt she was probably stereotyped because of the turban she was wearing. A common experience was being denied pain relief 'due to staff not believing they were in labour' (53) [soon dispelled, surely].

A case study of a Chinese woman says she was discharged even after contractions had started and she was in severe pain but the staff were angry even though she was dilated. Another one was still in pain even after an epidural and not believed that it wasn't working. A third one wanted painkillers because the stitches were not dissolving and were infected. They found cases where concerns were raised but fears were dismissed or belittled even though significant harm could have been avoided if they will listen to. In one case a black African woman had been in pain for hours despite requesting help and pain relief and was eventually treated for internal bleeding, while another one was reported as having a cold baby, but this was ignored until it was finally realised that it was not responding. Another case study concerned misdiagnosis of jaundice which led to brain damage.

[Do we know the ethicity/race of the racists here?]

Racist attitudes and behaviours by caregivers — 'stereotypes, micro-aggressions and assumptions about risk… are having a serious detrimental effect on people's maternity experiences'. Two thirds of respondents felt that. 31% of nonwhite respondents said they were treated poorly and that this was 'because of their race or ethnicity' [the shortfall — 35% — is made up by those who say it was race or religion]. 'Crucially, it is the persistent and prolonged exposure to micro-aggressions that causes harm' (56) [not sure there is much evidence specifically for this, and not sure how it links to cardiovascular causes for death].

Almost half the respondents said that racist attitudes led to distress and trauma. They define micro-aggressions as '"the everyday verbal, non-verbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalised group membership' (57) [referenced to Sue, D, undated, Microaggression: more than just race — I have looked it up]. They may not be consciously racist but they show 'thoughtlessness' and the centring of white perspectives as the norm. One example is 'failing to learn the correct pronunciation of someone's name'. Using this terminology can still 'obscure and minimise the damage it causes' but we are still talking about 'forms of racism'.

Stereotypes can be damaging and lead to degrading treatment and risk 'due to dangerous racist misconceptions' where even seemingly small areas can have serious consequences. There were 'a multitude of accounts' where Asian women were referred to as '"princesses" or "precious" and black women as "aggressive" or "angry"'. There were 'multiple reports' of professionals asking where are you from, not trying to pronounce names correctly, misidentifying people based on assumptions of race or ethnicity. In one case, a sonographer did not doublecheck a name and the wrong scan was performed: the patient was blamed. Sometimes 'direct incorrect assumptions' were made about educational status, domestic violence, marital status '(as in assuming black women are single mothers), Muslim women having lots of children, and hijab wearing women not being able to speak English'. There were frequent reports of feeling patronised and othered. These testimonies were supported by recent reviews by MBRRACE. Sometimes there were positive stereotypes but which 'can still have a negative impact', like assuming that black or brown women would know how to breastfeed or would have lots of family support, would just know what they are doing, and this sometimes led to difficulties getting support from staff and adequate postnatal support. Staff often thought they were treating everyone the same or were colourblind.

'There were many accounts' where people were put into high-risk categories 'due to factors relating to ethnicity' and were 'medicalised', not always based on 'observed medical indications'

[which contradicts the bit about being put at risk?].

This meant choices were sometimes reduced e.g. about inducing birth, or racist outcomes with care or policy about inducing births with ethnicity as a reason, 'oversurveillance' [can't have it both ways]. There was an 'invisibility/hyper- visibility paradox' — bodies are pathologised, but own views about their care are not heard. [Some stories seemed ridiculous], like a midwife who thought that black women do not bruise. All of this could lead to serious consequences like not picking up sepsis.

The problem might lie with training and how the curriculum centres on the white body — all the textbooks are based on white men, it seems [written by white men?]. All the Colleges seem to agree about the need to decolonise education and guidance and to investigate conditions that affect certain ethnic groups in a way that does not pathologise them [very tricky I would have thought]. There should be more emphasis on cultural safety. Apparently, New Zealand does better. Cultural insensitivities failures should be addressed, like being asked about cultural or religious needs, which had led to complaints from 14% of nonwhite women, including ridiculing 'cultural maternity practices' [a case study turned on the availability of halal milk, and another wanted to follow traditional Chinese customs and not shower immediately after delivery — even at the risk of sepsis?]. This is 'disrespectful practice' which actually contravenes much of the guidance.

There were some incidents of overt racism. One Ecuadorian woman was told that she would need to learn English if she wanted to live in this country. Another was told she must give her baby the BCG vaccine because she was from Africa and therefore liable to exposure to TB, because people from Africa and minorities '"live together"'. Some professionals said colleagues thought black women and babies have thicker skin, the ward smelt of curry when South Asian families were being cared for, that Chinese people are dirty. Others reported favouritism for white women such as being allowed visitors out of hours, receiving better care being granted more time for questions and extended more patience.

Nonwhite people are more subject to dehumanisation — 'disrespect, rudeness and lack of empathy… Not being seen as an individual or even as human'. Shared stories picked on 'a pervasive lack of curiosity or empathy, harsh or rough treatment, and even shouting and threats' (62) [more than anyone else?]. There was an embedded view that black bodies don't work in the correct way, there was a problem with African pelvises [apparently taught on a midwifery course] that black women are more likely to have diabetes or high blood pressure because of the food they eat and the weight they carry. They are also somehow, contradictorily, tougher and able to endure more pain — 'racist stereotypes which have their origin in slavery and eugenicist theory' [reference to a fact sheet on scientific racism from the National Human Genome Research Institute]. So one black woman was told that she didn't need pain relief and advised not to make some much noise, Asian women by contrast were reported that they were precious less able to tolerate pain.

Many reported they were subjected to a lack of basic dignity and respect, rudeness, and a failure to honour cultural practices or requests, made to feel like a burden, subjected to shouting, 'eye rolling' and even overt threats — in one case after sleeping with the baby [she was threatened with a report to social services]. There was 'intrusive or aggressive questioning during intimate procedures'(63), like being asked about immigration status 'while partially undressed'. One woman was refused a bedpan — '"I'm not absolutely sure [if it was because of my skin colour] but after that incident, I felt really sad during the labour"'. They ask themselves whether they would be subject to the same treatment if they were white [and has the Report done anything to reassure them on this ground?].

There were reports of poor care, lack of information about care, insensitive attitudes in stillbirth or injury cases, and bias compared to records in white women's maternity notes, according to lawyers — for example dismissive correspondence between midwives over mothers' feelings after bereavement, one case when a mother was left without support of any kind overnight. A case study reported being left for hours after a booking mistake even though they had paid for a private room, and even after admission, being refused re-entrance to their private room.

There were violations of the right to informed consents, sometimes for medical procedures. There was some use of 'coercion and obstetric violence' and lack of choice about care (66). 'These findings reveal a maternity service struggling to serve [people] or to support its staff. They are not unique to [nonwhite women] as we have seen from the Ockenden report. However, they are even more dangerous when combined with systemic racism as they reinforce inequalities and cement feelings that [nonwhite women]… Are unsafe'. A lawyer says that it is crucial that risks are explained and understood 'no matter what language you speak', but a majority of written testimonies said this did not happen, and there were some very serious cases, including failure to gain consent for medical procedures. Patients were told that medics just needed to do something. In one case, a patient had specifically requested not to have an injection to assist with the afterbirth, but was given one anyway [seems to be an induction procedure?] In a legal case, a solicitor requested no male staff and female interpreters, but this was denied, and a family member used instead which 'led to a lack of informed consent for vaginal birth' (67). There are many examples of women who did not have access to an interpreter or adequate translation services.

Many women were denied choice by not having the options explained to them in a way they understood. They were given tick boxes. They were not asked about cultural needs. 'When I asked for pain relief it was not given. I did not have options for place of birth discussed' and sometimes 'choices were actively undermined or refused' (68). Some preferences were resisted — 'e.g. to be induced, to have a cesarean, or not give birth at home'. In one case study a request for home birth was dismissed because the woman was told she would need an induction. A discussion of the options was delayed and she was still pressured by daily phone calls to come in for an induction. Another one made a birth plan and told midwives but at this request ignored 'which caused her significant distress' [does sound a bit precious].

Obstetric violence was described in the evidence and was experienced by nonwhite people 'on multiple occasions' [same one on multiple occasions, or multiple people on one occasion?] Who 'felt their ethnicity caused or played a significant factor in the scenarios' (69). One of the most common examples was vaginal examinations — a case study reports unprofessional conduct, no sympathy, and a belief that the reaction was commonly linked to her race, and aggressive nature, disbelief at signs of comfort and pain, a common attitude that she has come to learn is prevalent and based on a view that non-white women do not feel pain. [Sounds a bit pre-theorised]. Another close study refers to a lack of consent for three pregnancies, bullying, misinformation, a presumption that she was uneducated and naïve, being left battered and bruised, a late miscarriage as a result of domestic violence, not knowing who the men were who put their hands in her [really?] — they did not bother to introduce themselves and she now knows they were doctors but she was terrified bruised and battered. She used private midwives for the last two kids and an entirely different experience with consent care and safety. In other cases, women were forced to undergo interventions that they had explicitly not consented to — like forceps delivery — 'she was literally pinned down'(69)

'Verbal and psychological coercion was also commonplace'especially if women gave birth outside the guidelines — having a birth partner and doula there despite the pandemic, for example, being pressured for an induction, waiting 48 hours after the waters had broken [some sort of non-medical advice?]. Some did not have a consistent midwife. Others had very busy midwives. Others had a racially discriminatory midwife and could not change them.

Turning to structural barriers, the main one seemed to be 'respectful and non-discriminatory maternity care: lack of access to interpreting services and the impact of NHS charging'. (72) These pose serious risks to those nonwhite women who have English as a second language or have refugee and migrant or asylum seeker status. The lack of interpretation services was a common theme. Trusts have a duty of care to ensure effective communication. One woman was told interpreting was too expensive. Many stories referred to inappropriate methods such as Google Translate or using relatives. Accurate history is sometimes difficult, especially if there is a 'huge cultural sensitivity' about matters such as TB in Somalia, where 'it is thought to be a disease of poverty' (73) [so people do not disclose]. Lack of interpretation appears in 'multiple examples of legal cases'. In one case study that went to law, a baby suffered a brain injury as a result of lack of feeding support because there was no interpretation services — the NHS lost the case because they had not adequately recorded the details.

The charging scheme discriminated against some women. Some were racially profiled and this led to women disengaging. In one case, a woman was denied early treatment unless she paid upfront, others were asked for hundreds or thousands of pounds for routine care, were often told incorrect information about payment and entitlement, even if they were asylum seekers. There was often no specialist care like a diabetic clinic in places where certain ethnic groups who were liable were concentrated. They were poor governance pathways, for example in recording ethnicity and other demographics, clinical policy is not based on evidence, inflexibility for appointment times, limited resources in other languages like information leaflets and antenatal education.

Tiredness and burnout can cause uncivil behaviour and in those circumstances 'unaddressed prejudice and racism are more likely to surface' (77). 70% of healthcare professionals who submitted written evidence identified as nonwhite, 25% as white, the majority as midwives. Almost all of them said that systematic racism or racial discrimination is contributing to maternity outcomes and experiences [so they are accepting blame themselves or blaming others?]

There was a toxic culture, as in other reports like on Morecambe or the Ockenden report on Shrewsbury [where white people were mostly the victims?]. Kindness and compassion went missing, blame and bullying was common, and many respondents agreed. Midwives reported feeling bullied and disrespected. Black midwives spoke of mistrust including lack of trust towards the Nursing and Midwifery Council and disproportionate sanctions against nonwhite members who go through the process [of review of fitness to practice] — it was often used as a threat by management to revoke their status. The NHS was seen as too hierarchical. Student midwives often experienced racism in clinical placement, sometimes overtly racist comments. Nonwhite midwives often spoke about leaving all wishing to leave as a result of 'experiencing or witnessing racism' (79), but some felt unable to speak up, while those who did reported having to leave or facing harassment, being othered, not supported by universities, not being taken seriously.

Nonwhite people face a white ceiling, underrepresentation at board level. This has led to a lack of safety and reporting racism to white managers, especially as they are sometimes described as playing the race card, being oversensitive. There are no 'robust impartial mechanisms to report racism' (80) [reports like this don't really help either]. Black students fail more often and are less likely to be promoted. They lack role models, they feel comfortable only with other ethnic minority staff like Asian doctors or black obstetricians.

There are positive accounts of maternity care which mention 'good communication, person centred and culturally sensitive care'. Some birthing people described these positive experiences and gave examples of excellent care — one in 10 written testimonies reported good care (82) even with accounts that mention poor experiences there was still examples of good care sometimes at least one professional who was '"amazing"'. In the poll, 'most [nonwhite] respondents described positive experiences. 52% strongly agreed and 32% somewhat agreed that they were treated with respect… 50% strongly agreed and 37% somewhat agreed that they were spoken to in a kind and friendly way' (82). Some case studies report this — brilliant experience clear explanation brilliant interpreters, appropriate translations open and honest dialogue is being shown kindness and consideration. A midwife described good carers listening to people respecting their choices, giving evidence having diverse staff not assuming Western ideas are always best, proper training for racist behaviours, reporting colleagues without fear practising people's names asking people about cultural practices. Others reported respecting religious or cultural preferences, like not assigning male doctors to Muslim women, facilitating post birth ceremonies for Sikhs, trying to access halal meals, focusing on person centred care with people with specific histories, having kind and respectful conversations in recommending alternative birth plans. There are also good practice initiatives in various practices, sometimes involving liaison is with ethnic minority partnerships.

One particularly thorough approach is provided by National Childbirth Trust, whose training is provided by the University of Worcester who do a thorough programme on diversity and inclusion, working with and inclusion charity, paying attention to their language and practice, and even conducting their own research on the experiences of students from nonwhite backgrounds.

As a result they propose actions for the maternity system:

1. Commit to be an antiracist organisation. This means 'robust mandatory training on antiracism and at least annually, clear standards on racism and discrimination, proper reporting to ensure the safety of the person experiencing racism, a feedback culture that does not blame the person experiencing racism, follow-up on reports of racism, and organisationwide racial equity plan with tracking and metrics [racism police]

2. Decolonise maternity curriculums and guidance. Same antiracism training and embedding of antiracism and cultural safety. Wholesale review of education exams training and guidance 'to ensure the white bodies not centred as the norm' and variations are understood 'without pathologising black and brown bodies', more diversity for guideline groups, better assessments to include the impact of stereotyping and microaggression, proper care for nonwhite people

3. Make [nonwhite people] decision-makers in their care, putting nonwhite people in control of their care and respecting their dignity [vague], improving their communication gathering feedback rebuilding trust, continuity of care, right to change caregiver, investing in 'meaningful co production through policy-making' (92), targets for inclusive participation, and accountability mechanism with community representatives [all very vague and jobs worthy]

4. Create safe inclusive workforce cultures build a culture of care well-being and mentorship, set specific targets to increase representation, establish trauma informed teams of link lecturers, mandatory training on trauma informed practice and therapeutic supervision, do not allow bullying and racism with 'named paid roles', address stress-related sickness, develop positive workforce cultural initiatives to be measured by the Care Quality Commission

5. Dismantle structural barriers to racial equity through national policy change end NHS charging, invest in the NHS interpreting services, any ethnicity gap in maternal deaths, get more data, use better data to calculate staffing need, for example to allow extra time for language barriers and cultural and social needs.

Notes on methodology. The online call for evidence was posted on survey monkey, translated into 16 languages, 10 largely open-ended questions allowing participants to tell their story while supporting 'consistent analysis and identification of themes.

'This inquiry was not designed to be a formal academic study, although we have drawn on both research and community participation methods'. 'We are unable to control for other factors that can influence worst outcomes and experiences in maternity care, such as pre-existing conditions or social determinants of health. Our starting point that systemic racism exists and explicit questions to test this hypothesis could generate confirmation bias. The design could also reflect our subjective perspective as Birthrights and individuals with their own lived and professional experiences. As the sample was self-selecting, it is likely that were more likely to hear from people with poor experiences and outcomes including racism. We sought to mitigate this by framing questions neutrally, including explicit questions about positive experiences, and conducting the wider poll of over 1000 women including a control group of white women. For the online call for evidence we did not collect other demographics such as gender, sexual orientation or whether someone had a disability which limited the scope to explore intersectional discrimination. There were no responses in other languages… The online format required access to a computer or smart phone and a sufficient level of computer literacy. This means the design excluded the voices of the most marginalised people… Though we sought to deliver a UK wide call for evidence there were limited responses from Scotland and Northern Ireland. Notwithstanding these limitations, we believe the findings bring the voices of black, brown and mixed ethnicity women and birthing people to the fore in a way that other research does not. As such the inquiry as a powerful contribution so the discussion on how to urgently improve racial equality within maternity care' (98 – 99)