Challenging health inequalities in maternity services: the role we all play

Safe, kind maternity care must be a reality for everyone.  We all have a role to play in ensuring that pregnant women receive the support and care they have the right to expect, and that where there is any risk of inequality, that those risks are recognised and acted on.

Pregnancy remains very safe in the UK. But while childbirth can be the most joyous occasion in people’s lives, some groups of women are more likely to have a bad experience. Women are more likely to die in childbirth if they’re from a black or minority ethnic group[1], are older, or are from more socially deprived backgrounds.

The testimonies of the women who gave evidence to three recent inquiries (the  Birthrights’ inquiry report into racial injustice and human rights in UK maternity care; the Five X More Black Maternal Experience Report; and the Invisible report into the maternity experience of Muslim women) give us additional insight into poor outcomes and poor experiences.

These are powerful and upsetting accounts which bring to life people’s experiences, their feelings, and the impact on their lives and the lives of their families.

Creating the long-lasting change needed to address health and social inequalities can’t be done in isolation. No one organisation – no one profession – can do it on their own. But collectively, when we work together as regulators, employers, educators, professional organisations, midwifery and nursing professionals and the people and communities we support, we can create the conditions to make change possible.

That’s why in this article we set out two parts of the picture. The first is the role professionals can play, and how our standards can support them. And the second is the improvements we want to make to help us become a kinder, fairer regulator for everyone. 

The role of professionals, and how our standards can support them

The overwhelming majority of midwifery professionals set out to provide kind, excellent, safe care and will be dismayed at the findings of these important reports. We encourage all professionals to reflect on their practice and skills in the light of what we’ve learned.

Our standards are there to help professionals provide good, safe care. They set clear expectations for the professionals we regulate: midwives, nurses and nursing associates. They address both the behaviour and conduct we expect of our registrants, and what we expect in terms of their knowledge, skills and competence.

The standards relating to the way professionals behave and conduct themselves in both their professional and personal lives are contained within the Code. The Code explains that professionals should prioritise people, treating them fairly and without discrimination. Professionals must also challenge any discriminatory attitudes and behaviours towards those receiving care, as well any that are directed towards their colleagues.

Discriminatory behaviour is a serious breach of the Code. In the most serious cases we can take action, including removing people’s right to practise. Midwives must therefore apply the standards of behaviour set out in the Code when interacting with anyone using maternity services, no matter what their race or ethnicity – or other protected characteristics such as age or disability.

The skills and knowledge we expect from midwives are set out in our Standards of proficiency for midwives. These standards, which apply to all midwives, state what we expect of midwives joining our register to know and be able to do, and they inform the continuing professional development (CPD) of people already on the register.

The standards emphasise that professionals’ priority should be to ensure care always focuses on the needs, views and preferences of the woman; to help them make informed decisions; and support the decisions they make.

They also need to demonstrate that they have the knowledge and skills to recognise where some women may have additional complications and needs, for any reason, that may result in poorer outcomes. They should know what actions to take to improve safety, outcome and experiences - including understanding and challenging discriminatory behaviour and microaggressions, which the recent inquiries showed women from black or minority ethnic groups have experienced.

Understanding and challenging microaggressions

The Birthrights reports defines microaggressions as “The everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.”

Here are some of the experiences of microaggressions that Black, Brown and Mixed Ethnicity women reported:

• Women not being listened to despite them making repeated attempts to communicate something that’s important to them.
• Agitation in women who did not speak English was attributed to mental health problems when they were severely physically unwell.
• Black British women being said to have a ‘low pain threshold’.
• Perceived strength often being a way of justifying the refusal of pain relief.
• Being called ‘difficult’ when these were actually signs of hypoxia (having low oxygen levels in the blood which can cause confusion)
• Inaccurate descriptions of women’s ethnic group and origins throughout their records. For example, one woman was described variously as Caribbean, from Sierra Leone and from Jamaica.
• Issues with language and interpretation and inappropriate reliance on interpretation by family members.
• Assumptions around symptoms made on the basis of language ability and/or ethnic group.
• Assumptions being made around immigration status or education.

The NMC: Valuing equality, diversity and inclusion

We’re committed to becoming fairer and more inclusive. So we’re reflecting on the findings of these reports in relation to our regulatory activities and our role as an employer.

We know we have further to go, but here are some of the steps we have taken in recent years to help ensure all people that we, or our professionals interact with, are treated fairly.

• Our Ambitious for Change research enabled us to analyse the impact our regulatory processes have on nurses, midwives and nursing associates from different backgrounds and identities. We’re working with our stakeholders, particularly employers, to address the issues it raises.
• We’ll consider the findings of the Birthrights, Five X More and Invisible reports, alongside a variety of important work from across the sector, when we review the Code and revalidation in the coming years. We’ll look for opportunities to strengthen our expectations on inclusive and non-discriminatory care.
• We’re auditing fitness to practise (FtP) cases that involve discrimination, rolling out new guidance in relation to handling cases of discrimination, and delivering an enhanced package of equality and diversity training for panel members and FtP decision makers.
• We know that professionals from a Black and Minority Ethnic background can also experience discrimination, unfairness and disproportionate disciplinary action. Our resource for employers, Managing concerns, is clear that all nursing and midwifery professionals have the right to be treated fairly and with respect. 
• We’ve set out an action plan detailing what we’ll do to deliver our EDI commitments over the next three years.

The women and families who’ve taken the time to re-live their experiences through these reports must have their voices heard. We want to make sure fewer families have bad experiences or preventable tragedies in pregnancy by promoting the top-quality care that all women, babies and families have the right to expect. And, alongside our partners in health and care, we share the same goal: to support midwives and maternity services to challenge poor care and deliver future excellence.  

[1] Reports | NPEU > MBRRACE-UK (ox.ac.uk)

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