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When inequality is baked in before birth, it can’t remain a fringe concern

Inequality shortens lives and severely impacts health outcomes, yet the evidence shows the health gap is widening. Doctors and patient advocates maintain that truly transformational change is possible if we begin to treat inequality as the urgent, serious health issue it is.

“Data and statistics don’t lie,” said Dr Christine Ekechi, a consultant gynaecologist and obstetrician and an advocate for women’s health. She added: “If somebody still is not convinced of the issues it’s because they don’t want to be.”

Indeed, while much more research is needed into the causes, the evidence is compelling that huge disparities in health outcomes exist - and there are few areas in which it is as glaring as maternity and women’s health, particularly where this intersects with race and class.

A major review this year, commissioned by the NHS Race and Health Observatory, found “overwhelming” evidence of “vast and persistent” health inequalities based on ethnicity – with maternity one of the areas where inequalities are largest. The researchers examined 178 studies published in the last 10 years for their review. It included evidence of negative interactions, stereotyping, disrespect, discrimination, and cultural insensitivity.

The impacts on health outcomes are stark. Black women are four times more likely to die in pregnancy and childbirth than white women, found the 2021 MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) report by the National Perinatal Epidemiology Unit at the University of Oxford. Other studies show links between deprivation and neonatal deaths, and between stress caused by racial discrimination and pre-term births.

The findings resonate with Sandra Igwe, mother of two and founder of The Motherhood Group, an organisation that supports and gives voice to Black mothers. She was denied pain relief while in labour with her second daughter, causing her to, literally, pull her hair out. She said: “I've always heard that term growing up - ‘strong black woman’ - but I didn't know how dangerous it was when it came to accessing maternity care.

“When I asked for pain relief, I was told that there was a queue. I begged and pleaded but I never got it and that was quite horrifying. I didn't know what more to do apart from pull my hair out, just to soothe my own pain.”

Sandra Igwe, founder of The Motherhood Group

Her experiences are detailed in her upcoming book, My Black Motherhood. She describes how lazy comments, thoughtless oversights and ignorant stereotypes – what she terms ‘microaggressions’ – can pile up to contribute to these startling statistics. She said: “What's your first reaction when a pregnant woman walks through your door, screaming and crying in pain? Is it to show care and empathy? Or are you thinking that's just some stereotypical, exaggerating, dramatic, Black woman?

“These views unfortunately can end up with so many complications and it just starts off with a thought.”

Sandra with her two daughters and her upcoming book, My Black Motherhood

The Black women she supports through her organisation often do not access the care that they and their babies need. She said: “They think that they won’t get any genuine support or have their concerns recognised, or that they'll just have the blame shifted onto them.”

Dr Panicos Shangaris, President of the Royal Society of Medicine’s Maternity and the Newborn Forum, said that better cultural understanding was important and called for more cross-disciplinary working. He said: “We need to do more. For example, we should organise more educational events on this topic involving different medical specialties.” He believes that fostering an environment in which everybody - especially “difficult to reach” patients - feels engaged with their care is an important starting point.

Dr Panicos Shangaris, President of the Royal Society of Medicine’s Maternity and the Newborn Forum

Better education needs to be focused on normalising the Black experience within healthcare, suggested Dr Christine Ekechi. For example, by having medical textbooks that show people with darker skin and reviewing the Apgar score, which is used to assess a baby at birth and is harder to carry out on darker skin. She said: “We – and I include myself – were just not taught to consider these things at medical school.

“We need to overhaul things like this, so that it becomes the norm. That is going to be more effective and useful than making people sit down and do tick-box, mandatory training on racism.”

Unless we act, Dr Ekechi argues, the cycle is destined to perpetuate. She said: “A lot of these conditions are really baked in even at the point of conception.

“The health of a child is impacted by their state as a foetus, which is determined by their mother. It’s this cycle that keeps going.

“We have such significant and persisting inequalities that affect the outcomes of particular individuals before they’ve even crossed the threshold into medicine.”

Worryingly, the signs are that inequalities are widening rather than narrowing. In 2020, The Health Foundation published a 10-year review of Professor Sir Michael Marmot’s landmark 2010 report into health inequalities. It found that the health gap has increased between wealthy and poor areas, and improvements to life expectancy have stalled – and even declined for the poorest 10 per cent of women. What we do about it is a matter for discussion. A good place to start is the Royal Society of Medicine’s inaugural Tackling Inequalities conference, to be held this autumn, at which Professor Marmot will give a keynote address.

Many of the major levers we can pull are at the societal level but there are things we can and should do individually.

Recognising that all humans have blind spots and biases is the first step. The second and most important is committing to plugging those gaps through education. The positive benefits to health outcomes and society at large would be as staggering as the inequalities we aim to flatten.

The Royal Society of Medicine has recently launched a major multi-year programme to tackle health inequalities, opening with a flagship conference in early 2023 in partnership with NHS England and NHS Improvement.

This is the second in a series of features in support of the RSM’s Tackling Inequalities programme. Each examines health inequalities through the lens of a different RSM section. This article focused on maternity. Thank you to all contributors.

You can join the conversation on social media using the hashtag #tacklinginequalities. If you have a suggestion for a future feature or wish to contribute, please email

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