MBRRACE: Why More BME women and babies die. A BME woman responds.

Access Denied image

Guest Blog by Beth (an AIMS member)

I remember questioning a few midwife friends about how Black and Minority Ethnic (BME) women are treated in the maternity system. The consensus is we are treated differently but not in a good way. I wish I had known earlier. Outcomes and experiences are worse even when you take away the obvious social economic factors.

BME women like me are more subjected to interventions because of arbitrary criteria such as BMI, our baby’s growth is measured against a population which is not similar to ours, and I noticed that the gestational diabetes criteria negatively affects a lot of Asian women. Our options of where and and how to birth are therefore significantly, and I’d say unfairly, limited. The constant narrative that we’re not optimal for birth because of our body size, this and that. All of my friends who are of oriental descend have been treated horribly when giving birth. None of us fall into the stereotypical vulnerable groups (non English speaking, low income, uneducated, domestic violence, substance abuse etc). None of us are over 40 years old, either.

The truth remains that the NHS maternity risk assessment is racist, non evidence based and arbitrary. The midwives and obstetric staff feel that they have a right to carry out protocols against us because they’re written in hospital guidelines. We’re considered not just as a sub class of people but our bodies are less superior and non optimal for birth because we’re not white, not a certain body size and not significant enough in number. It’s the high intervention rates, abusive practices and attitudes that make accessing maternity services more dangerous for BME women. I say the lack of acknowledgement of the issue means it’s not addressed.

When someone doesn’t think BME women deserve human rights (life) and doesn’t really care about them, they are less likely to take their concerns seriously, less likely to take care with their bodies, nor, I suppose, do they want to save them in an emergency. The NHS is unlikely to acknowledge that or the fact that higher intervention rates can cause higher mortality rates because they can cause complications and complexities.

If more interventions really mean better safety, over 40 years olds and BMEs are subjected to more interventions so you’d expect mortality to come down and not go up significantly. Something’s not adding up. I don’t think the real issue is age nor race nor ethnicity. We’re very much designed to survive whatever the colour of our skin.

I think the problem is the poor attitude towards women – the power imbalance in the care model exacerbated by institutional racism. I don’t think it’s just the obvious issue with differences in colours of skin. There’s tribalism between different groups of similar skin colour. Having institutional protocols mean that poor treatments of particular groups go undetected. All these factors are what makes pregnancies and births more dangerous for many BME women, all else being equal.

Britain, our home, is multicultural. Now is the time for our healthcare system to move on with the times and provide a maternity care model that understands and responds to women’s needs with fair and evidence based assessments. Treat every woman with respect and care. Give us all continuity of carer (in pregnancy, birth and postnatal recovery), a relationship-based model, which has been proven to improve outcome, experience and importantly reduce errors (i.e. reduce mortality). The disproportionately high maternal mortality rates for BME women have been highlighted in the latest MBRRACE report. The structural inequality and poor attitudes in the healthcare system needs to be addressed urgently. (https://www.npeu.ox.ac.uk/mbrrace-uk/reports).

The quality of healthcare we get and our chance at survival shouldn’t be determined by the colour of our skin. We are the same with the same human needs underneath it all. It’s time for us to all stand together to demand the NHS to prioritise maternity services and stop denying us care, damaging our health (harming women and babies) when we need care the most. We have worked hard to pay for our health system. It is not right for our needs to go unmet. The NHS must respond to women’s healthcare needs for our country to thrive.

Note from admin: If you would like to support or join in campaigns for quality and equality in maternity services, please contact AIMS at www.aims.org.uk.

York Homebirth Midwives: between a rock and a hard place (and women crushed in the middle)

Guest blog by Emma Ashworth

“If you arrive at the home of a woman and she refuses to allow you to access her home or to provide care to her, you must explain that you will need to leave and explain this decision to her. You should inform the woman that you will be happy to return to provide care should she want you to do so. The conversation should be fully documented.”

York Teaching Hospital NHS Foundation Trust: Home Birth Guideline Version No: 9, August 2017 – August 2020. Page 7

This quote from the York homebirth guidelines could lead to catastrophe.

While the senior midwives at York have said that they are reacting to a situation where they were not permitted in the house, the worrying phrase is this, “[the woman] refuses to allow you… to provide care to her”.

Women have been told that if they decline blood pressure monitoring, or intermittent monitoring, or even vaginal exams that their midwife “has been told that she must” leave their house and abandon them without care. Midwives have argued that if the mother doesn’t want to have interventions or tests, why should they even be there? What is their purpose? The knitting midwife expectantly and watchfully waiting in the corner, only intervening when necessary, does not seem to be the type of midwifery that York Trust is aiming for despite the fact that this type of midwifery leads to the best outcomes as is seen by the results of independent midwives.

Women have reported that midwives have coerced them into vaginal exams that they didn’t want with the threat of leaving them to birth alone. They have had to make the decision to allow someone to penetrate their vagina when they didn’t want them to, or to be left without clinical care for themselves or their babies.

In a discussion with one of the senior midwives at York Trust, I was assured that the threats that women were experiencing were not the intention of the policy, and that recently midwives had stayed with women despite the women declining certain interventions. I was also assured that the midwife that I spoke to would take my feedback to the community and home birth midwives to ensure that there was clarity in the guideline. She also confirmed that the guideline was in the process of review, so perhaps the very clearly written text in the current guideline saying that women in their own home are not permitted to refuse to have someone’s fingers inside them if they want a midwife to stay will be removed. However, despite my attempts to follow up this with the Trust, to date (7th August) I have not received a response to my initial or follow up requests.

In the meantime, Birthrights and AIMS have worked together on this issue, leading to an information sheet for women and midwives who might find themselves in this situation.

There are some really key points here that the Trust and its midwives need to consider about these guidelines. Midwives are under an obligation to act within the law, and coercing women into interventions is illegal. While the Trust may argue that there is no point in the midwife being there if the woman doesn’t want to have some clinical checks, we need to remember that women can decline any or all interventions at any time – and that a midwife’s role is far more than vaginal exams and listening in to a baby’s heartbeat. There is huge value in her being there, offering her support and knowledge and if necessary being able to intervene clinically. The Trust’s argument that there’s no point in the midwife being there belies the fact that skilled midwifery is in stepping in when needed, not about taking blood pressure. We need to remember that many of these interventions are not necessarily helpful, and can be harmful in some situations (and can also be very useful in others).

The AIMS information sheets on vaginal exams discusses some of the pros and cons of routine vaginal exams. Their sheet on monitoring in labour explains some of the risks and benefits of intermittent and continuous monitoring. If a woman wants to decline auscultation now, she can accept it for her next contraction, or decline it again. If a midwife forces her into a check on the threat of abandoning her, the stress of that on the woman may itself severely impact on her labour, and could cause damage to her or her baby, and the midwife is legally responsible for this. A midwife who undertakes an intrusive examination after obtaining consent through coercion needs to know that she is committing an assault on that woman, and that she could be criminally charged. Part 1.5 of the Nursing and Midwifery Code states that midwives must “Respect and uphold people’s human rights.” And 2.5 says, “respect, support and document a person’s right to accept or refuse care and treatment” 17.1 of the Code states that midwives must, “take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse.” And yet, this guideline is instructing midwives that they must either neglect a woman, who while she is in labour she is by definition vulnerable (by leaving), or abuse them (by committing assault).  At the same time, if the midwife refuses to follow the guideline and stays with a woman who declines some or all interventions or checks during her labour, she is at risk of being disciplined by the Trust. And if she leaves, she and the Trust are likely to be liable for any adverse outcomes to mum or baby!

If women find themselves in the situation where they are being coerced in their own home, I would advise that they remind the midwife of her obligations under the NMC code and the law. Showing the midwife the Birthrights document could be enough to encourage the midwife to break out of the intolerable situation that she’s been forced into by this unfair and unreasonable Trust document. Know that what is being asked of you in your labour is not reasonable, it is not normal practice and it is not something you need to say yes to.

Midwives – rise up! You are autonomous practitioners and you cannot accept the risks to your own safety and practice that this guideline traps you in. You need to escape because no matter which way you choose you are exposing yourself to risk. Be part of the fight to change this guideline! Stay with women and request support from senior midwives (who have assured me that they will give it).  Don’t let this happen to you and to the women you’re caring for!