[Relevant documents: Oral evidence taken before the Health and Social Care Committee on 15 December 2020, on Safety of maternity services in England, HC 677; Eleventh Report of the Joint Committee on Human Rights, Black people, racism and human rights, HC 559.]
Welcome, everyone, to this important debate. I remind hon. Members that some changes have been made to normal practice, to support the new hybrid arrangements. Timings of debates have been amended to allow technical arrangements to be made for the next debate. There will be a suspension between each debate. I remind Members participating physically and virtually that they must arrive for the start of debates. Members are expected to remain for the entire debate.
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That this House has considered e-petition 301079, relating to Black maternal healthcare and mortality.
It is an honour to speak under your chairmanship, Sir Gary. I am also honoured to open this debate on behalf of the Petitions Committee and the more than 187,000 people who signed the petition organised by campaigners Tinuke Awe and Clo Abe.
The petition highlights the shameful fact that in 21st-century Britain, the colour of a woman’s skin affects how safe she and her child are during pregnancy and birth. That is one of the starkest examples of racial health inequalities in this country. As Tinuke and Clo have pointed out, the latest data show that black women are more than four times more likely than white women to die during pregnancy or in the six weeks after giving birth. Women from Asian backgrounds are twice as likely as white women to die during pregnancy. To put that into context, I should state from the outset that the UK is one of the safest countries in the world to give birth. Deaths during pregnancy are very rare. I am sure the Minister will reiterate that in her response.
Around one in 10,000 pregnant women dies every year from causes related to their pregnancy. Every single one of those deaths is a tragedy, but they are a very small proportion of all pregnancies. The situation has also improved slightly over the last 10 years. Those figures mask the underlying, long-standing and shocking inequalities in maternal mortality, yet we do not have a base of research and evidence to fully explain their root causes and to point the way forward. There is still no Government target to eliminate the gap. That needs to be addressed urgently.
What do we know about women who die during or shortly after pregnancy? Pregnancy alters the way the body works. Two thirds of all pregnant women who die fall victim to complications such as heart disease or the care they receive while pregnant. Most do not die during childbirth itself. Dr Christine Ekechi, co-chair of the race equality taskforce at the Royal College of Obstetricians and Gynaecologists, points out that black women are more likely to have pre-existing health conditions that lead to greater risks during pregnancy. However, she also highlights that the obvious question to ask is why black non-transmissible health issues such as cardiac disease and high blood pressure are more prevalent in the first place. If it is a result of existing social and economic inequalities, that must be addressed.
I thank the members and Chair of the Petitions Committee for choosing this subject for debate. My constituency contributed the second highest number of signatures to this petition, which reflects the concerns of both black and white people in my constituency.
It is particularly tragic when a new mother dies. She will die early in life, leaving behind a newborn or other children. Everyone in maternity services wants maternity care to be a properly resourced and highly professional team. A black woman is four or five times more likely than a white woman to die during childbirth or shortly thereafter, and nobody wants that to be the case. It is a dreadful situation and it must be addressed. I have four proposals for the Minister. I know that she understands this issue very well, having worked in the health service. She cares about it, so I look forward to hearing her response.
First, the monitoring must be clear and publicly accessible. The publication of covid statistics has provided a real example of this. It has shown how, when information needs to be brought into focus and targeted at the public and everybody in the health service, the regular and consistent publication of statistics can enjoin us all in a public effort. Coherent statistics must, therefore, be published.
Secondly, as my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) has said, we must have a target to end this black maternal mortality gap, with milestones set for progress year by year. The Joint Committee on Human Rights, which I chair, heard evidence from the chief midwifery officer that there is a great deal of concern about this issue but no targets have been set. We know that the NHS works to targets and to milestones. Good intentions are not enough.
Thirdly, we have to reduce health inequalities—this is a general but important point—and income inequalities, which mean that if someone is black they are more likely to have a low income, and if they are on a low income they are more likely to have poorer health.
It is an honour to serve under your chairmanship, Sir Gary. First, I congratulate Tinuke and Clo, the co-founders of Five X More, on working tirelessly to change black women’s maternal health outcomes, and on putting forward this petition, which gained over 187,000 signatures.
The racial disparities in maternal mortality rates are completely unacceptable. A black woman is four times more likely than a white woman to die in the UK due to pregnancy or childbirth. Just think about that—that is four times as many women passing away well before their time, and four times as many families suffering the pain and grief of losing a loved one.
It is not just those women who have sadly died who have been victims of this disparity. Research by the Nuffield Department of Population Health has shown that women of black African and black Caribbean heritage are, respectively, 83% and 80% more likely than white European women to suffer a near miss of maternal death. That reflects, and is the consequence of, the wider disparities in care, which countless women have recounted from their experiences. As well as the socioeconomic inequality that disproportionately affects black people, a study by MBRRACE-UK showed that only 29% of women who died during pregnancy and childbirth were deemed to have received good care, with improvements in care being judged to have potentially made a difference to the outcome in 51% of those cases—evidence that there are clearly improvements to be made.
The attention shone on this issue in recent months, and highlighted by the sheer number of people who have signed the petition, must be used as a spur for the Government and the NHS to develop a clear action plan. Furthermore, it highlights the damaging nature of the Government’s recent race report, which sought to sideline almost any suggestion that racism could be a factor in the different outcomes experienced by people in Britain today. Racism is not just a perception or historical experience, as Tony Sewell wrote in his foreword to the recent report.
It is a pleasure to serve under your chairmanship, Sir Gary. I thank the campaigners for bringing this really important issue to Parliament and for raising awareness on behalf of all women. Over 1,186 Vauxhall constituents signed the petition that has led to this important debate.
As the mother of two young children born just over the road from Parliament, at St Thomas’ Hospital, I know that giving birth should be one of the most natural and exciting experiences that any mother can have. I think back to my first pregnancy—the fear, excitement and mixture of emotions. Like many women from a black or minority ethnic community, I was not aware that I suffered from a disease called fibroids until I had my first maternal scan. That brought additional fear and anxiety around my childbirth, but for far too many women, pregnancy and childbirth can be complicated and dangerous. When I got pregnant, I also realised that I was a sickle cell carrier.
We have known for some time that maternal and perinatal mortality rates are significantly higher for women of black, Asian and mixed heritage and their babies. That is why we have to do everything we can to ensure that pregnancy and childbirth is as safe as it can be for all women in this country. We have the data. We know that the death rate in childbirth for black women is five times that for white women. In 2021, that cannot be acceptable.
To tackle the problem, we must first acknowledge the structural and institutional racism that exists in our healthcare system. We know that black and minority ethnic women are sometimes not listened to during the course of their care, and this can be subject to unconscious bias and microaggression. As a result, their symptoms are dismissed as normal during pregnancy, whereas they should be investigated a lot further.
The NHS is aware of the disparity, but it has no target to end it. I hope that by raising awareness of this issue, we will help to kickstart a national debate that will lead to the Government taking real action to address it. My colleagues have already asked the Minister to respond by looking at those key targets. We need to work with the NHS to implement the Joint Committee on Human Rights’ recommendations, which are clear. They are about reducing racial disparities in black and minority ethnic maternal health outcomes, and specifically about introducing those targets, so that we can measure those protections.
It is a pleasure to serve under your chairship, Sir Gary. I thank the right hon. Member for South West Surrey (Jeremy Hunt), the Chair of the Health and Social Care Committee, for asking me to respond on behalf of the Committee. Too often our Parliament is viewed as old, with blind spots on issues such as the health inequalities that affect black people, and black women in particular, so I am grateful to each of the nearly 200,000 people who signed the petition.
We have already heard that black women in the UK are four times more likely to die during pregnancy or childbirth than other women, and up to twice as likely to experience a stillbirth than white women. This is not coincidence or fluke. We see in the available data and in people’s experiences how health services, designed disproportionately by non-black people, fail to meet the needs of black people. It is an institutional problem.
The Select Committee is currently looking into the safety of maternity services in England. The brilliant Tinuke and Clo from Five X More came to speak to us and share their experiences, and I thank them for leading this petition and for their campaigning work. Clo told the Committee that there needs to be greater investment to understand the huge disparity in health outcomes for black women. We currently do not collect data on near misses, morbidity, illnesses or poor outcomes for black women. I hope the Minister announces some changes to that.
Clo also told us that only once we uncover the experiences of black women going through maternity services and set targets to do better will we have better outcomes for all black women. The same sentiment was echoed when I met Mars Lord, a doula and birth activist working on the Black Mums Matter Too campaign, which is not only highlighting the shocking inequality facing black women and their children relating to maternal mortality, but taking action to save lives. Mars is working with Peppy Baby, which gives black birth parents free expert support, delivered remotely via an app.
It is a pleasure to serve under your chairmanship, Sir Gary. I start by paying tribute to Tinuke and Clo from Five X More, who have been leading the charge in calling for action on black maternal health. Black women are four times more likely to die in pregnancy and childbirth—we have heard that many times today, and we will probably hear it some more, but I really want it to hit home. We know this, but we have no target to end it.
During my own pregnancy, it was not hard to find instances where, as a black woman, how I was perceived or believed drastically impacted the care I received, from complaints about how I was feeling to being denied scans. We know that black women are perceived to experience less pain. We know this, and we have no target to end it.
Things went from bad to worse for me. I was swollen. My blood pressure would get so high that I would feel dizzy and my nose would bleed. My doctor eventually had me rushed to the hospital for further tests and scans, and I was admitted to the hospital with pre-eclampsia. My last conversation with the consultants was harrowing. They said that my pregnancy had become very dangerous and there were only two outcomes: my child would die, or both myself and my child would die. My diagnosis was too late for any intervention, and simple steps—which I soon found were simple things such as taking aspirin—were no longer an option for me. The consultants’ advice was for a late termination and a delivery to save myself. They also explained that my condition was deteriorating so quickly that I would immediately have to nominate someone to make the decision for me if I should become unconscious.
Some 83% of women of African origin, like myself, and 80% of Caribbean women suffer a near miss in pregnancy and childbirth. Not only do we not have a target to end this, but we do not have information about the health issues that black women go on to face. I did not have to make this decision, because a scan scheduled the day after that meeting showed that my baby’s heart had stopped beating. I was induced, and after something like 18 hours of labour, she was born. As a person of faith, even then, I still had faith that maybe the doctors were wrong and everything would be okay, but she did not move, she did not cry, and there was no miracle. Black babies have a 50% increased risk of neonatal death, and a 121% increased risk of stillbirth, like my own daughter. With figures like that, I wonder how much of a chance she really had. We know this, and we have no target to end it.
It is a pleasure to serve under your chairmanship, Sir Gary. I thank my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) for bringing this e-petition debate on black maternity healthcare and mortality before the House. I also thank Tinuke and Clo, the founders of the Five X More campaign, who have been fighting to get this issue taken seriously.
Other Members have touched on these heartbreaking and stark statistics, but they bear repeating: black women are four times more likely to die during pregnancy or up to six weeks postpartum, women of mixed heritage are three times more likely to die, and Asian women are twice as likely to die. Each loss of life is a tragedy, and that disparity is unacceptable. It needs to be understood and it needs to change.
I also want to mention the Royal College of Obstetricians and Gynaecologists’ term “near misses”. The numbers of women who survive childbirth and are left with long-term morbidity are currently not recorded, but are part of a wider health picture. They must be taken into account. For the past year, covid has exacerbated many of these issues. In fact, even when other factors such as age, obesity and location were taken into account, black and Asian women are more likely than white women to be hospitalised. We need to understand why that is the case, because the statistics can only tell us so much. A commitment to looking into how and why that is the case is urgently needed. I am sure that all of us in the debate today would welcome that.
These tragic deaths are part of a wider picture, a story of health inequality, with black women facing disparities when it comes to stillbirths, cancer diagnoses and outcomes, and access to fertility treatment, among other things. We must recognise that disparities in health outcomes are driven by social factors—poverty, education and housing—as well as discrimination. None of that is new. It is not earth-shattering. It is not changing, either. That simply is not good enough. So we need action, and we need action now.
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Across all ethnicities, most pregnant women who die have complex medical needs, but leading maternal health researchers such as Professor Marian Knight have expressed concerns that our health and social care system is just not set up to deal with that complexity. Clinics are often based at different hospitals, requiring separate appointments. Communication between them does not seem to happen in the way it should. Women are often expected to juggle other childcare and work commitments while attending myriad appointments at a range of different institutions. Not all women have the same support and security at home and at work, and the system does not account for that.
Accounts have shown that the symptoms that pregnant women present with are too often dismissed and attributed to pregnancy itself, when they could be indicators of serious underlying medical complications. Pregnant women from all backgrounds report not being listened to despite the fact that that is crucial to the physical and mental wellbeing of both mother and child. Professor Knight points to what she calls the “constellation of biases” that black and Asian women are subject to. Those range from lack of listening, learning and nuance around women’s backgrounds and the most appropriate care, to micro-aggressions, all the way to completely unacceptable race-related perceptions such as the entirely unsubstantiated notion that black women have higher pain thresholds. If pregnant women are not being listened to and their symptoms are not taken seriously, or if they feel that they will not be, that is a recipe for tragedy.
It is important that public awareness of that issue has finally begun to increase, which is in no small part thanks to the work of such campaigners as Tinuke and Clo and the initiatives that they have launched, such as Black Women’s Maternal Health Awareness Week, which was first held last September, and the petition that we are debating. More women are now coming forward with their experiences, and five times more have shared their stories. One woman recounted:
“As soon as the second midwife was on shift she just seemed to have one goal in mind and that was delivering my baby as soon as possible, she didn’t seem to care about easing any part of my pain or reassuring me for the many worries I had at the time—she rushed my labour along and as a result almost cost me my sons life.”
Another said:
“I already seemed like that hyper-emotional black woman worried about nothing and I let that silence me. I really wish in this moment I expressed my concern or spoke up, because I honestly couldn’t have fathomed that what happened next would come.”
The reaction on social media to Channel 4’s recent “Dispatches” documentary was also very telling. One Twitter user said:
“For many Black women ‘The Black Maternity Scandal’ on Ch 4 is sadly not shocking or eye opening at all. Not being listened to in times of pain has become far too normal and it has to change.”
Another wrote:
“For many of us Black and Brown women, this felt like the first time our stories and traumatic, hurtful experiences got a small hearing on national TV.”
Pregnancy can be a special and exciting time, but it can also be exhausting and terrifying. For any woman to have to spend it not being listened to or not receiving the most appropriate care because of the colour of her skin is nothing short of appalling, so it is unsurprising that there is now an increasingly vocal consensus on the urgent need for more research and evidence, and for firm commitments from the Government and the NHS to end the scandal. We need to address the under-researching of health issues that black women face, and get a clear picture of the data on maternal deaths among different ethnic groups. Many different ethnicities are grouped together under broad categories, which risks missing cultural nuances, misrepresenting experiences and leading us to the wrong conclusions.
Maternal deaths are just the tip of the iceberg. For every woman who dies, many more will have severe pregnancy complications, and there is evidence of disparities between ethnic groups in that respect, too. However, the number of those cases and the impact on their families and lives is not recorded. Lack of research on those so-called near misses is a gap in the knowledge base that must be urgently and proactively corrected.
Tinuke and Clo are asking MPs to act by signing up to the Five X More black maternal health pledge, which I know many colleagues who have spoken today have already supported. One of the asks is that the Government implement the recommendations of the Joint Committee on Human Rights, including the introduction of a firm target to end the disparity in maternal deaths. I would be grateful if the Minister would tell us whether the Government agree with the Joint Committee on Human Rights, the chief midwifery officer and the petitioners that such a target must be put in place. It would also be useful to know whether the Government intend to address the data gap in medical research in the upcoming women’s health strategy.
I want to end by quoting what Tinuke said in an interview with The Guardian last year:
“In 1991 when my mum gave birth to me she was at greater risk of dying. In 2020 when I gave birth to my daughter that risk had increased and I was five times more likely to die…I’ll be damned if my daughter, whenever she decides to give birth, is 25 times more likely to die.”
That truly is a source of shame for this country, which is why today must mark the day that future generations start to look back and wonder how on earth this situation was ever tolerated for so long.
Finally, we must recognise that this is not just about the health status of the mother; it is also about the delivery of care. We have to face up to a difficult truth. Polling by the Joint Committee on Human Rights found that 60% of black people felt that they were not likely to get equal care in the NHS, and 78% of black women felt that the NHS would not give them equal treatment. For white people, those are shocking statistics, particularly as so many black women and men play such a crucial part in providing NHS services. Those figures are based on the experiences and expectations of black women in a society where black people are not treated equally.
This is a matter for the consideration not only of everyone in every part of our society, but of everyone in every part of the NHS and everyone involved in maternity care. Like the Chair of the Petitions Committee, I hope that this debate will mark the start of rapid and transparent progress towards ending this egregious inequality.
This is not about a chip on our shoulder; it is about addressing the real inequality of black maternal mortality rates, which result in women unnecessarily passing away. It is a disparity that requires the Government to take seriously racial and ethnic disparities. Therefore, what we are asking today, and what the campaigners have been asking the Government to do, is to listen and to really take the data seriously. I hope the Minister will introduce an NHS target to end this disgusting disparity.
In my own constituency, I have been doing my best to support my constituent Ernest Boateng. His wife, Mary Agyeiwaa Agyapong, sadly lost her life to covid-19. Mary was pregnant, and a nurse at Luton and Dunstable University Hospital in my constituency. Shortly after undergoing a C-section, Mary sadly died. I have been so moved by Ernest’s resolve and commitment over the last year to seek answers and to make sure that no other family faces such a tragic loss in the same way. I presented Ernest’s petition for greater protections for pregnant women during the pandemic to Parliament earlier this year. This is hugely important, especially as 55% of pregnant women hospitalised during the first months of the pandemic were from black, Asian and minority ethnic backgrounds.
I have written to the Minister multiple times to ask her to meet Ernest. He is the father of two children, and his one-year-old, little Mary, will never get to meet her mum. He is campaigning to make things better and safer for other expectant parents, but sadly every time I have asked, the Minister has responded that she is too busy to meet me and Ernest, so I use this opportunity to ask for even just 20 minutes of her time. I am sure that she will stand up and say the right things, and I know that her heart is in the right place. I am more than happy to assist, if she is willing to listen to the experiences of Ernest, so that no family has to face the devastating loss that his has.
When I talk about this, I am asked how long ago it was and how far along I was. I just want to say that when any woman loses a baby, however her pregnancy ends—miscarriage, stillbirth, or even an abortion if she had to have one—it is not for anyone else to quantify how much pain she must feel, as if to decide how much empathy to show, and it is certainly not for them to decide how much care she should be shown.
I would like people to stop blaming black women—that is all I have heard in response to some of the messages that have been put out. So often, black women are viewed as the problem, but we could be the solution if people would just listen to us, respect us and care for us. We are not a lump of comorbidities—some of us who go on to have these tragic experiences did not even have any comorbidities. We are black women who have decided to bring life into this world, and that choice has become a matter of life and death and health. The inequality we face is not our fault. Inequality is an institutional and political outcome—an institutional and political choice—and it is the duty of the Government to end it, not to outsource responsibility and blame those who are suffering.
In the US, they have just had a Black Maternal Health Week, and $200 million were put towards ending this disparity in training clinicians. In the UK, we have a Government who have ordered reports saying that institutional racism does not exist. So when the Minister responds today, I do not want to hear what the Government think is wrong with women who look like me; I want to hear what they will do to protect women who look like me, and the children we have. I want to hear that this Government realise that if they are not part of the solution, they are part of the problem, and I want them to acknowledge the institutional racism that we face and to have a target to end it. The colour of a woman’s skin should have no bearing on whether she or her child live or die.
The Government must commit to a target to reduce the disparity in mortality rates. The Government must support Five X More pledges, including the recommendations relating to black maternity health in the report “Black people, racism and human rights” produced by the Joint Committee on Human Rights. There needs to be a full and independent review that seeks to end the disparity once and for all. The NHS must commit to robust data collection to aid the understanding of these outcomes. For a start, we need to move beyond the term BME. When women are dying, it is not good enough use data catch-all terms. We need to do more to deliver a workforce that reflects the diversity of the communities it serves.
On a final and quick point, I have not mentioned “no recourse to public funds”. That is, of course, the huge elephant in the room when it comes to health outcomes. Some women face costs of £7,000 or more for essential maternity care. These are the very women who are at risk of increased mortality. It is time for that practice to end.