BAME maternal health disparities


Rt Hon Steve Barclay MP
Secretary of State for Health and Social Care 39 Victoria Street London

20th March 2023

Dear Mr Barclay,

RE: BAME maternal health disparities. It is not due to race but racism.

My mother, who is Sri Lankan, recounts her traumatic experience of pregnancy in the Netherlands as powerless and dehumanising. Her concerns were not listened to, instead her symptoms of pre-eclampsia were attributed to ‘climate differences’. The cost was my little sister suffered blue baby syndrome, a lack of oxygen in the blood. As a medical student this confuses me as this is a common condition and the treatment is effective if diagnosed early. Sadly, my mother’s experience is not an isolated case of malpractice against BAME women. Some 83% of women of African origin and 80% of Caribbean women suffer a near miss in pregnancy or still birth (Nair et al. 2014). My anthropology modules at UCL encourage me to question the structural violence which perpetuates these health disparities. This letter aims to advocate against these health disparities to provide safe and respectful maternity care for BAME women.

In 2018, an inquiry by the MBRRACE found Black women were five times and Asian women two times more likely to die in the perinatal period than white women. They described this as an ‘urgent human rights issue and urgent action must be taken to address it’ (Birthrights, 2022) . The same report in 2021 found this exact finding, there was no change. On the other hand, the Sewell report, which is used to inform government policy, told us not to worry by ‘emphasising the low numbers overall’. These ‘low numbers’ include the lives of thousands of BAME women. As a medical student, I am held to high regard by the GMC for any decision I take and risk losing my license and prosecution if I operate in the same, reckless manner as suggested by the Sewell report.

This injustice is gaining momentum; a petition titled ‘Improve maternal mortality rates and healthcare for black women in the UK’ gained over 187,000 signatures in 2021. ‘The Black Maternity Scandal’ aired on channel 4 publicised the issue and was highly praised by the BMA. The Five X More black maternal health pledge was signed by 20 MPs to tackle inequalities head on.

Likewise, The Motherhood Group has recently implemented initiatives such as Black Maternal Mental Health Awareness week, which was held in trusts throughout the nation last September. Awareness is great for clinicians to reflect on how to provide better care (Maternal Mental Health Alliance, 2012). The Maternity Disparities Taskforce 2022 is a huge step in the right direction. However, it limits to ‘addressing how wider societal issues affect maternal health’ (GOV.UK., 2022). The Sewell Report also mentioned ‘addressing’ these inequalities four years prior. When will ‘addressing’ turn into effective action?

Blackness is not an illness

Often health disparities in BAME maternal outcomes are justified through socio-economic inequalities or high risks of pre-existing health conditions, as in the Sewell report. However, research shows after considering socio-economic inequalities, BAME women continue to have worse health outcomes in comparison to white women (Davis, 2019; Mullard, 2021). The Sewell report failing to understand racialised health disparity as a by-product of structural violence reflects a disregard for the experiences of BAME women.

Structural violence is the vulnerability specific groups of people experience through social oppression (Griffiths, 2005). It manifests itself through higher risks of disease as well as worse health outcomes. This systematic violence is not always direct, it is built into systems, such as the NHS. (Farmer, 2004:307). This would mean socio-economic inequalities among racial groups cannot be used to account for higher rates of maternal deaths. Instead, we need to tackle why disproportionate levels of poverty exist in some racial groups. We need to question how systems like the NHS perpetuate this structural violence.

Similarly, blackness is often viewed as a risk factor for complicated pregnancy. Dr Christine Ekechi, co-chair of the race equality taskforce at the Royal College of Obstetricians and Gynaecologists, attributes this increased risk to black women more likely having pre-existing health conditions (RCOG, 2021). However, many of the health conditions she mentions are non-transmissible such as high blood pressure and cardiac disease. Again, the question we need to ask is what social and economic structures increase the prevalence of ill health in BAME populations?

Emphasising blackness as a risk factor to increased poverty or pre-existing health conditions is a form of ‘neoliberal governance’(Rose 2007:4). Rose describes this as the responsibilisation of individuals to take care of themselves and their futures. This negates the level of agency people have over their ‘local biologies’; the environment they are situated in (Lock and Nguyen). This further perpetuates structural violence. The cost of this is that black women cannot trust the NHS. Polling by the Joint Committee on Human Rights found ‘78% of black women felt that the NHS would not give them equal treatment’ (House of Commons and the House of Lords 2020). Trust underpins any relationship, and it is especially important in vulnerable experiences such as pregnancy. If black women do need feel safe, they are less likely to access the care they require.

Race is a not biological, it is a social construct.

Maternal health disparities further deepen social inequalities. In my anthropology module, I was surprised to learn there is greater genetic variation within racial groups than between them (Goodman, 2016). In the medical curriculum, race is often viewed as a risk factor for certain diseases or poor health outcomes. However, these racial groups are a social construct, there is no gene or cluster of genes that belong to any given racial group. It is racism that materialises race (Mullard, 2021). ‘Disparities are a biological expression of race relations’ (Davis, 2019). Black and brown bodies are not broken or a risk factor for poor maternal outcomes, instead they are the site for structural violence.

The materialisation of a race group generates racialised stereotypes, which can be detrimental for maternal outcomes ( DelVecchio Good et al 2003). Good describes aversive racism as unconscious use of racial stereotypes by health care workers which impacts the care provided for black people. In the context of maternity, images of the ‘angry black woman’ often presents the black female as dramatic and over emotional (Nolan, 2018). This potentially informs a ‘constellation of biases’ where black women experience a lack of listening and unacceptable race-related perceptions such as the unsubstantiated notion that black women have higher pain thresholds (Knight M et al 2009). A study in Addenbrooke’s Hospital published three weeks ago shows for vaginal births, black Caribbean-British women are 8% less likely than white women to receive an epidural (Bamber 2023). He argues the reason for this may be empathy biases from healthcare professionals, such as interpretation of labour pain from different ethnic groups.

Clearly, the NHS is failing on its promise to deliver safe and equitable care to all (Delamothe 2008).

What are the next steps?

Last October, you were urged by 155 organisations including the BMA and Royal College of Physicians to recommit and publish the white paper on health disparities (Clarke-Ezzidio 2023). The focus of this letter was to ‘prevent ill health in the first place’ and called for ‘action against racism’ in the NHS. Despite this you refuse to publish this paper, which symbolises a lack of care for the unsafe healthcare received by minority patients. The NHS is still not a safe and equal place for BAME pregnant women.

A social construct like race needs to be treated socially. To reduce health disparities among BAME pregnant women, I urge you to:

      – Decolonise maternity education through integrating teaching on structural violence in medical school curriculums to tackle diagnostic bias and to destabilise the concept that race is a biological risk factor for many diseases (Bailey et al., 2013; Sobo et al., 2020)

      –  Publish white paper on health disparities to help target the structural violence in wider society that impacts health outcomes.

      –  Increase funding into tackling wider societal barriers that affect maternal health.

Why is this urgent?

The UK is regarded a safe place to give birth, but it’s sad to see how the colour of a pregnant woman’s skin potentially endangers her life and her baby’s life. Action and change are required and possible. It is a step in keeping this promise. For instance, Black Maternal Health Week takes place yearly in the US. More than $200 million was used to fund disparity training for clinicians (White House, 2021).

To sum up, I want to leave you with a quote from Tinuke Awe.

“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.” (Topping, 2020).

Yours sincerely,

Piradab Vijayaratnam

Reference list

1) Bamber, J. (2023). Childbirth pain relief study reveals inequalities for BAME mothers [online] Cambridge University Hospitals. Available at:

2) Birthrights(2022).Systemicracism,notbrokenbodiesAninquiryintoracialinjustice and human rights in UK maternity care. [online] Available at: systemic-racism_exec-summary_May-22-web.pdf.

3)  Clarke-Ezzidio,H.(2023).Thehealthcrisisnobodyistalkingabout.[online]New Statesman. Available at: white-paper-cancelled-steve-barclay-nhs-strikes-sajid-javid [Accessed 20 Mar. 2023].

4)  CommissiononRaceandEthnicDisparities(2021).CommissiononRaceandEthnic Disparities: The Report. [online] Available at: ment_data/file/974507/20210331_-_CRED_Report_-_FINAL_-_Web_Accessible.pdf.

5) Davis, D. A. (2019). Obstetric racism: the racial politics of pregnancy, labor, and birthing. Medical Anthropology, 38(7), 560-573.

6) Delamothe,T.(2008).Foundingprinciples.BMJ,[online]336(7655),pp.1216–1218. Available at: [Accessed 11 Nov. 2019].

7)  DelVecchio Good, M., James, C., Good, B. and Becker, A. (2003) The Culture of Medicine and Racial, Ethnic, and Class Disparities in Health Care. in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care , ed. Brian D.  Smedley, Adrienne Y. Stith, and Alan R. Nelson. Washington, D.C.: IOM, The National Academies Press, pp. 594-625

8) Farmer, P. (2004). An anthropology of structural violence. Current anthropology, 45 (3), 305-325.

9) FIVEXMORE.(2017).MPPLEDGE.[online]Available at: [Accessed 20 Mar. 2023].

10) Goodman, A. H. (2016). Disease and dying while black: how racism, not race, gets under the skin. New directions in biocultural anthropology, 67 -78

 11) GOV.UK. (2022). New taskforce to level-up maternity care and tackle disparities. [online] Available at:

12) House of Commons and the House of Lords (2020). House of Commons House of Lords Joint Committee on Human Rights Black people, Racism and Human Rights Eleventh Report of Session 2019-21 Report, Together with Formal Minutes Relating to the Report by Authority of the House of Commons and the House of Lords. [online] Available at:

13)  Knight, M., Kurinczuk, J.J., Spark, P. and Brocklehurst, P. (2009). Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities. BMJ, [online] 338(mar03 2), pp.b542–b542. Available at:

16)  Lock, M.M. and Nguyen, V.-K. (2010). An anthropology of biomedicine. Chichester, West Sussex ; Malden, Ma: Wiley-Blackwell.

17) Manktelow, B.N., Mbrrace-Uk (Program and Maternal, Newborn And Infant Clinical Outcome Review Programme (Great Britain (2018). MBRRACE-UK perinatal mortality surveillance report : UK perinatal deaths for births from January to December 2016, summary report. Leicester: Department Of Health Sciences, University Of Leicester, June.

18) Maternal Mental Health Alliance. (2017). Black Maternal Mental Health Week 2022 | Maternal Mental Health Alliance. [online] Available at: 2022/ [Accessed 20 Mar. 2023].

19) Mullard, J. C. R. (2021). Race, Racism and Anthropology: Decolonising Health Inequality in a Time of Covid-19. Medicine Anthropology Theory, 8(1), 1-19.

20) Nair, M., Kurinczuk, J.J. and Knight, M. (2014). Ethnic Variations in Severe Maternal Morbidity in the UK– A Case Control Study. PLoS ONE, 9(4), p.e95086

21)  Nolan, S. (2021). The ‘Angry Black Woman’ Trope Is All Wrong. [online] Shape. Available at: black-woman.

22)  Petitions – UK Government and Parliament. (2021). Petition: Improve Maternal Mortality Rates and Health Care for Black Women in the U.K. [online] Available at:

23) RCOG. (2021). RCOG responds to Lancet report linking adverse birth outcomes to inequality. [online] Available at: lancet-report-linking-adverse-birth-outcomes-to-inequality/.

24) Topping, A. (2020). ‘Something has to be done’: tackling the UK’s Black maternal health problem. [online] the Guardian. Available at: tackling-the-uks-black-maternal-health-problem.

25) White House (2021). FACT SHEET: Biden-Harris Administration Announces Initial Actions to Address the Black Maternal Health Crisis. [online] The White House. Available at: releases/2021/04/13/fact-sheet-biden-harris-administration-announces-initial- actions-to-address-the-black-maternal-health-crisis/.

Image source: Unsplash (2021). Photo by Mustafa Omar on Unsplash. [online] Available at:

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