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Intersectionality in maternal health

Intersectionality is the complex process of an individual’s social position interacting with various systems of oppression and marginalisation. These structural systems operate simultaneously and exacerbate each other, producing an individual’s unique experience of inequity.

Maternal mortality is widely accepted as a measure of population health, as well as an indicator of social and economic development, and how human rights are evaluated. The United Kingdom (UK) is seen to be a safe country to have a baby – the maternal mortality (deaths during or up to six weeks after the end of pregnancy) rate in the UK is 10.9 deaths per 100,000 live births(1). However, within these statistics, the impact of intersectionality is clearly exposed. Persistent ethnic disparities in maternal mortality risk have repeatedly been highlighted(2) – the risk of maternal death for Black women is 3.7 times higher than for White women(3). Asian women and mixed ethnicity women also experience increased risks of maternal mortality compared to White women, at 1.8 and 1.3 times more likely respectively(3). 90% of all maternal mortalities between 2018-2020 faced multiple biases(3). The overlapping intersections of being from ethnic minority groups, and being from a poorer background, as well as other barriers, prevented the women who died from receiving the necessary care(3). A similar ethnic disparity exists for severe maternal morbidities (near death experiences) shortly before, during and immediately after childbirth(4).


Efforts to understand why ethnic minorities are overrepresented in maternal mortalities have been limited, mostly focusing on individual-level risk factors. The underlying reasons are multiple, complex, and not fully understood, but racism is believed to be at the root(5). It is important to reference the historical underpinnings of obstetrics. In the 1800’s, the ‘father of modern gynaecology’, Dr J Marion Sims, performed reproductive experiments on Black, enslaved women(6-8). The power structures of colonialism and the legacies of this continue to shape contemporary experiences. Moreover, Black, Asian and ethnic minority women also experience poorer care in UK maternity services(9) facing racial stereotyping, microaggressions and not being listened to(3, 5). Concerningly, none of the non-English speaking women who died during pregnancy or 6 weeks after between 2015-2017 received an interpreter for their entire maternity journey(10).

The intersection of ethnicity and health and the bias this causes in pain management has long been studied(11, 12). A US study of White medical students and residents found that half of participants endorsed beliefs that Black individuals had thicker skin and less sensitive nerve endings than White individuals, rating their pain as lower, leading to less accurate treatment recommendations(13). The existence of cultural stereotypes for ethnic groups impact upon what is deemed as acceptable behaviours and attitudes towards individuals from those groups(14). It has been found that pregnant and postnatal Asian and Black women have been denied adequate pain relief, have had their pain disregarded, or have been assumed to have higher or lower pain thresholds than White women(3, 5, 15-18). A review of maternal mortalities found that Black British women were said to have low pain thresholds and assumptions about their symptoms were made based on language ability and/or ethnicity(3).


In addition to the ethnic disparities, women living in the poorest areas of the UK are twice as likely to suffer maternal mortality than women in the most affluent areas(3). Limited research of structural, community level markers of racism, and maternal mortality has been undertaken in the UK to better understand the intersection of how being a woman from an ethnic minority group and living in deprivation, compounds an individual’s experiences. However, research in the United States (US) has linked the increased maternal mortality for Black women to structural markers of racism - income inequality and neighbourhood polarisation(19, 20).


A further contributing intersection is sexism. A gender bias exists within research and subsequently, healthcare(21, 22). Only 2% of medical research funding goes towards pregnancy, childbirth, and female reproductive health(23). Moreover, amongst other barriers, a deep mistrust of research exists among ethnic minority and marginalised groups, leading to historical under-representation in research studies(24, 25). This potentially undermines the validity of the evidence produced, further driving inequities. Women are excluded from some research areas, sometimes without clear justification(26). The exclusion of pregnant and lactating women was of real concern during Covid-19 vaccine trials as this led to delays in this group being able to be vaccinated(26, 27). Reassuringly, the first-ever Government-led Women’s Health Strategy for England has been set up to tackle the gender health gap and further gender equality(28).

The ethnic disparity in maternal mortality is rightfully gaining increased awareness, with growing pressure on the Government. A recommendation by the Women and Equalities Committee to set a target and strategy to end these disparities was recently rejected(29), a widely criticised decision(30). Government stated ‘we do not believe a target and strategy is the best approach towards progress’(29). Although this may be the case, it undoubtedly sends a clear message to society about the Government's urgency in prioritising and addressing this.

Historically, intersectionality has mainly focused on race and gender(31), sometimes in isolation. Less is understood about the additional intersections women and birthing people may face of disability/ableism, sexual orientation/homophobia, and gender identification/transphobia – a future qualitative and quantitative research need.

A multifaceted approach is required to disrupt the power hierarchies that contribute to the inequalities in maternal mortality and morbidity. To acknowledge the multiple intersections, upstream policies to address the societal context of institutional racism and sexism, as well as downstream interventions to dismantle bias and challenge discrimination is vital.

References:

1. Knight MB, K.; Patel, R.; Shakespeare, J.; Kotnis, R.; Kenyon, S.; Kurinczuk, JJ. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit: University of Oxford; 2022.

2. Knight M, Bunch K, Kenyon S, Tuffnell D, Kurinczuk JJ. A national population-based cohort study to investigate inequalities in maternal mortality in the United Kingdom, 2009-17. Paediatr Perinat Epidemiol. 2020;34(4):392-8.

3. Knight M, Bunch K, Vousden N, Banerjee A, Cox P, Cross-Sudworth F, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2022;43:101237.

4. Nair M, Kurinczuk JJ, Knight M. Ethnic variations in severe maternal morbidity in the UK – a case control study. 2014;9:e95086.

5. Birthrights. Systemic racism, not broken bodies. An inquiry into racial injustice and human rights in UK maternity care. England: Birthrights; 2022.

6. Ojanuga D. The medical ethics of the 'father of gynaecology', Dr J Marion Sims. J Med Ethics. 1993;19(1):28-31.

7. Wall LL. The medical ethics of Dr J Marion Sims: a fresh look at the historical record. J Med Ethics. 2006;32(6):346-50.

8. Brown HL, Small MJ, Clare CA, Hill WC. Black women health inequity: The origin of perinatal health disparity. Journal of the National Medical Association. 2021;113(1):105-13.

9. MacLellan J, Collins S, Myatt M, Pope C, Knighton W, Rai T. Black, Asian and minority ethnic women's experiences of maternity services in the UK: A qualitative evidence synthesis. J Adv Nurs. 2022;78(7):2175-90.

10. Cosstick E, Nirmal R, Cross-Sudworth F, Knight M, Kenyon S. The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. eClinicalMedicine. 2022;52.

11. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187-204.

12. Mossey JM. Defining racial and ethnic disparities in pain management. Clin Orthop Relat Res. 2011;469(7):1859-70.

13. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301.

14. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-10.

15. Canty L. It’s not always rainbows and unicorns: The lived experience of severe maternal morbidity among black women. Journal of Midwifery and Women's Health. 2020;66(5):684.

16. Wang E, Glazer KB, Sofaer S, Balbierz A, Howell EA. Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2021;31(1):75-81.

17. Eniola FN, A. Niles, P. Morton, C. Searing, H. Women’s Experiences with Severe Maternal Morbidity in New York City: A Qualitative Report. New York: New York City Department of Health and Mental Hygiene; 2020.

18. Chambers BD, Taylor B, Nelson T, Harrison J, Bell A, O'Leary A, et al. Clinicians' Perspectives on Racism and Black Women's Maternal Health. Women's health reports (New Rochelle, NY). 2022;3(1):476-82.

19. Dyer L, Chambers BD, Crear-Perry J, Theall KP, Wallace M. The Index of Concentration at the Extremes (ICE) and Pregnancy-Associated Mortality in Louisiana, 2016-2017. Maternal and child health journal. 2022;26(4):814-22.

20. Vilda D, Wallace M, Dyer L, Harville E, Theall K. Income inequality and racial disparities in pregnancy-related mortality in the US. SSM - population health. 2019;9:100477.

21. Stillwell RC. Exclusion of women from COVID-19 studies harms women's health and slows our response to pandemics. Biology of Sex Differences. 2022;13(1):27.

22. Upchurch M. Gender Bias in Research. Companion to Women's and Gender Studies2020. p. 139-54.

23. Guthrie S, Lichten CA, Leach B, Pollard J, Parkinson S, Altenhofer M. Pregnancy research review: Policy report. Santa Monica, CA: RAND Corporation; 2020.

24. Smart A, Harrison E. The under-representation of minority ethnic groups in UK medical research. Ethn Health. 2017;22(1):65-82.

25. Scharff DP, Mathews KJ, Jackson P, Hoffsuemmer J, Martin E, Edwards D. More than Tuskegee: understanding mistrust about research participation. J Health Care Poor Underserved. 2010;21(3):879-97.

26. Kons KM, Wood ML, Peck LC, Hershberger SM, Kunselman AR, Stetter C, et al. Exclusion of Reproductive-aged Women in COVID-19 Vaccination and Clinical Trials. Women's Health Issues. 2022;32(6):557-63.

27. Van Spall HGC. Exclusion of pregnant and lactating women from COVID-19 vaccine trials: a missed opportunity. Eur Heart J. 2021;42(28):2724-6.

28. Department of Health and Social Care. Policy paper: Our vision for the Women's Health Strategy for England. England: Gov.UK; 2021.

29. House of Commons Women and Equalities Committee. Black maternal health: Government Response to the Committee’s Third Report Fifth Special Report of Session 2022–23. England: UK Parliament; 2023.

30. Mahase E. Government isn’t doing enough to end “shameful” inequality in maternal mortality, MPs say. BMJ. 2023;381:p865.

31. Crenshaw K. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. The University of Chicago Legal Forum. 1989;140:139-67.





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