MIDIRS Midwifery Digest: The use of Cultural Safety Huddle and Handover guides to improve care delivery for Black, Asian, and Minority Ethnic patients
By Hannah Alice King on 26 May 2021
Patient safety in the NHS and maternity
The National Health Service (NHS) serves an increasingly diverse clientele in terms of ethnicity, culture and religion (Diversity UK 2020). There have been huge developments in terms of improving maternity services which have fortunately reduced maternal and neonatal mortality over the past 10 years, despite increasingly complex patients giving birth and being born in the UK (National Maternity Review 2016). However, it is concerning that, while the overall rates of maternal and neonatal mortality have reduced, certain subgroups (most notably Black and Asian heritage groups) are enduring a disproportionately larger burden of poor health outcomes. These include maternal death (including mortality from COVID-19), neonatal death, preterm birth, neonatal low birth weight and stillbirth; the reasons for these disparities are often unclear and multi-faceted (Garcia et al 2015, Draper et al 2018, Li et al 2019, Knight et al 2019, Knight et al 2020).
Discrimination, bias and stereotypes – viewing racism as a determinant of health
There is a long, complex history of discrimination, stereotypes and bias against those of Black and
Asian heritage in the UK, which originates in the transatlantic slave trade, imperialism and colonialism (Historic England 2020). Institutional racism has been investigated within the criminal justice system (MacPherson 1999) but has not been investigated within the NHS in an equivalent, in-depth way. It is not unreasonable to suggest that the NHS suffers from systemic and institutionalised racism, often presenting in seemingly benign and covert ways, with the potential for mistreatment, negligence and poor health outcomes for non- white patients (Adebowale & Rao 2020). For example, specifically examining the literature surrounding Black women in the Western world, when compared to white women, this group is evidenced to experience:
- Poorer postnatal mental health (Grobman et al 2016)
- Lower satisfaction with labour care, higher rates of caesarean section as mode of delivery, and less analgesia in labour (National Perinatal Epidemiology Unit (NPEU) 2020)
- Higher rates of maternal haemorrhage (Main et al 2020)
- More mistrust of their health care providers (Lyndon 2019)
- More generalised mistreatment such as being threatened or shouted at (Vedam et al 2019)
- Higher odds of severe maternal morbidity (Nair et al 2014)
Due to the multifactorial nature of these disparities, it is impossible to blame racism, bias or discrimination entirely, yet it is also impossible to exclude racism entirely as a contributing factor. While causal links cannot be directly inferred, exposure to racism has been evidenced to be significantly related to poor mental and physical health (Paradies et al 2015).
Is safety culture leaving the most vulnerable behind?
Initiatives surrounding patient safety and safety culture have improved the overall standard of care delivered to maternity patients (NHS Improvement 2019a, 2019b). However, a discordance is perpetuated which has exposed not only poorer outcomes for Black and Asian heritage women and their babies, when compared to their white counterparts, but also dissatisfaction and lack of involvement with health care provision (Draper et al 2018, Knight et al 2019, NPEU 2020).
A new inquiry, The Safety of Maternity Services in England, will examine the failings in maternity service provision and produce recommendations to address these concerns (Health and Social Care Select Committee 2020). If institutional bias and racism is highlighted as a concern this may further propel the issue to the forefront of the NHS agenda. In this instance, the focus may be shifted towards training patient-facing staff in anti-racism and recognising personal implicit bias to address the institutional and systemic racism which persists in the NHS (Hall et al 2015, FitzGerald & Hurst 2017).
Racism in the NHS is subtle and entrenched and it cannot, therefore, be confidently concluded that the 29 per cent of women in the latest MBRRACE report who assessors judged would have had a changed outcome with improved care, did not experience bias, discrimination or racism on some level (Knight et al 2019, Adebowale and Rao 2020).
Read the full article here.
King HA. MIDIRS Midwifery Digest. Vol 31, no 1, March 2021, pp 46-51.
Original article © MIDIRS 2021
The Royal College of Midwives has launched a position statement on Racism in the Workplace. Read the position statement here.