The tragic death of Nicole Thea at just 24 years old has brought to the forefront the discussion regarding being black and pregnant and why that means she is more likely to die during pregnancy than a white woman of her age and physicality. Nicole was a social media influencer known for her dancing and jewellery line. On the 12th of July it was confirmed that Nicole and her unborn son had tragically passed away and the family confirmed later that she died from what they describe as a ‘massive heart attack’.
Despite how tragic this is, it unfortunately is not an isolated incident. High profile celebrities like Beyoncé and Serena Williams have been vocal in recent years regarding their struggles during and after pregnancy. As a black female doctor passionate about women’s health this is a topic that plagues me.
In 2019, MBRRACE-UK produced a report detailing investigations into maternal deaths in the UK & Ireland between 2015 and 2017 as well as lessons to be learnt to inform maternity care. Within this report, a total of 209 women died in pregnancy✝︎ with heart disease being the most common cause of death.
The report drew attention to inequalities evident within women’s care, namely; ethnic group, age and living in deprived areas. Focusing on ethnic groups, it highlighted that black women are 5 times more likely to die in childbirth than white women. In fact every ethnic group has an increased risk in pregnancy as compared to white women (Asians: twice as likely, Mixed ethnicity: thrice as likely). Unfortunately the data from the report is unable to provide us this insight as to why this is. This ‘why’ needs further unpacking and therefore future research. It will provide us with ways in which we can tackle these inequalities. The report does however encourage us not to take these results in confinement.
The UK is not alone when it comes to the disparity between ethnic groups in relation to maternal deaths. In the United States a similar trend can be found. Between 2011 and 2017, the CDC documented women who were black were 3 times more likely to die than their white counterparts and up to 2 times more likely than other race. In a more global sense, the WHO reports the highest maternal death rates remain in low income countries. The reasons for this can be attributed to poverty, distance to facilities, lack of information, cultural beliefs and inadequate facilities. These factors may also play a role in developed countries but less so.
We therefore need to consider other reasons for this racial disparity.
My first thought would be that black women ARE in the minority. We can’t treat what we don’t see. This means that the difference in management may be unintentional because we don’t see enough of them to recognise there may be a difference in the way they present or respond to management. Coupled with this may be the fact that some diseases in pregnancy such as extremely high blood pressure have risk factors that just include being black. Add to this another layer, health professionals already know that when treating high blood pressure in adults certain drugs just work better for black people and this may translate into some maternity care. All these factors could make for a snowball effect impacting on the care of the black woman in pregnancy.
Serena Williams praises the care she got in her maternity journey but also highlights that she has to fight to receive the right care and treatment. A BBC article from 2019 echoes similar thoughts - Dr Ria Clarke within that article, highlights that black women sometimes feel they may not be taken seriously and therefore downplay their symptoms. This also plays in a cultural stereotype of the ‘strong black woman’ - we are taught from a young age not to complain and do what we ‘have’ to. In maternity care that could literally be the thin line between life and death.
Finally, the element of racial bias is an important factor to consider despite how uncomfortable it is. Within the BBC article a recent black mother at the time felt that other mothers in similar situations were shown more empathy. She felt she wasn’t listened to despite her being vocal and felt disappointed when she was proven right about her post partum condition. In these instances health care professionals on an individual level as well as organisation wide first need to realise the potential for racial bias, that it could be playing a factor and then combat it. Without admitting there is something wrong we cannot move forward.
So after all this information, what do we do?
Firstly, I want to reassure you. In this context, it may seem that pregnancy and childbirth really isn’t all that safe. Pregnancy and childbirth in developed countries is safe and the majority of health care professionals are always working to provide the best care for our patients. Secondly, working as black female gynaecologist puts me in a unique position to advocate for patients like myself which is absolutely what I intend to do, every day of my life. However, you the reader of this article also have a role to play, whether you’re black or not you now have information that can guide you. You can also be an advocate.
Lastly, specifically to the women in the room; The MBRRACE-UK report’s key message is for women to speak up for themselves and to stay connected with their usual care providers. Women, you know your bodies best, you know how you feel, you know when something is wrong. So speak up.
Support yourselves, protect yourselves, champion yourselves.
Article written by Dr Olayisade Ajibola-Taylor, trainee in the Liverpool region. She has spent the last two years working in various hospitals, honing her skills within Women's Health. She is due to start her training in Obstetrics and Gynaecology in August 2020 within the Manchester region. She runs a Twitter/Instagram account called Honeypot Fables that is focused on women’s health topics and advice.
✝︎Pregnancy in this context covers pregnancy and the 6 weeks post delivery