National Maternity and Perinatal Audit. Ethnic and Socio-economic inequalities in NHS maternity and perinatal care for women and their babies. Assessing care using data from births between 1 April 2015 and 31 March 2018 across England, Scotland and Wales.

Executive summary

Introduction

The purpose of this report is to describe inequalities in maternity and perinatal care for women and their babies in England, Scotland and Wales during the period 1 April 2015 to 31 March 2018. Using routinely collected data, care and outcomes experienced by women and babies using NHS maternity services are measured and stratified by ethnicity and by Index of Multiple Deprivation (IMD), a proxy for socio-economic deprivation. This report focuses on the following maternal measures: ● caesarean birth (presented as elective, emergency and both combined) ● birth without intervention ● major postpartum haemorrhage (1500 ml or more) and the following perinatal measures: ● an Apgar score of less than 7 at 5 minutes ● breast milk at first feed ● neonatal unit admission at term.

Methods

This report uses existing NMPA linked datasets. Ethnicity is coded using the Office for National Statistics (ONS) 2001 census categorisation of 16+1 codes for ethnicity,2 grouped into white, South Asian, Black and Other (comprising ‘Mixed’ and ‘Other’ combined). Socio-economic deprivation is measured using the Index of Multiple Deprivation (IMD), an area-based measurement of multiple deprivation calculated for each lower-layer super output area (LSOA) in England and Wales, and data zone in Scotland.3 IMD is based on residential postcode and grouped into quintiles of national distribution (quintile 1 = least deprived to quintile 5 = most deprived) for analysis. Results for each maternal and perinatal measure are reported by the mother’s ethnic group and IMD quintile. The results presented in this report are crude and therefore descriptive. The results do not take into account the interactions that contributory factors, such as parity, age, pre-existing co-morbidities, ethnicity and deprivation may have on each other, the complexities of which are not easily interpreted in an audit report such as this. An advisory group comprising professionals and a diverse range of service user representatives with experience of accessing maternity care was involved in the sprint audit. The advisory group was involved in the choice of measures for inclusion in this report, interpretation of results, identifying key messages, and reviewing the draft report and recommendations.

Key findings

Our results demonstrate differences in outcomes of maternity and perinatal care among women and birthing people, and their babies, via comparisons between those living in the most deprived and the least deprived areas in Great Britain, and in those from ethnic minority groups versus white ethnic groups.

Women from South Asian and Black ethnic groups and those from the most deprived areas had higher rates of hypertension and diabetes when compared with women from white ethnic groups and those in the least deprived areas. Smoking was considerably higher among women and birthing people from white ethnic groups and those in the most deprived quintile. Women from Black ethnic groups had a higher rate of experiencing a birth without intervention. While this may be desirable in many situations, it may also represent circumstances where interventions are desired or indicated but do not occur. Rates of caesarean birth (both elective and emergency combined) and rates of emergency caesarean birth were highest for women from Black ethnic groups and higher for women from South Asian groups when compared with those from white ethnic groups. Women and birthing people from Black ethnic groups had higher rates of major postpartum haemorrhage (1500 ml or more) when compared with women and birthing people from white ethnic groups. In contrast to the usual association of increased deprivation with increased morbidity, a decreasing trend for major postpartum haemorrhage (1500 ml or more) was observed from the least to most deprived. Babies born to women from South Asian ethnic groups were less likely to have an Apgar score of less than 7 at 5 minutes but were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Babies born to women from Black ethnic groups were more likely to be assessed as having an Apgar score of less than 7 at 5 minutes and were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Rates of receiving breast milk at their first feed were significantly lower for babies born to white women and to those living in the most deprived areas. We also found areas of concern with regard to data completeness and rates of missing data by ethnic group and IMD. Our results show 1 in 10 women and birthing people in Great Britain (1 in 5 in Scotland) did not have their ethnic group recorded, and IMD was missing for 6%.

Recommendations

R1 Target efforts for a life-course approach to improve the health of people, addressing the wider social determinants of health as well as specific health-related risk factors. Offer individualised preconception and antenatal information tailored to their circumstances, including BMI, smoking, pre-existing comorbidities (hypertension and type 2 diabetes) and whether this is their first birth or they have previously had a caesarean birth. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, public health policy makers) R2 Target efforts to reduce smoking. Audit rates of carbon monoxide testing and referrals for smoking cessation for women during pregnancy, and audit compliance with monitoring for fetal growth restriction. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, stop smoking services, public health policy makers) R3 Support research and investigation into why women from ethnic minority groups and more deprived areas have higher rates of stillbirth, taking into consideration differences in care, specific risk factors and the wider determinants of health. (Audience: National Institute for Health Research, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services) R4 Improve availability and quality of information about choices during pregnancy and labour, with particular attention to the development of evidence-based shared decision-making tools for place, mode and timing of birth and pain relief options. Consider using the IDECIDE tool (when available). (Audience: Healthcare professionals working in maternity services, maternity services providers, NHS England, NHS Scotland, NHS Wales) R5 Avoid term admissions to a neonatal unit through improving transitional care provision, by establishing facilities where they are not currently available; or in hospitals that do have transitional care facilities, by expanding cot space availability and increasing numbers of appropriately trained staff. (Audience: Maternity and neonatal services providers) R6 Offer all women breastfeeding information and support, and target support in specific areas where breastfeeding rates are lowest (see also Priority 4c, intervention 3 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, health visitors, primary care providers, maternity care services) R7 Review equality and diversity training provision and update to include the risks associated with deprivation, and how to recognise and avoid unconscious bias (see also Priority 4d, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, medical Royal Colleges, Royal Colleges of Nursing and Midwifery, General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council, higher education institutions) R8 Ethnicity should be asked of and accurately recorded for all pregnant people using agreed ethnic group coding systems that should be updated regularly in accordance with the most current census groups. Consideration should be given to methods for self-reporting of ethnicity whenever possible (see also Priority 3, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, maternity service providers, general practitioners, primary care providers, NHS England, NHS Scotland, NHS Wales) R9 Review the ethnic diversity and rates of socio-economic deprivation in the local area of each NHS trust or board and consider ways to reduce inequalities in healthcare outcomes (see also Priority 4, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, primary care providers, public health bodies, local government) R10 Prioritise further research in NHS maternity and perinatal care that could improve outcomes for women, and their babies, from ethnic minority groups and those in the most deprived areas. Undertaking quantitative analysis to investigate ethnic and socio-economic inequalities and report on the mediating factors and causal pathways; along with qualitative research to include exploring the experiences of people accessing maternity care. (Audience: National Institute for Health Research, UK Research and Innovation, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services