To what extent can a pregnant woman's socioeconomic status and/or ethnicity influence her birthing journey? Previous research on indicators of labour induction have concentrated on medical risk factors, such as a woman's age, the presence of diabetes or hypertension or an infant's birth weight and gestational age. Carter et al (2020) investigated whether socioeconomic factors such as maternal education, income or neighbourhood deprivation were independently associated with labour induction in the UK, controlling for medical factors. They found that the risk of labour induction differs by socioeconomic status, with nulliparous and multiparous women with fewer educational qualifications and those living in disadvantaged places having ‘a greater likelihood of labour induction than women with higher qualifications and women in advantaged electoral wards’ (Carter et al, 2020).
According to Walsh et al (2011), ethnicity can influence perinatal and obstetric outcomes; gestational time is shorter in black and Asian women compared with white European women and racial and ethnic disparities in caesarean section rates also exist. Walsh et al (2011) compared labour outcomes between women from Ireland and Eastern European countries, reporting that the latter were more likely to labour spontaneously, and during spontaneous labour, the duration was shorter and less epidural analgesia and oxytocin augmentation for dystocia were used, despite insignificant differences in birth weight. Walsh et al (2011) stated that this confirmed the ‘healthy migrant effect’, indicating a selection bias where ‘women who are able to migrate and be mobile are more likely to be healthier when compared with native-born counterparts’.
However, considering a wider context, MacLennan et al (2022) analysed black, Asian and minority ethnic women's experiences of UK maternity services, and found ‘evidence of mistreatment and poor care for ethnic minority women in the UK maternity system’. Whereas woman-centred midwifery care was reported as positive for all women, it was often experienced as an exception by ethnic minority women in an overstretched technocratic birthing system. When Gurol-Urganci et al (2022) investigated English NHS hospitals providing maternity services, they not only found that ‘[h]ospitals with a higher rate of induction had a lower risk of adverse birth outcomes’, but also pointed out that women's advocacy groups and organisations representing healthcare professionals were concerned that increasing use of induction of labour would harm maternal experience, and that ‘“singling out” women based on their age, ethnic background or BMI may be considered discriminatory’.
A National Institute for Care and Health Excellence (NICE, 2021) consultative draft guideline on inducing labour suggested that induction of labour should be considered ‘from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy’, for example, those with a BMI 30kg/m2 or above, those aged 35 years or above or those with a black, Asian or minority ethnic family background. NICE later abandoned this advice after doctors and campaigners expressed concerns about the draft guideline, ‘warning that stratifying risk by race alone was “a blunt tool”’ (Torjeson, 2021).
Expanding on this, Douglass and Lokugamage (2021) wondered whether ‘racial profiling’ for induction of labour improved safety or perpetuated racism. Referring to a statement from the Royal College of Obstetricians and Gynaecologists that implied that ‘induction has no downsides’, Douglass and Lokugamage (2021) observe that the college had apparently failed to consider ‘the recent long-term adverse outcomes data for inductions of labour in uncomplicated pregnancies from Australia, or the increasing evidence that the risk of stillbirth is reduced by amplifying continuity of midwifery care models’.
There is clearly a debate to be had in relation to the midwifery care offered to women from ethnic minorities. In this context, it might be helpful to consider what anthropologist Ruth Benedict noted in the foreword to her book, Race and Racism (1959); ‘to recognise race does not mean to recognise racism. Race is a matter for careful scientific study; racism is an unproved assumption of the biological and perpetual superiority of one human group over another’.
However, it is diffi cult to have a constructive debate about this topic at a time when the midwifery profession is facing challenges on many fronts, which may detract from a singular focus on the question of ethnicity and good midwifery practice. For example, when Glenister et al (2020) evaluated all 122 UK maternity services with midwifery units, they found that ‘92% of local admission guidelines varied from national guidance’ and ‘76% contained both some admission criteria that were “more inclusive” and some that were “more restrictive” than national guidance’. The authors speculated that some of the ‘more restrictive’ admission criteria they identified may ‘disproportionately affect women from religious and ethnic minorities, and those of lower socio-economic status’ (Glenister et al, 2020).
Although Benedict (1959) pointed out that ‘the culture of any one race is of many degrees of complexity’, that should not prevent helpful discussion of ethnicity and socioeconomic conditions in relation to midwifery practice.