The United Nations' (2016) sustainable development goal 3.1 is ‘to reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030’. In line with this, the UK committed to a goal of reducing maternal deaths in England by 50% by 2025 (Department of Health and Social Care, 2017). The UK has reported progress in achieving this goal, as the maternal mortality ratio has decreased from 13.95 per 100 000 live births in 2003–2005 to 8.79 women per 100 000 live births in 2017–2019 (Knight et al, 2021a). However, in 2020–2022, the maternal mortality ratio significantly increased to 11.54 per 100 000 live births, even after deaths from COVID-19 were excluded (Rimmer, 2024).
For Black women in the UK, there has been an increase in the maternal mortality ratio, and in 2009–2022, the difference between Black and White women continued to widen (MBRRACE-UK, 2024). In 2020–2022, Black women were almost three times more likely to die during pregnancy (or up to 6 weeks after birth), compared to White women (relative risk: 2.87) (MBRRACE-UK, 2024). This was a statistically insignificant decrease in the rate reported in 2019–2021 (P=0.728) that Black women were four times more likely to die during pregnancy (Knight et al, 2019). Compared to White women, Black women are also more likely to experience severe maternal morbidities, such as hypertensive disorders in pregnancy, like eclampsia, with African women having a relative risk of 1.83 and Caribbean women 1.80 (Nair et al, 2014; Knight et al, 2016).
Complex and interconnected factors, such as lifestyle behaviours, social determinants of health, pre-existing morbidities, access to maternity services, racism and unconscious bias in maternity services, are thought to fuel disparities in pregnancy outcomes among Black women (Garcia et al, 2015; Souza et al, 2024). This article reviews and discusses some of the factors that have been found to contribute to maternal health inequalities for Black women, while considering the implications for practice.
Socioeconomic and demographic factors
Maternal health is a social issue known to be affected by a range of demographic and socioeconomic factors (Souza et al, 2024). Factors such as age, socioeconomic status, ethnicity and marital status are non-biomedical but greatly impact maternal health risk and outcomes before, during and after pregnancy (Hatch et al, 2011; Souza et al, 2024).
Maternal age and socioeconomic status are known independent risk factors for severe maternal morbidity and mortality (Knight et al, 2009). The average maternal age in the UK has been steadily increasing, from 27.7 years in 1990 to 30.9 years in 2022 (Office for National Statistics, 2024a). Although conceiving in older age is increasingly common, it is associated with a higher risk of maternal morbidity and mortality (Knight et al, 2009; 2020; Vousden et al, 2024). A major reason for this is that women >35 years are more likely to have pre-existing medical comorbidities and may have experienced previous pregnancy complications. This can increase the physiological burden to cope with the demands of pregnancy, leading to severe morbidity and sometimes death as a result of thrombosis or thromboembolism (McCall et al, 2017). National and international studies have found that women aged ≥35 years had increased odds of progressing from severe maternal morbidity to mortality when compared to women under 30 years old (Kayem et al, 2011; Diguisto et al, 2022).
In most UK studies (Jardine et al, 2021; Vousden et al, 2024), socioeconomic status is determined using the index of multiple deprivation, which measures income, employment, health, education, crime, housing and living environment (Ministry of Housing, Communities and Local Government, 2019). A study on the impact of socioeconomic status on inequalities in birth outcomes, found that the risk of stillbirth, preterm birth and fetal growth restriction increased with increasing socioeconomic deprivation (P<0.001) (Jardine et al, 2021). However, the population attributable fractions (the percentage that a specific risk factor contributes to the burden of a disease in a population) for socioeconomic deprivation for stillbirth (23.6%), preterm birth (18.5%) and fetal growth restriction (31.1%) reduced significantly after adjusting for ethnicity, body mass index, age, parity and pre-existing medical conditions (Jardine et al, 2021).
Adjusting for other risk factors, including deprivation, had a minimal effect on the impact of ethnicity on increased risk of stillbirth (from 11.7% to 12.6%), preterm birth (remained at 1.2%) and fetal growth restriction (from 16.9% to 19.5%). Confirming these findings, Black women consistently had the highest rates of stillbirths, regardless of their deprivation quintile (Jardine et al, 2021). This concurs with recent UK reports of babies born to Black women consistently having the highest rates of stillbirth each year, with a rate of 6.5 per 1000 births compared to 3.5 per 1000 births for White women (Office for National Statistics, 2024a). Vousden et al (2024) investigated the contribution of factors such as age and social deprivation to ethnic disparities in maternal mortality in the UK. They reported that Black women were still 2.43 times more likely to die compared to White women, with Black Caribbean women having the greatest risk (adjusted odds ratio 3.55). These reports suggest that although socioeconomic deprivation and age contribute majorly to the risk of adverse birth outcomes, they do not explain a large portion of the inequalities reported for Black women. There are elements beyond these that contribute to the high mortality rates for Black women, which need to be investigated.
Access to antenatal care
Inadequate access to antenatal care is another factor associated with increased risk of maternal death, particularly for ethnic minority groups (Nair et al, 2014; 2015). The National Institute for Health and Care Excellence (2021a) recommend that all women should book for antenatal care at ≤10 weeks, with no antenatal visits missed. Minimum level of care is defined as booking at <13 weeks with three or fewer visits missed.
Nair et al (2015) found that women who died were 15 times more likely to use antenatal care inadequately (concealing pregnancy, late booking, not receiving minimal level care), compared to those who survived (adjusted odds ratio: 15.87). The population attributable fraction for poor use of antenatal care in maternal death was 10.5%, meaning that if poor use of antenatal care was completely addressed, maternal mortality would reduce by 10.5% (Nair et al, 2015). Knight et al (2016) reported that women who did not use antenatal care adequately had a two-fold higher risk of severe morbidity, compared to women who did (adjusted odds ratio: 1.97). Black women were four times more likely to have poor use of antenatal care compared to White women, with African and Caribbean women having odds ratios of 4.46 and 4.35, respectively (Knight et al, 2016). Furthermore, of the women who died in 2020–2022, 42% did not receive the recommended antenatal care and 70% received the minimum level of care (Felker et al, 2024).
The increased risk that late booking and inadequate antenatal care contribute to the maternal mortality ratio may be because women do not receive advice and services that are important for early pregnancy, such as folic acid supplementation and other nutritional and physical activity advice, abstinence from alcohol and smoking cessation (Cresswell et al, 2013). Screening tests and health assessments to identify risk factors for adverse outcomes and pregnancy anomalies early on may be missed (Hatherall et al, 2016).
Several factors are associated with inadequate use of antenatal care, including (Rowe et al, 2008; Cresswell et al, 2013; Puthussery et al, 2022):
Need for interpreters
An investigation into engagement with maternity services between 2015 and 2017 found that none of the non-White ethnic women in need of interpreters received this service throughout their maternity care, with just over half (57.1%) ever accessing interpreters during antenatal care (Cosstick et al, 2022). Furthermore, women who could not speak/understand English preferred to use trusted family members or friends as interpreters because they did not trust the quality and confidentiality of the interpretation provided by maternity services and were not given a choice of who the interpreter should be (Rayment-Jones et al, 2021).
It is important to note that using family members and friends as interpreters has its own risks. Family/friends may have limited knowledge of medical terminology that can compromise the complete transfer of information to women. Family members may also find it uncomfortable, inappropriate or emotionally difficult to convey sensitive or negative news about women's health. This can blur the objectivity of interpretation and the quality of care that women receive as a result (Hadziabdic et al, 2014; Rayment-Jones et al, 2021).
Late booking
Puthussery et al (2022) found that Black African women were three times more likely to initiate antenatal care late (booking appointment >12 weeks) than White British women (adjusted odds ratio: 3.37). Black African women were also four times more likely to start antenatal care extremely late (≥20 weeks) compared to White women (adjusted relative risk: 4.03) (Puthussery et al, 2022). Black women, particularly Somali and other African women, were also more likely to book late for antenatal care (>12 weeks) compared to White British women (adjusted odds ratio: 1.58) (Cresswell et al, 2013). When women were grouped according to place of birth and English language ability, of those born in the UK and who could speak English, only African and Caribbean women had an increased risk of booking late when matched to White British women (odds ratio: 1.40) (Cresswell et al, 2013). This highlights that there may be factors outside language barriers and non-UK nationality that deter Black women from seeking antenatal care early.
Somali women reported being wary of artificial labour induction, so they provided incorrect dates for their last menstrual period to avoid this (Hatherall et al, 2016). Somewhat confirming these fears, a National Institute for Health and Care Excellence (2021b) draft recommendation (later revoked) proposed inducing women from ethnic minority groups from 39 weeks' gestation, as opposed to the 41 weeks recommended for White women (Torjesen, 2021).
Cultural influences
Some Black women may be unfamiliar with the healthcare system, and a lack of cultural sensitivity and competency in health services is often a major reason for Black women's poor access to antenatal care (Esegbona-Adeigbe, 2018). A literature review found that many studies have reported that Black women's expectations of maternity care are shaped by cultural norms and beliefs (Esegbona-Adeigbe, 2018). Garcia et al (2015) noted that there was a dearth of maternity interventions tailored to address the cultural needs of ethnic minority women. Jones et al (2017) explored the experiences and perspective of stakeholders involved in culturally appropriate maternity interventions in various countries, including two dated studies from the UK. Changes such as respecting women's languages, relatives and cultural preferences and community involvement, fostered trust, feelings of respect and being understood, which encouraged uptake of antenatal care (Jones et al, 2017; Chinouya et al, 2019). It is important that the maternity care offered to Black women is respectful of their choices and decisions and sensitive to their cultural needs, so that trust can be built between healthcare professionals, the system and women, ultimately improving antenatal care uptake among Black women.
Lifestyle factors
Lifestyle factors, such as maternal nutrition, physical activity, smoking, substance use and alcohol consumption, can impact maternal health outcomes (Nair et al, 2015; Souza et al, 2024).
Smoking
Smoking in pregnancy increases the risk of spontaneous miscarriage, placenta previa, ectopic pregnancy, sudden infant death syndrome, low birth weight, stillbirth, asthma and obesity in infants, and severe maternal morbidity and mortality (Nair et al, 2015; Pineles et al, 2016; Avşar et al, 2021; Vousden et al, 2024). In the UK, smoking is less prevalent among ethnic minority groups, particularly Black adults (4.7%) compared to White (13.2%) and mixed ethnicities (17%) (Office for National Statistics, 2024b). Cosstick et al (2022) also found that ethnic minority women (5.8%) smoked less than White women (48.3%) during pregnancy.
Although overall, unhealthy behaviours such as smoking and substance abuse are less prevalent among ethnic minority groups compared to the White majority, acculturation and social deprivation have been shown to influence maternal health behaviours, increasing the likelihood of women engaging in negative behaviours during pregnancy (Hawkins et al, 2008; Pinho-Gomes and Mullins, 2023). It is important that healthcare professionals do not overlook the possibility of Black women having these behaviours and that positive health behaviours are promoted among these women.
Nutrition
Maternal nutrition is another crucial contributing factor to the risk of adverse pregnancy outcomes for both mother and fetus. High intakes of fruits, vegetables, oily fish, eggs and plant-based whole foods are associated with a reduced risk of pre-eclampsia, preterm birth and small for gestational age, compared to high consumption of processed meats, sugary drinks and salty snacks (Hillesund et al, 2014; Cetin and Laoreti, 2015). Higher calcium intake also reduces the risk of hypertensive disorders of pregnancy (Schoenaker et al, 2014).
Reports on dietary patterns among ethnic minorities are conflicting, likely because of the aggregation of various ethnic groups with different cultures and varying levels of acculturation. Studies on dietary intakes among Black pregnant women in the UK are lacking; however, the UK pregnancies better eating and activity trial reported that Black pregnant women who were living with obesity had an ‘African/Caribbean’ dietary pattern characterised by high portions of rice, cassava, red and white meat, fish and plantain (Flynn et al, 2016). This was associated with a significantly increased risk for gestational diabetes mellitus. More research is needed on the dietary habits of Black pregnant women and any associations that may heighten their risk of adverse pregnancy outcomes, in order to inform the development of tailored dietary advice for Black women during pregnancy.
Multiple disadvantage
Lifestyle patterns are influenced by social determinants of health, such as social deprivation and low income (Souza et al, 2024). Living in the most deprived areas and/or having low-income can influence factors such as access to nutritious food and purchasing power, which are primary predictors of food choices, often resulting in poor nutrition and unhealthy behaviours (Whybrow et al, 2018; Stone et al, 2024). These negative behaviours can inadvertently increase the risk of pre-existing morbidities and dual burden malnutrition (undernutrition and obesity), which are risk factors linked to adverse pregnancy outcomes for mother and baby. Black women are reported to have higher rates of these morbidities compared to other ethnicities (Kayem et al, 2011; Nair et al, 2014; 2015; Cetin et al, 2015; Godfrey et al, 2017; Public Health England, 2019; Langley-Evans et al, 2022).
The risk of maternal morbidity and mortality increases with an increase in the number of risk factors a woman is exposed to. For example, an older pregnant woman living in a deprived area who has pre-existing medical problems, smokes and does not receive optimal antenatal care has a higher risk of death compared to a woman who has one or two of these risk factors (McCall et al, 2017). Being from a Black ethnic group further compounds multiple disadvantage, as Asian and Black people are more likely to have lower incomes and live in the most deprived 10% of neighbourhoods, compared to the White majority (Jivraj and Khan, 2013; Ministry of Housing, Communities and Local Government, 2020; Institute of Race Relations, 2024). Black women are also at a higher risk of morbidity and mortality compared to White women, regardless of their social or economic status (Jardine et al, 2021; Cosstick et al, 2022; Vousden et al, 2024).
Racial discrimination and bias
Although the impact of socioeconomic inequalities on the health of minority groups is established, investigations into the inequalities that Black women face have found that social disadvantage alone does not account for the stark differences in pregnancy outcomes between UK Black and White women (Vousden et al, 2024). In 2021, the Commission on Race and Ethnic Disparities (2021) released a highly controversial report attributing the higher risk for adverse outcomes among minority ethnic groups to sociodemographic factors and existing comorbidities. The report concluded that racism and discrimination were not widespread in the UK health system. However, it is argued that the fact that these sociodemographic factors are distributed according to ethnicity is a manifestation of institutional racism (Williams et al, 2019; Anekwe, 2020).
A UK national study investigating ethnic disparities in maternal mortality found that the causes of maternal death between different ethnic groups in the UK are the same, with cardiovascular disease as the leading cause of death in all groups between 2009 and 2018 (Knight et al, 2021b). Knight et al (2021b) found that the reason why the risk of death was significantly higher for Black women was that there were multiple areas of bias in the care received by most women that died between 2009 and 2018. The lack of structures to deal with multiple complex circumstances was a common bias for all ethnic groups, a manifestation of institutional bias. For Black women, among other biases such as microaggressions, they mostly experienced a lack of individualised care, which was defined as ‘when a woman was not properly treated because her needs for individualised care was not recognised (deliberate or unintentional)’ (Knight et al, 2021b).
Other studies have captured the voices of Black and other ethnic minority women who experienced near-misses, birth complications or baby loss because of the care they received (Birthrights, 2022; Peter and Wheeler, 2022). In the largest study into maternity experiences of Black women that took place in 2021, 1340 women shared their experiences of UK maternal care in the past 5 years; the negative experiences reported far outweighed the positive ones (Peter and Wheeler 2022). These negatives experiences were centred around:
There is a history of dehumanisation of Black women in the medical field, which may be the root cause of the mistrust that Black women have of healthcare. J Marion Sims conducted violent experimentation on enslaved Black women to standardise the vesicovaginal fistula procedure; this was conducted without anaesthesia, although it was available at the time (Wall, 2006; Nuriddin et al, 2020).
Future steps
Socioeconomic status and other demographic factors do not explain why Black women in the UK are at a higher risk of death during pregnancy and postpartum. Racism should be recognised as a fundamental adverse determinant of health and a huge contributor to UK maternal health inequalities. Many differences in socioeconomic status are driven by institutional racism, and further research is needed to understand the extent to which discrimination and unconscious bias during pregnancy, labour and postpartum impact the maternal outcomes in the UK.
The mistrust that Black women have reported regarding maternity services stems from historical dehumanisation, abuse and discrimination. This historical trauma is exacerbated by negative experiences of dismissal and disrespect during maternity care. It is imperative to provide healthcare professionals with accurate information on the anatomy of Black women. Healthcare professionals must be made aware of biases and stereotypes of Black women that they may hold, often instilled from cultural racism in wider society.
Although healthcare professionals are required to undertake regular equality, diversity and inclusion training, this is often ‘tick box’ (Ford et al, 2025). To drive change, this training needs to do more to identify and challenge unconscious bias and stereotypes in healthcare. We cannot not deny that there is racism in the system, because whether we define racism as institutional, unconscious, conscious, implicit or explicit, the impact that it has on the pregnancy outcomes of Black women and their babies remains the same.
Conclusions
Negative experiences of maternity services, including discrimination and bias, during pregnancy informs minority ethnic women's decisions and behaviours for subsequent pregnancies, fostering fear and mistrust, causing women to be less likely to book early for antenatal care or report concerns in time, thereby increasing their risk of adverse outcomes and that of their children. Black women need to be listened to and treated with respect during their maternity care. Their concerns must not be ignored or downplayed. This is one crucial way that the inequalities attributed to racism can be addressed.