Most research on midwife-led care and birthplace choice takes women already classified as ‘low risk’ as a starting point. Despite the well-documented benefits of midwife-led care (Brocklehurst et al, 2011; National Institute for Health and Care Excellence (NICE), 2017; Cohen et al, 2018; Scarf et al, 2018; Hutton et al, 2019), increasing numbers of women are classified as high risk, and consequently are put on an obstetric-led care pathway, especially in labour and birth. However, the mechanisms of the classification into low and high risk merit scrutiny, as data suggest this disproportionally affects Black and brown women and leads to higher rates of intervention in that population (Weisband et al, 2018; Webster and NMPA Project Team, 2021; Melamed et al, 2022). This article will explore the mechanisms for this, including the use of the white body as the ‘norm’, leading to both under- and over-diagnosis, social determinants of health, misuse of race-based risk algorithms, and falsely locating the cause of poorer outcomes in physiology rather than in social determinants.
The question of risk, pathology and ethnicity must be careful to neither pathologise normality, nor to normalise pathology. The arbitrator of the line between the normal and the pathological is itself a political issue and varies over time, by country and even by maternity care provider. Discussing the context in the USA, Niles et al (2021) emphasised the problem of the medico-legal regulatory environment's authority to define low and high risk, and therefore to place midwifery care within certain boundaries and terms, reifying itself as arbitrator. The risk discourse then clashes with the midwifery drive to humanise and individualise care, as evidenced in the UK in research into the tension between hospital guidelines and women's choice (Downe et al, 2019; Feeley et al, 2020; Larner and Hooks, 2020).
Note on terminology
In this article, the author uses the term ‘ethnicity’ to refer to a person's background, community and identity. The term ‘race’ is also used, as it has been included in some healthcare assessments, but it is important to note that this term can be problematic, as it has implications of (unfounded) genetic difference, leading to the idea of some races being ‘other’.
Defining the ‘norm’
The Caucasian (male) body as the norm has long been noted by Black feminists (Hull et al, 1982; Crenshaw, 1988; 1991; Gishen and Lokugamage, 2019), and even the human genome project is replicating this global bias (Cox, 2023). This lack of representation of racial differences in medical care and research can lead to underdiagnosis, such as not recognising jaundice in Black neonates (Fair et al, 2023) or false readings on pulse oximeters (Jamali et al, 2022). Similarly, the APGAR neonatal score has been reported as not fit for purpose, as it was designed for White babies (Fair et al, 2023). Recent strides have been made to rectify the issue of lacking representation, such as the ‘Mind the Gap’ project (Mukwende et al, 2020).
Racism in the form of microaggressions, caregiver bias and discrimination impact both health needs and under- or overdiagnosis in complex ways. For example, in maternity care, there is a tragic litany of underdiagnosis as a result of racialised women not being listened to or taken seriously (Peter and Wheeler, 2022), women losing trust in care providers (MacLellan et al, 2022) or Black women being at greater risk of being diagnosed with severe mental illness than White women (Nazroo et al, 2020).
Additionally, the ‘norm’ as the standard for classification as low risk may inadvertently discriminate against the ‘other’. For example, normal, or common, body mass index levels for childbearing women vary by ethnicity (Kinnunen et al, 2019). If the norm for Caucasian males is the standard for defining ‘low risk’, there will be Black women who fall outside this category. This may categorise Black or brown women as ‘high risk’ or ‘outside of normal range’ at a disproportionate rate. Orthodox Jewish women in the UK have on average over six children (Rocker, 2018), meaning the guidelines informed by NICE (2023) that categorise ‘grant multiparity (parity 4 or more)’ as a risk factor would classify many of their births as ‘high risk’. This may unfairly discriminate against them, if in fact their outcomes are not significantly worse for their fourth and subsequent pregnancies (Rocker, 2018). Where more detailed research has been done into ethnicity as a risk factor for type 2 diabetes, ethnic specific calculations and different cut-off points were recommended, challenging the idea of one standard measure (Caleyachetty et al, 2021).
However, what is common is not necessarily non-pathological. For example, regarding body mass index, it may be the case that a disproportionate rate of women from any specified ethnic group maybe be over- or underweight, as defined by what is healthy for them. Normal but unhealthily high body mass indexes in children have been reported in the USA (Thornton, 2019). Low haemoglobin levels have been found among some women who suffer long-term poverty, exacerbated by gender inequality (Thakur et al, 2014). Similarly, there are caesarean section rates of over 40% in some areas (NHS England, 2024), which are increasingly common but not necessarily desirable or healthy. In the USA, the use of a race-based algorithm for diagnosis of kidney disease may have led to late diagnosis in members of the Black population, leading to worse long-term outcomes or even higher morbidity rates (Taber et al, 2016; Hernandez-Boussard et al, 2023).
Social determinants of health
The long-term impact of the social and economic inequalities that disproportionately affect Black and brown communities undoubtedly cause higher rates of medical, social and obstetric risk factors (Draper et al, 2022; The King's Fund, 2023). Combined with the well-documented racism and racial bias of care givers, there are resulting higher rates of pathophysiology (Bambra et al, 2020; Hackett et al, 2020; Taylor, 2020; Fernandez Turienzo et al, 2021).
Given the existence of generational structural racism, there is often difficulty separating the causes of any observed medical differences; whether they are caused by innate physiological difference or by social determinants both in daily life and medical care. For example, a Black woman screened for gestational diabetes based on ethnicity and found positive, may be offered and accepted an induction of labour, which can lead to an emergency caesarean section and subsequent breastfeeding difficulties and a urinary tract infection. This case may have many complex factors relating to an interplay of social and physiological determinants, as well as caregiver bias. The work by March of Dimes on pre-term birth and racial disparity in the USA is an impressive attempt to map and analyse upstream and downstream factors of social determinants of health and racism (Braveman et al, 2021).
Confusing poor outcomes with pathology of the black body
Where outcomes are demarcated by ethnicity, it is usually social determinants, not physiology, that make the difference. Medical anthropologists Gravlee and Sweet (2008) claimed that using race and ethnicity in biomedicine lacks a rationale, obfuscates social determinants and ‘reinforces the insidious assumption that racial inequalities stem from innate, immutable differences between racially defined groups’. The point is not to emphasise race, but rather racism, with its long- and short-term effects. In their examination of advice regarding the choice for vaginal birth after caesarean section in the USA, Kane et al (2022) argued for removing race-based algorithm risk assessments. The authors advocated for full discussions of values and preferences, including the ‘context of the effects of structural racism on their bodies, environments, and hospital care’ (Kane et al, 2022).
Extrapolating beyond evidenced physiological differences risks seeing ethnicity or race as a risk factor in itself. It is possible to attribute genetics to melatonin levels in skin, or possibly the genetic propensity for South Asian women to develop gestational diabetes (Lamri et al, 2022). But beyond any direct physiological causality, it is important not to confuse poor outcomes with inherent risk, and thereby fall into the trap of pathologising Black- or brown-ness itself. The example of the NICE (2021) suggesting that all Black women be offered induction of labour at 38 weeks because race was seen as a risk factor itself was a stark example of this pathologisation (Stubley, 2021). This view risks looking at race and poor outcomes from the wrong end of the telescope and seeing being Black as the cause, rather than racism as the cause via social determinants such as poverty, weathering or caregiver racism and bias.
Erroneous use of race risk algorithms
Trying to use ethnicity to calculate ‘risk’ depends on whether there are significant biological differences or specific physical attributes that are common in some ethnic groups, and vary more from group to group than within the group. Despite discussions around differences in pelvic shape (Handa et al, 2008), propensity for perennial trauma (Wheeler et al, 2012) or effectiveness of different blood pressure medication (Greene et al, 2022), as examples, there is no conclusive evidence of race or ethnicity as a significant factor. Tong and Artiga (2021) stated that ‘the use of race to inform clinical diagnoses and decision making may reinforce disproven notions of race as a biological construct and contribute to ongoing racial disparities in health and health care’.
Kane et al (2022) made a strong case that routine use of race in a risk calculator for vaginal birth after caesarean section in the USA leads to iatrogenic harm and undermines both the woman and her relationship with her healthcare providers. As a result of race raising the risk factor in this calculator, more Black women had a caesarean birth, with associated higher rates of maternal morbidity. Kane et al (2022) concluded that regardless of whether race-as-a-risk-factor is a claim about physiology or an acknowledgement of the social determinants of health, the resultant higher scores for ‘risk’, ie the pathologisation, led to more interventions and iatrogenic harm.
Reducing pathologisation and promoting relationality in practice
There is a need to move away from both pathologisation (avoiding too much, too soon) and doing too little too late because of underdiagnosis from either faulty measurements or disregard for some women's voices. The author contests that it might be possible to achieve more egalitarian, women-centred care by acknowledging the benefits of midwifery-led care for women with intermediate risk factors, confronting racism and the social determinants of health, and promoting community-based women-centred midwifery practice.
Intermediate risk factors
As a result of both increased acuity rates and screening, there has been an increase in interventions for ‘intermediate’ risk factors, where the relative benefits and risk of intervention are not clear cut; for example, induction of labour for a large estimated fetal weight (Warwick Clinical Trials Unit, 2023) or advanced maternal age (Royal College of Obstetricians and Gynaecologists, 2013).
For Black and brown women with physiology outside of the ‘norm’, access to midwife-led care can still be facilitated and likely beneficial (Niles et al, 2021), regardless of the exact cause or origin of the condition (social or physiological). Reducing the emphasis on automatically promoting an obstetric pathway for all women with intermediate risk factors may lead to improved outcomes. Secondary analysis from the Birthplace study (Brocklehurst et al, 2011) showed that women with intermediate risk factors had better maternal outcomes if women had home births, compared to birthing in an obstetric unit. These two groups of women had comparative neonatal outcomes, although these outcomes were worse than for women with no risk factors where other variables were similar (Li et al, 2015; Rowe et al, 2016). The low number of women with intermediate risk factors using midwife-led units meant that there were insufficient data to analyse outcomes.
In a freestanding midwifery unit with a robust but accessible process for women with intermediate risk factors, using the service showed excellent results (Gutteridge, 2015). Women with a body mass index over 35, women having a vaginal birth after caesarean section and women with twins or diabetes all showed excellent outcomes and high maternal satisfaction (Gutteridge, 2015). This midwifery unit served an area with a large south Asian population. Many of the women had haemoglobin levels below the set minimum level of 105g/L, although it is unclear whether this was related to normal physiology for that ethnicity or to the documented levels of poverty and sex inequality within those communities leading to women being malnourished. The author carried out a private interview with the lead midwife for the freestanding birth centre in 2022, to discuss a 1-year trial carried out to lower the minimum haemoglobin level to access the unit from 105g/L to 90g/L. According to the lead midwife, there was no increase in women needing postnatal blood transfusions, leading to a permanent lower threshold.
Acknowledging racism, not race
Looking at midwifery care for Black and brown women, acknowledgement of the structural factors must not be demoralising, but rather a galvanising force for change. MacLellan et al (2022) highlighted that when commissioners and care providers feel the cognitive dissidence of knowing that they are offering a rushed and substandard service, ‘othering’ can help them cope; ‘this “othering” creates and sustains inequalities, such that unequal health outcomes are understood simply as a reflection of wider structural conditions, in the context of resource constraints, and easily accepted as the norm’ (MacLellan et al, 2022). However, the challenge is to work on a multi-agency level, in an overtly anti-racist way, engaging with government, non-governmental and community organisations to address issue of inequality and social justice.
Relationality in the midwifery model of care
Where Kane et al (2022) and Hernandez-Boussard et al (2023) recognised that individualised care would be an improvement to race-based risk algorithms, within the midwifery model of care a deeper level of relationality is possible. Community-based midwifery practice with an emphasis on relationality may offer a counterbalance to pathologisation. This allows for midwifery to be a restorative force, engaging with pluralistic, heuristic knowledge, community power and webs of social care and support. ‘Being “with woman,”…cannot be a prescription and obtains meaning only when organically arising from a reciprocally meaningful relationship’ according to Rocca-Ihenacho et al (2021).
The NHS offers high-quality care, free at the point of use, which is undoubtedly a crucial element of equal care for all. However, as part of the medico-industrial model, it is also influenced by its historical place in patriarchal medicine, colonial and imperialist history, and ongoing structural inequalities and racism (Bambra et al, 2020; Hackett et al, 2020; Taylor, 2020; Fernandez Turienzo et al, 2021). The idea of racial categorisation stems from a racist colonial ideology (Roberts, 2011). This plays a role in the negative experience of many Black and brown women being cared for in obstetric-dominated mainstream settings (Birthrights, 2022; Gohir, 2022; Peter and Wheeler, 2022). Despite midwifery's claim to being a woman-centred profession, Black and brown women's experiences reveal there being, at times, only lip-service to a genuine women-centred midwifery model of care (MacLellan et al, 2022). A Black pregnant or birthing woman is the canary in the coalmine that reveals the flaws in the system; a genuine women-centred model would meet each woman where she is, not only those with enough social capital to navigate the system.
Acknowledging the inherently social and cultural nature of birth, there is a disconnect in basing births in large hospitals, with their medico-industrial culture and racial historical and ideological specificities, rather than in the grassroots community health provision of their origin (Davis-Floyd and Cheyney, 2019; Niles et al, 2021; Ashley et al, 2022). Midwifery care rooted in communities, both geographically and culturally, may increase access to midwifery care across the board, bridging the gap between the NHS behemoth and the women it is trying to serve. This would allow for a genuine women-centred midwifery model of care, which is difficult to achieve within the confines of the dominant medical model. To recentre midwifery in the communities of women, creating a midwifery service arising out of, and being an integral part of, the communities' birth culture and social meaning of birth (Davis-Floyd and Cheyney, 2019) could be a powerful force. At best, it would have the potential to redress the history of intersectional oppression of sex, race and class still impacting NHS midwifery. For women suffering from ‘weathering’ (Dominguez, 2008) and alienated from healthcare systems as a result of racism, genuine, reciprocal, relational care can be a restorative force.
In the previous example, where the author interviewed the lead midwife of an NHS freestanding midwifery unit developed in an area with a high rate of south Asian women, the midwifery team carried out weekly outreach visits for 6 months before inviting those women to the trust premises to outline and discuss plans for the new unit. In developing the space, they emphasised the importance of a joint area for families and staff and the importance of ‘breaking bread’ together (Gutteridge, 2011; 2013), elements that were also emphasised by Rocca-Ihenacho et al (2021) when reviewing a freestanding midwifery unit.
Conclusions
It takes a village to raise a child, and so it takes a village to integrate a women-centred relational midwifery service. And it is in those midwifery relationships within and as part of communities of Black and brown women that we could begin to find the balance between intervening and improving the health of those who need it, and promoting physiology in those who do not.
Key points
- Many Black and brown women are classified as ‘high risk’ and follow obstetric-led pathways.
- This may be the result of social determinants of health, or over-pathologisation.
- There may be times when social determinants are mistaken for innate physiological differences, leading to iatrogenic harm.
- There is both over and underdiagnosis resulting from racial bias in midwifery care.
- Community-based, relational, women-centred midwifery models of care can reduce the problems of pathologisation and redress some social inequalities.