The experiences of black, Asian and minority ethnic student midwives at a UK university

The ‘closing the gap’ report highlighted that ‘42% of [black, Asian and minority ethnic] students did not feel that the curriculum reflected issues of diversity, equality and discrimination reporting a lack of [black, Asian and minority ethnic] specific content as a mainstream way of thinking’ (Universities UK and National Union of Students, 2019). The report highlighted that black, Asian and minority ethnic students continue to be 13% less likely to be awarded a first- or upper-second class degree than white students (Universities UK and National Union of Students, 2019). A quarter of black, Asian and minority ethnic staff working in UK universities reported that they had experienced racism and one in 20 black, Asian and minority ethnic students cited racial harassment as the reason for leaving their studies (Equality and Human Rights Commission, 2019).

Of the 1.3 million people employed within the NHS, less than a quarter of staff (22.1%) are from black, Asian and minority ethnicities (NHS Digital, 2020). Workforce race equality standards capture key performance indicators for equality, diversity and inclusion and a recent comparison of data over the past 5 years shows limited progress in the NHS's ambitions to drive down systemic inequalities between white and black, Asian and minority ethnic staff (Issar, 2021). Against some indicators, the situation for black, Asian and minority ethnic staff has even seen a deterioration, highlighting the fact that inequalities persist (Pendleton, 2017; Ross et al, 2020) and in some cases are widening.

Student midwives in the UK are required to undertake an educational programme of study delivered equally across two organisational structures: a higher education institution and the NHS (Nursing and Midwifery Council (NMC), 2019a). It is against this established backdrop of inequality in both organisations that additional challenges may present for black, Asian and minority ethnic student midwives.

Background

Recent data show that while the overwhelming majority of undergraduate students in higher education institutions were white, the biggest rate of entry increase for any ethnic group was for black school leavers, up from 21.6% of black applicants in 2006 to 47.5% in 2020 (Universities and Colleges Admissions Service, 2020), with candidates from Chinese ethnic groups having the highest entry rate for school leavers of 71.7% (Universities and Colleges Admissions Service, 2020). While this could be interpreted as evidence of an improving landscape within higher education for black, Asian and minority ethnic students, it is recognised this may be unevenly distributed across the sector. Greater numbers of black, Asian and minority ethnic students are admitted to post-1992 universities (Reay, 2018), which have clear strategies for widening participation and are traditional hosts for professionally regulated healthcare programmes. Continued disparities in black, Asian and minority ethnic student attainment suggest a need for research into the experiences of this student body, as studies remain sparse and located within the fields of medicine, allied health professions, physiotherapy and pharmacy (Seston et al, 2015; Claridge et al, 2018; Hammond et al, 2019; Morrison et al, 2019). Recommendations from the tackling racial harassment in higher education report (Universities UK, 2020) call for university leaders to ‘engage directly with students and staff with lived experience of racial harassment’, yet it is clear there are limited studies exploring this. Burnett (2021) refers to ‘anecdotal’ insights from student midwives across the UK reporting the failure of higher education institutions and the NHS to adequately respond to microaggressions and overt racism of other students. Other reflective pieces from student midwives also contribute to our understanding in this area (Hamza, 2021) but further empirical data is urgently required.

Workplace and organisational culture have been defined as based on shared ideas and social behaviours (Catling et al, 2017), which intersect with institutional leadership styles and priorities. Evidence suggests that both organisations—higher education institutions and the NHS—are actively engaged in trying to improve access, equity and inclusion for staff and service users but also highlights that inequalities persist (NHS England, 2017; AdvanceHE, 2021). Nursing and midwifery are seen as caring professions, adhering to the NHS constitution's values (Department of Health and Social Care, 2012) and the Code (NMC, 2018). This means some professionals may be unwilling to recognise themselves as perpetuating behaviours that disadvantage black, Asian and minority ethnic colleagues or students (Barbee, 1993). Evidence of underrepresentation in the registrant workforce can be found among black, Asian and minority ethnic midwives who constitute only 14.6% of the profession, well below the 41.6% in nursing (NHS Digital, 2020). This diminishes to only 10% of black, Asian and minority ethnic staff being employed in managerial positions (NHS Digital, 2020). This suggests that urgent action is required to meet the NHS long term plan target to ensure leadership in organisations is representative of the black, Asian and minority ethnic workforce by 2028 (NHS, 2019).

It is this complexity that provides additional challenges for student midwives from black, Asian and minority ethnic backgrounds. They are required to negotiate two systems with associated ingrained barriers to their success and progression, presenting the potential for ‘double disadvantage’. The first step to addressing this balance is to understand the experiences of these students undertaking undergraduate midwifery study in a UK university.

A note on terminology

Throughout this paper, the term ‘black, Asian and minority ethnic’ has been used. It is beyond the scope of this paper to fully discuss the problematic use of terminologies when discussing racism in the UK. However, the authors recognise the debates around the use of broad-based terminologies to identify groups of individuals to describe visible or ‘racialised difference’, which can be imposed on minorities by the white majority. This can be experienced as dehumanising, disempowering and reductive, ignoring multiple intersecting complex aspects of identity in favour of ‘unitary categories’ of homogenous groups (Howarth, 2009). These terminologies risk perpetuating and reproducing the concept of ‘race’ as something essential rather than socially produced. It has been argued that it ‘reproduces unequal power relations’ (Gabriel, 2021), privileging whiteness as the normative position against which all other people are measured. The term black, Asian and minority ethnicities has been mobilised to discuss all minority ethnicities, despite not having widespread recognition of its meaning nor its ability to include white minority groups, such as Gypsies, Roma and Travellers (Aspinall, 2021). It has also been argued that the concepts of race, ethnicity and associated categorisations are rooted in colonialism (DaCosta et al, 2021). Throughout the course of this research, the authors have begun to engage with these debates and moving forward will use this in their curriculum development and teaching.

The term black, Asian and minority ethnic was chosen in an attempt to be as inclusive as possible and because it has become a recognised shorthand for multiple ethnicities, most recently as a result of recognising the health inequalities and disadvantages experienced during the COVID-19 pandemic (Morales and Ali, 2021). It has been widely used in data collection and analysis to capture trends and has had some success in exposing problems that may have remained hidden without a broad collective terminology to capture them. It is in this spirit that the terminology was used in data collection. The authors recognise that all terminology around race and ethnicity is problematic and DaCosta et al (2021) has insightful discussion on alternatives to the term. The present study's methodology seeks to counter this trend by giving voice to the individual and in turn providing nuance to the phenomenon of racism as experienced by five student midwives.

Box 1.Interview questionsOpening questions

• Can you tell me about your decision to study midwifery?
• What were your hopes and fears about being a student midwife?

Key questions

• Think back to what you were doing before you became a midwife. What are the main differences between your attitudes and feelings then and now?
• Can you tell me about a time or an experience which made you feel positive about being a student midwife?
• Can you tell me about a time or an experience which made you feel negative or unhappy about being a student midwife?
• How do you think people in practice and at university see you?
• How do you see yourself as a student midwife who identifies as black, Asian or from a minority ethnicity?
• Do you think your experience as a student midwife who identifies as black, Asian or from a minority ethnicity is different to your peers?

Closing questions

• Is there anything you would like to add about your experiences of being a student midwife?
• Are there any questions that you were expecting me to ask you that I haven't asked?
• Is there anything that you would like to ask me?

Aims

This study aimed to explore the experiences of student midwives who identify as black, Asian or minority ethnic and are undertaking an undergraduate midwifery programme in a UK university.

Methods

A qualitative approach informed by Sandelowski (2004, 2010) was used to explore black, Asian and minority ethnic student midwives' experiences undertaking an undergraduate midwifery programme at a UK university. Braun and Clarke's (2006) thematic analysis framework was used to analyse the interview data and develop themes.

Sampling

A sample of five participants who identified as black, Asian or minority ethnic were recruited using purposive sampling. E-mails were sent by the student researcher, who also identified as black, Asian or minority ethnic, to all eligible students and the study was advertised via the university Blackboard site. Eight participants initially expressed interest but three did not confirm an interview date with the student researcher. One follow-up e-mail was sent to those who registered their interest initially, but if they did not reply to confirm their participation, no further action was taken. All five participants were studying an undergraduate midwifery programme at a university in the Midlands, UK.

Data collection

Semi-structured interviews were conducted online by the student researcher, who prepared by undertaking a research module. Study specific preparation included a formative pilot interview followed by a reflective session and ongoing supervisory guidance from the lead researcher prior to and throughout the interview timeline.

Five participants were interviewed between March 2021 and September 2021 lasting between 30 and 40 minutes. Interviews began with an open-ended question: ‘can you tell me about your decision to study midwifery?’ Key questions were followed by further prompts in view of participants' responses, such as: ‘can you elaborate on that?’ (Box 1).

Interviews were conducted by a student researcher, as the lecturer researchers had the potential to teach and assess the participants. All interviews were audio recorded and transcribed verbatim, then anonymised by the student interviewer prior to circulating to the wider research team. Anonymised transcripts were jointly analysed by all members of the research team. Data collection was completed once all five students who volunteered to participate in the study were interviewed.

Ethical considerations

Ethical approval was granted by the University Faculty Research Ethics Committee (ref: FHSRECHEA00222) as part of the Undergraduate Research Bursaries at Northampton University programme. Following contact with the student interviewer, participants were provided with a participant information sheet and any questions were addressed. Informed consent was sought, and consent forms were signed by participants.

Involvement in the study was voluntary and participants could withdraw from the study without repercussions. This was supported through recruitment and interviews being conducted by the student researcher, as students may have otherwise felt coerced to participate if lecturers had acted as interviewers. None of the five participants chose to withdraw their data. Anonymity and confidentiality were assured in the study's design. Data were anonymised by the student researcher following transcription and no identifiers were in the final transcripts used for data analysis. Access to the data was restricted to the research team. Electronic data were password protected, stored and managed in accordance with Data Protection Guidelines (Data Protection Act, 2018). Participants' rights were protected with mitigation against possible risks arising from their participation. Acknowledging this could be a sensitive area of discussion, the centralised university counselling and mental health support services operate on a self-refer basis and were available to participants if needed.

Data analysis

Data were thematically analysed using Braun and Clarke's (2006) framework. Initially, the three researchers independently read the interview transcripts several times to ensure immersion in the data and create initial codes. Following individual review, initial codes were jointly developed leading to identification of the initial themes. These were reviewed and refined to create the final key themes and sub-themes.

All members of the research team examined the interviews, applying Guba and Lincoln's (1989) framework for assessing credibility, dependability, transferability and confirmability. A key element of the peer participatory approach to data collection in the study supported the student researcher in thematic analysis both independently of and collaboratively with the lecturer researchers as a form of triangulation and to support data transferability (Polit and Beck, 2022).

Results

The three themes constructed from data analysis were ‘invisibility’, ‘emerging visibility’ and ‘managing visibility’. Invisibility identified a Eurocentric midwifery curriculum and a lack of black, Asian and minority ethnic representation both within the classroom and in clinical placement. Emerging visibility describes their observations of racist attitudes and practices and managing visibility discusses how participants modify their behaviour in the light of these experiences.

Theme: invisibility

Invisibility describes participants' experiences of ‘invisibility’ and ‘othering’ within the midwifery curriculum, placement settings and classroom. This manifested primarily through being viewed as a minority in the classroom among peers, coupled with a lack of black, Asian and minority ethnic representation in teaching and learning materials and within the academic teaching team.

Sub-theme: a Eurocentric curriculum

Participants articulated their experiences of a Eurocentric-based midwifery curriculum at university where ‘white’ was prioritised/dominant. One participant recognised that Eurocentric ideologies of knowledge and understanding are used to write texts and literature. It is these resources that in turn informed healthcare programme development, design and delivery. Acknowledging the systemic nature of the Eurocentric lens through which teaching was developed and delivered was an experience shared by all the participants.

‘At university a lot of learning is all based on white people, how to see a [deep vein thrombosis] on white ladies…it's all for people that are not dark skinned, but only black or people from different backgrounds would notice this, others wouldn't because they don't need to think about it.’

(Participant 4)

‘Yes exactly, it should be taught. I shouldn't have to reply on my experience, I should be taught with text and materials that tells me exactly how it is.’

(Participant 1)

Participants reported that this was perpetuated in their clinical placements.

‘I have been [on placement] in the community before and had comments from midwives saying that they were not sure and not confident on how to tell a black baby had jaundice and that they hadn't seen it before.’

(Participant 4).

In particular, the participants recognised the importance of observing skin colour as an indicator of health and wellbeing and in consideration of the need to reduce health inequalities for women, birthing people and newborns from black, Asian and minority ethnic groups.

‘Like when we are taught about jaundice and things to look out for, it's always on white babies…whereas myself and other black student midwives do notice that it's not being spoken.’

(Participant 3)

A clear example provided by two participants referred to the standardised electronic records system in clinical placement whereby, as a measure of neonatal wellbeing within the initial APGAR score, the element of ‘colour’ only allowed one option to be recorded, that of ‘pink’.

‘The daily examination on the [electronic records] system, it has the colour of the baby, it has pink. It doesn't have any other options like brown…We know that brown babies don't go pink. This is something that myself and another black student have noticed… so needs more awareness.’

(Participant 3)

‘I have had black babies that are not pink, they were never pink, they were always dark from the outset, but they were still well babies.’

(Participant 1)

While participants recognised black and brown skin colour was often invisible in the curriculum, they also recognised there was often a monocultural focus to the curriculum, citing a lack of cultural representation within classroom learning.

‘We just don't really learn about other cultures, it's like the British way or no way, no other opinions or ways of doing things is right and I don't agree with that.’

(Participant 5)

Two participants referred to a disconnect they experienced between learning in the classroom and its failure to reflect practices from within their culture(s), for example, washing a newborn soon after birth.

‘I know in my culture we wouldn't wait certain days to wait for baby to be washed and then they get moisturised again but it's just point blank it isn't spoken about, this is not what we do.’

(Participant 2)

The opportunity to learn and share a range of cultural norms was deemed important in supporting the development of cultural sensitivity.

‘To me, it's important we learn about…different religions and cultures.’

(Participant 5)

Sub-theme: a lack of representation

The participants spoke about a lack of diversity within their cohort, in practice and within the teaching team. This appeared to be magnified within the classroom setting.

‘Do I feel comfortable when it's just me? Because the majority of the time it usually is.’

(Participant 2)

One participant recalled how this was reflected in the clinical placement environment.

‘So in placement, obviously, I feel I stick out like a sore thumb because there are hardly any black student midwives at my [placement].’

(Participant 5)

This feeling of underrepresentation was further magnified within the wider maternity services and midwifery profession when on clinical placement.

‘There are not many [black, Asian and minority ethnic] midwives at my [placement], there are Asian doctors but very limited midwives who are like me.’

(Participant 5)

‘When I envisioned a midwife before [starting the programme], I did not envision a black midwife.’

(Participant 2)

When participants could see themselves represented through black, Asian or minority ethnic midwives, they viewed them as role models within the profession.

‘It is lovely seeing black and other midwives. I don't know whether it is a comfort thing, but I gravitate towards them.’

(Participant 2)

In turn, it was with a sense of pride one participant was able to recognise themselves as a positive role model for other black, Asian and minority ethnic students.

‘I also find the same with other students, they gravitate towards me, as I am the same as them.’

(Participant 2)

One student discussed their active involvement in an equality, diversity and inclusivity project.

‘[In order to] make others like us feel more included and better represented and given a voice…we just feel like we need that platform we need a body.’

(Participant 1)

While the participants experienced invisibility in terms of teaching materials, resources and systems, experiences in placement areas had ‘emerging visibility’.

Theme: emerging visibility

Participants articulated a position where their visibility as a black or brown person became vicariously exposed, as they viewed themselves through the eyes of the midwives who were responsible for supporting their learning in practice. They recalled examples of being present in the ward office or staff coffee room during their placements when racist attitudes and behaviours were shared.

‘A lot of the midwives refer to them as “black ones”, leave them to it, they are noisy etc…they make awful comments about them.’

(Participant 2)

Although participants did not recall midwives stereotyping black, Asian and minority ethnic service users in their presence, when they questioned some of the statements made, the midwives were unable to provide any evidence to support their views.

‘Some midwives were talking about an Asian lady who was labouring, and they've said, “oh she will need an epis [episiotomy] before she's even got to that point.” I did actually ask a midwife once what that was about…what did that mean? And she said it's well known that Asian ladies are “smaller down there” and they won't be able to push without tearing, so they just know it will end up with instrumental or at least an epis. I hate how there are stereotypes already even before we have given the women a chance, it doesn't seem fair to them.’

(Participant 5)

For one participant, her behaviour in response to being a bystander when negative comments were made about a black, Asian and minority ethnic service user manifested itself negatively, causing them to act in a way that felt ‘wrong’ in order to ‘fit in’ and manage the awkward situation they were in.

‘I just remember feeling very awkward at this point and I did smile, like a smirk, but not because I found it funny, because I wanted to be like the others who were laughing and wanted to fit in. That sounds so bad, but I think as students that's just what you do and as a black student you just do anything to fit in with the others even if it's wrong, does that make sense?’

(Participant 5)

Participants witnessed this behaviour extending to their colleagues.

‘I've heard a few comments from midwives when another Asian midwife on shift was eating her dinner and it was curry. It smelt amazing, but a white midwife walked past and said, “oh shock, you are eating curry!” The Asian midwife laughed, maybe because she felt uncomfortable, but I felt uncomfortable for her, maybe in this situation a non-[black, Asian and minority ethnic] student midwife wouldn't pick up that that's an uncomfortable situation? I'm not sure.’

(Participant 4)

This was extended to include an example of a participant experiencing hostility from a midwife as a result of being black, Asian or minority ethnic. One of the participants had been risk assessed during the pandemic as unable to provide care to service users who had tested positive for COVID-19, her ethnicity contributing towards the outcome of the risk assessment. When the participant explained this to the midwife, she was labelled an ‘unwilling student’ who had ‘attitude problems’.

‘[The] band 7…didn't like me because I was black, and she said I have attitude. So yet again, another person thinking because I'm speaking up, I am a typical angry black girl.’

(Participant 4)

Theme: managing visibility

As a result of observing racist attitudes and behaviours around them, at least two participants concluded that there was a risk that some midwives would not want to support and work with them, both of them using almost the same words.

‘I did think…[what] about a midwife that didn't want to work with me because of my skin colour?’

(Participant 3)

Despite there being no examples of explicit hostility from service users or any of the participants having their care declined, three of them felt anxious about the possibility of this happening.

‘I often worry about whether anyone will refuse my care because of my skin colour. Thankfully that hasn't happened, but I imagine it will in my career at some point.’

(Participant 4)

This consciousness led the participants to manage their visibility.

Sub-theme: monitoring behaviour

All the participants talked about how they were conscious of a constant need to make additional effort in monitoring how they presented themselves, both at university and in the clinical areas.

‘I always make sure that I'm dressed in the appropriate uniform, I am conscious of the way I speak and who I speak to. I am conscious of turning up on time, professionalism all the time.’

(Participant 1)

Two participants said this required them to present a persona to the outside world that did not match their inner sense of self.

‘I feel like I have two personalities to be honest… I feel like I have to change who I am to be accepted in this profession and in this world.’

(Participant 2)

‘Sometimes I feel that in order to fit in and feel included, I need to try to be a different person or a different type of me to be accepted or to be treated like others.’

(Participant 5)

This additional effort was identified by some of the participants as a site of difference from the experiences of white student midwives.

‘I just feel that I have to try harder than some of my friends in the cohort that aren't black, Asian or minority ethnic. I always try to come across as really friendly or really confident and it's not that I am really confident, but it's so that the midwives don't think of me badly I guess. I feel like I have to try harder than others, definitely!’

(Participant 5)

Four participants expressed how it had become so ‘second nature’ to them that they had difficulty in recognising the extra effort that they were having to make.

‘I have noticed sometimes in new situations meeting new people I come across as overfriendly and maybe this is so that they like me more and that my skin colour is not an issue. This might not be it, it's hard to tell now to be honest, because it's become second nature to me.’

(Participant 4)

‘Maybe because I'm doing so well, it's masking anything…that could potentially be an issue.’

(Participant 1)

‘I have noticed if a group of people are talking during a lecture, it's often my name that gets called out, but to be honest I don't notice it that much because sadly it's become normal for me.’

(Participant 2)

For one participant, the act of talking about it to the interviewer allowed her to recognise this for the first time.

‘Now you mention it, I have done this before. I have always done this my whole life, overcompensating so that they won't notice and so that my personality shines through stronger than my skin.’

(Participant 3)

Sub-theme: unwanted burden

More generally, three participants were frustrated by the additional burden of having to manage how they presented themselves at work and at university to consistently present a friendly and confident demeanour. This burden was both unwanted and tiring.

‘I think sometimes we have to prove that we are human beings the same as everyone else…I'm trying to break those stereotypes, I don't want to have to overcompensate, I don't want to have to smile all the time, I want to be able to relax without people thinking I'm in a mood.’

(Participant 2)

‘I have to act really confident and outgoing and really smiley and its tiring to pretend to be like that all the time.’

(Participant 5)

Two participants explicitly linked this burden to a specific stereotype, held as widely known.

‘I find that if you're not nice or you don't come across smiley and happy you come across angry and that angry black girl stereotype comes out.’

(Participant 3)

Discussion

The present study's findings provide insight into the experiences of student midwives who identify as being from black, Asian and minority ethnic communities, both in the classroom and in placement environments, while studying midwifery. Through analysis of their experiences, the themes of ‘invisibility, ‘emerging visibility’ and ‘managing visibility’ were identified.

Decolonising the curriculum

Decolonising higher education curricula is centred in the ‘Rhodes Must Fall’ campaign originating in South Africa (Ndlovu-Gatsheni, 2016) and in the UK the ‘Why is my curriculum White?’ campaign (‘Why is my Curriculum White?’ collective, 2015). These started a movement that has been furthered by ‘Black Lives Matter’ in 2020. All called for a fundamental review of university curricula, acknowledging that many ideologies of knowledge are rooted within a history of colonialism and viewed through a white lens. It is acceptance of whiteness as the default, unmarked and normalised and the ‘othering’ of non-whiteness spanning all subject provision that requires challenge at all levels and in all aspects of higher education.

It was clear from the participants in the present study that action to redress the underrepresentation of black, Asian and minority ethnic academics used within UK higher education institutions to better reflect the diversity of the student body is now paramount, but will likely take time to achieve. Higher education institutions therefore recognise their responsibility to address this in different ways, such as the inclusion of compulsory equality, diversity and inclusion training for all academics. Despite this, evidence suggests such strategies only result in small-to medium-sized effects on outcomes for black, Asian and minority ethnic students (Kalinoski et al, 2013). Morgan (2016) identified that staff required repeated engagement with workshops as opportunities to explore racial stereotypes, unconscious bias and its impact on black, Asian and minority ethnic attainment before individual behaviour change was observed. A ‘deflection of responsibility’ by lecturers, often attributed to competing demands, management structure and an overall sense that ‘it was someone else's responsibility’, frequently resulted in ‘limited action’ (Barefoot et al, 2018). Programme leaders who participated identified strategies to challenge possible racial discrimination and its effect on the attainment gap for black, Asian and minority ethnic students, including recognition of own privilege, inclusion of black, Asian and minority ethnic role models in teaching and learning materials and increasing diversity within teaching teams (Barefoot et al, 2018).

It is widely recognised that black, Asian and minority ethnic women, pregnant people and their newborns disproportionately experience poorer outcomes within UK maternity services (Office for National Statistics, 2015; Knight et al, 2018; 2021; Public Health England, 2020). However, Beckford-Procyk (2020) highlights that the same attention has not currently been afforded to midwifery theory, with a paucity of literature in this area. Recent publications on the physical assessment of newborns, women and pregnant people with darker skin tones are welcomed (Ménage et al, 2021; Raynor et al, 2021) but it is recognised that wider contributions are needed in this area. Within midwifery curricula, there is a need to ensure resources reflect the diversity of those accessing maternity services (Harkness and Wallace, 2021). Providing this opportunity within their education programme ensures that upon qualification, students are enabled to follow the Code (NMC, 2018) to deliver high-quality care that is inclusive and ensures equality for all. Healthcare faculties within higher education institutions must continue to engage with, and ensure that they drive the development of, inclusive learning and teaching materials, reading lists and simulation models that avoid a Eurocentric and ethnocentric focus, instead giving equal focus to those from black, Asian and minority ethnic groups. In this way, they can fully embed the key theme of antidiscriminatory care identified within the standards for pre-registration midwifery programmes (NMC, 2019a) and standards of proficiency for midwives (NMC, 2019b). As these standards are in the process of being validated across all UK higher education institutions, this represents an opportunity for significant organisational change.

Stereotypes

Although ‘invisible’ within the curricula, when students are ‘seen’, it appears to be in terms of being a stereotype—an ‘oversimplified opinion, prejudiced attitude or uncritical judgement’ (Merriam-Webster, 2021)—rather than holistically and as an individual. Two examples were given relating to stereotyping of South Asian women, which are longstanding (Bowler, 1993), becoming engrained and leading to South Asian women being less likely to receive adequate analgesia (Henderson et al, 2013) as well as well-documented poorer outcomes for mother and baby (Manktelow et al, 2015; Knight et al, 2021). Language barriers and tensions between the midwife's need for women to conform to hospital protocols and practices and the women's deeply rooted cultural and religious traditions (Goodwin et al, 2018) can lead to the homogenisation of South Asian women as ‘bad patients’ who increase the workload of the midwife (Bowler, 1993).

As a result of the need to ensure anonymity in this small purposive sample, the ethnicity of participants is not known. However, central to the concerns of all participants in this study as to how they are perceived were direct and indirect references to them being stereotyped in relation to the concept of the ‘angry black woman’. It has been argued that this stereotype originates in slavery in the US, used to depict a person who refused to conform to expectations (Motro et al, 2021) and verbally aggressive matriarchal charicatures (Kent, 2021). Stereotyping of black, Asian and minority ethnic people is potentially ‘pervasive and parasitic’ (Ashley, 2014) and therefore it is likely that all interactions between black, Asian and minority ethnic and white students, midwives and service users are foregrounded on this understanding. While studies have found that some black women professionals have been able to subvert this as an act of resistance and empowerment (Ong, 2005; Wingfield, 2010), black, Asian and minority ethnic student midwives cannot enact this same resistance because of their need to gain ‘approval’. Approval is needed to support their continuation and progression on the programme before they have any potential agency as a ‘professional’ to challenge individuals and systems that reinforce disadvantage to both black, Asian and minority ethnic service users and themselves. The existence of this ‘stereotype’ means that white students and academics can interpret any behaviour of black students as aggressive or angry, when in white students, it may be interpreted in more benign ways or simply not assigned any negative interpretation. Certainly, this is evidenced in multiple accounts from all five participants in this study. It has been argued that the stereotype is itself an instrument of racism. Where black women legitimately express anger at the racist micro or macro aggressions that they experience and thus fulfil the stereotype in the eyes of the white majority, the stereotype then serves to blame them (Morgan and Bennett, 2006) rather than holding those individuals responsible for their words and behaviour. By being silent, the racism goes unchallenged, further disempowering black women and holding them in a double bind.

In the present study, participants appear to proactively mobilise compensatory behaviour to ensure that they do not uphold and reaffirm negative stereotypes that underpin racism and consequently cause them to be ‘racilialised’ (Itzigsohn and Brown, 2015). The additional work that black nurses must undertake to ‘remain and succeed in white institutions’ has been labelled as ‘emotion practice’ (Cottingham et al, 2018) or ‘emotional double shift’ (Evans, 2013). In their study capturing data from audio diaries from 48 nurses of colour in the United States, Cottingham et al (2018) concluded that one potential impact is having to divert emotional resources away from providing the care required of them to service users in order to manage their own emotional responses to the microaggressions they encounter—the cumulative effect of subtle and persistent patterns of dehumanising behaviour (Pierce, 1970)—and which can cause them to become depleted by a constant sense of unease. What this means for black, Asian and minority ethnic student midwives in the present study was that they were in the unenviable position of having to accommodate not one but two institutional spaces that appear to foreground whiteness as the default position (Evans and Moore, 2015), coupled with witnessing a lack of culturally competent practice at times within those spaces. They were seeking to gain admittance to the profession, further limiting their agency to challenge behaviours. The authors then suggest that black, Asian and minority ethnic student midwives have an even greater workload than the ‘double shift’ of registered black, Asian and minority ethnic midwives to contend with. While this ‘emotional labour’ has been explored in high status professions (Evans and Moore, 2015), with qualified nurses (Cottingham et al, 2018), and has been identified in a study on black, Asian and minority ethnic physiotherapy students (Hammond et al, 2019), this is an important area for further study within black, Asian and minority ethnic student midwives.

There is a significant and growing body of evidence that there is a clear causal relationship between being exposed to racism and poorer health outcomes. One systematic review of 293 studies, primarily from the United States, concluded that racism was significantly linked to poorer mental health, including increased risk of depression, anxiety, post-traumatic stress disorder and suicidal ideation (Paradies et al, 2015). A longitudinal study in the UK concluded that cumulative exposure to racial discrimination leads to a deterioration in mental health overtime, which is as a result of not only actual experiences of being exposed to racism, but also the corrosive effect of ‘vigilance and anticipatory stress’ of encountering racism (Wallace et al, 2016). Furthermore, the consequences of experiencing microaggressions— and, for some of the present study's participants, overt racist behaviour—not only impacts negatively at a psychological level but, it has been argued, takes an academic toll for students (Perez Huber and Solorzano, 2015). Studies have shown through the ‘ethnic density effect’ that living within areas with a greater proportion of ethnic minority populations can have a protective or ‘buffering’ effect and reduces the risk of suffering mental health challenges (Becares et al, 2009; 2012). It can be hypothesised that student midwives living away from home and experiencing less diverse workforces and communities for the first time are likely to be a greater risk. Therefore, it is very likely that these cumulative and persistent experiences will also impact negatively on retention and progression rates for black, Asian and minority ethnic student midwives. This is an important area for further qualitative and quantitative investigation.

Strengths and limitations

While the use of a purposive sampling technique, as a form of non-probability sampling, is widely recognised within qualitative studies because of its ability to provide information-rich cases under study, it is acknowledged this means the findings of this study may not be representative. Similarly, while there is not an agreed minimum number of participants within qualitative studies, the sample of five participants can also be considered a limitation, meaning the findings may not be generalisable to midwifery students studying at other universities in the UK.

A further limitation of this study was that it was conducted in a single UK university. The ability to extend recruitment for this study to other UK universities representing the four countries, England, Wales, Scotland and Northern Ireland would allow for regional and national comparisons. This would also provide more theoretically generalisable findings to further develop a more focused, individualised and nuanced approach to tailor support for student midwives who identify as black, Asian and minority ethnic and accelerate the agenda to decolonise curricula in UK universities.

Nevertheless, a particular strength of the study is the original contribution it makes to an underexplored area of midwifery education, as well as giving a voice to an underrepresented group within the wider student body.

A further strength lay in the peer participatory approach, both between student researcher and academics and the student researcher and the participants. It supported recruitment of participants, allowed for honest representation of experiences, issues and challenges and presented the ability to begin to dismantle hierarchies of power and knowledge. It also suggests one way of embedding domain 5 (promoting excellence: the midwife as colleague, scholar and leader) of the standards of proficiency for midwives (NMC, 2019b) within a pre-registration curriculum, by giving a students the opportunity to be part of a primary research study and providing tangible evidence to them of how research can help to potentially influence policy and practice.

Conclusions

The starting point for this study was the established evidence base that there are barriers to attainment for black, Asian and minority ethnic students within higher education institutions, and within the NHS there are separate but additional barriers to progression and promotion for black, Asian and minority ethnic staff. Recognising that black, Asian and minority ethnic students undertaking an undergraduate midwifery programme may therefore experience inequalities and additional challenges to those of their white counterparts across both organisations supported the need for this qualitative study. Following interviews with five participants, three themes were identified: ‘invisibility’, ‘emerging visibility’ and ‘managing visibility’, experienced both in university and practice placements.

Strategies combined with recognition for the need to redress the dominance of white, Eurocentric and ethnocentric fundamentals across higher education in the UK are now long overdue as a means to positively influence the attainment gap for black, Asian and minority ethnic students. Healthcare faculties, curricula and programmes need to be rebalanced across UK higher education institutions to better reflect the diversity of the student body and the service users they support. Development of inclusive learning resources that give representation to black, Asian and minority ethnicities should be prioritised in the literature and evidence base within fields of study. These must be embedded within module reading lists and delivery.

Specifically embedded within the NHS Constitution the Code and further strengthened within the standards for pre-registration midwifery programmes and standards of proficiency for midwives are principles of cultural competence, equality, diversity and inclusion for all maternity service users and their families. Higher education institutions should use the opportunity to review how these principles are applied for their own student body. They should also act accordingly to support the organisational change needed to redress the imbalance surrounding black, Asian and minority ethnic student attainment. Embracing the opportunity to implement these fundamental standards for undergraduate midwifery curriculum as part of programme approval and validation across UK higher education institutions by 2022 is a vital step in positively influencing the attainment gap for black, Asian and minority ethnic student midwives. It will also help ensure that the midwives of the future do not perpetuate any engrained prejudices, attitudes and behaviours based on negative stereotypes that they may encounter during their journey to registration.

Key points

• Black, Asian and minority ethnic student midwives in the UK are likely to face additional challenges to their white peers in progressing through their programme because of structural systems of disadvantage within the NHS and higher education institutions.
• Black, Asian and minority ethnic student midwives in this study did not feel represented in the faculty, curriculum or teaching materials at university.
• They encountered racist attitudes and behaviours in practice placements and gaps in knowledge from practising midwives relating to identifying potentially pathological conditions in darker skin tones.
• They worried they may not be welcomed by some midwives responsible for supporting them in practice, as well as some service users because of the colour of their skin.
• They felt the need to modify their behaviour to ensure they always appeared smiling and confident, in order to be accepted within white majority spaces.

CPD reflective questions

• What does ‘cultural competence’ mean to you and how do you demonstrate this in your working life?
• How are you able to identify conditions such as pathological jaundice in a newborn or deep vein thrombosis in black or brown skin tones, other than by visual inspection?
• How do you create an inclusive environment to meet the needs of all students to support their learning and progression?
• How can you effectively challenge overt and covert racist attitudes and behaviours within yourself and the people you work with?