In 2010, 25.1% of women giving birth in England and Wales were born outside the UK . According to the 2011 Census, 86% of the population of England and Wales self-identified as White (80.0% White British), 2.2% Mixed, 7.5% Asian or Asian British (2.5% Indian, 2.0% Pakistani), 3.3% Black African, Black Caribbean or Black British, and 1% Other ethnicity . This represents a significant increase since 2001 in minority ethnic groups, especially non-British White groups, Black African, Indian and Pakistani groups.
Ethnic group has been defined as “a collectivity within a larger population having real or putative common ancestry, memories of a shared past, and a cultural focus upon one or more symbolic elements which define the group’s identity…” . An ethnic group is characterised by race, skin colour, national or regional origins, religion and language. It evolves over time in response to social and political attitudes and is self-defined .
Studies in Europe and North America have indicated that, even in a developed country context, women from minority ethnic groups have poorer pregnancy outcomes than White women. The last two UK triennial enquiries into maternal deaths found that women from minority ethnic groups were at significantly greater risk [4, 5]. In particular Black African and, to a lesser extent, Black Caribbean women had significantly higher mortality rates than White women, thought to be due to later engagement with maternity services , though it was emphasised that some Black African women may have been newly arrived refugees or asylum seekers with a less than optimal history and circumstances. Similarly, in an analysis of severe morbidity over the period 2005–2006, after adjustment for age and socioeconomic status (SES), Black African and Black Caribbean women had twice the incidence of severe morbidity compared to White women .
A study based on UK birth registrations (and thus country of birth rather than ethnicity) found that low birthweight (<2500 g) was most common in babies of women born in South Asia and that women born in the Caribbean and West Africa had a higher incidence of very low birthweight babies (<1500 g) . Linkage to infant death records for the years 1983 to 2001 showed that infant death rates were highest in babies of Pakistani mothers, and also high in babies of Caribbean and West African women, a finding confirmed in a more recent study of infant mortality . Ethnic minority groups are more likely to live in areas of deprivation, however, analyses have shown that socioeconomic status explains little or none of the mortality differentials between ethnic groups [8, 9] although it does explain some of the variation in birthweight .
In a study comparing birthweight of first and second generation Asians in the UK, mean birthweight after adjustment was higher in babies of second generation women . This was thought to be due to improved nutrition, education, community integration, better command of English, cultural and religious beliefs and practices, and socioeconomic factors including jobs and housing . Health campaigns in the 1980s, such as the Asian Women and Babies Campaign and the Hackney Health Advocacy Programme, which encouraged the use of advocates and link workers to facilitate uptake of services, led to reduced rates of labour induction and caesarean section, and increased mean birthweight .
One likely pathway linking ethnicity and poor perinatal outcome is antenatal care . A range of studies have shown that women from minority ethnic groups, especially Black and Asian women, attend later in pregnancy and have fewer antenatal checks than White women [13–16]. They also have fewer pregnancy ultrasound scans, are less likely to attend antenatal education classes, have more hospital admissions in pregnancy, and less choice regarding place of birth. Barriers to women attending for antenatal care include language, a shortage of interpreters, advocates and link workers, and cultural attitudes towards male health care professionals . Women born outside the UK, even if English speaking, may have a poor understanding of how the NHS works, and have difficulty understanding healthcare jargon . Informed choice is not easily available to these women unless they have interpreters or advocates. Stereotyping and racism are also evident in some staff attitudes .
A population based survey in 2006 found that women from minority ethnic groups worried more about labour and delivery than White women did. In particular, although embarrassment was not a major concern, it featured more often as a significant issue for ethnic minority women than for White women .
The importance of training of health care professionals in cultural sensitivity and the use of interpreters, advocates and link workers has long been emphasised in government reports [5, 19]. The Commission for Racial Equality (now the Equality and Human Rights Commission) published a code of practice for maternity units aimed at eliminating racial discrimination and increasing equality of opportunity. However, initiatives tended to be geographically scattered, targeted only at numerically significant minority populations and time limited . More recent reports have again highlighted these problems [20, 21].
There is evidence of a perception amongst some staff that if minority ethnic group women behaved more like White women, the health disadvantages of these groups would disappear . Midwives stereotypically view Asian women as needing less support, being generally well supported by their families, as having a lower pain threshold in labour [16, 23], that they make a fuss, are non-compliant and too demanding [16, 24]. However, women of different backgrounds may respond differently to pain, for example, Pakistani women have been reported to have more open and emotional reactions than White women . In a Norwegian study of 67 Pakistani women born in Punjab, there were no differences in length of labour or mode of delivery compared to 70 Norwegian born women, but there were significant differences in their use of analgesia. Getting appropriate pain relief depends on effective communication and empathy, and methods of pain relief such as epidural and spinal analgesia require information-giving, opportunities for discussion, and cooperation. No Pakistani women, only half of whom spoke Norwegian, had an epidural, even those with long labours. After adjustment for potential confounders, the only factor significantly associated with receiving pain relief was mother’s country of birth . Inadequate pain relief, less confidence and trust in staff, and being left alone and worried in labour or shortly after the birth were also reported more by Asian and Black women in a UK survey . However, in using simpler groupings of 'Asian’ and 'Black’ women, that study did not separate the views and experiences of women of Bangladeshi, Indian and Pakistani origin or those of Black African women and Black Caribbean women, all of whom represent rather different ethnic groups with different histories and patterns of migration to the UK.
Women of all ethnicities born outside the UK may have particular difficulty with the transition to motherhood. The effects of being away from family and isolated in a foreign country, can lead to considerable unhappiness. Cultural differences may result in different expectations: whereas women in Northern Europe are encouraged to be up and active almost immediately following a normal birth, women from other groups may view the early postnatal period as a time for rest and seclusion, anticipating support from staff, friends and family and recognition of their changed status [26, 27]. The attitudes of health workers to different practices at this time may range from being responsive to being insensitive or derisive .
The aims of this study were to examine use of services and perceptions of maternity care among women who had recently given birth and who self-identified as coming from seven specific ethnic groups compared to women self-identifying as White. Lumping women from Black and Minority Ethnic groups together is recognised as of limited value in trying to understand differences in care associated with ethnicity, as is groupings like 'Black’ or 'Asian’. Thus, the opportunity to break down the groupings further was taken in order to better understand differences in care and perceptions of that care.