CEMACH report 2007: women from Black and minority ethnic groups
The Confidential Enquiry into Maternal and Child Health (CEMACH) reviews all maternal deaths in the UK and makes recommendations to improve care. The 2007 report reviews deaths which occurred in the years 2003 to 2005. This document is a summary of the report findings in relation to women from Black and minority ethnic groups. The immigration status of the mother did not appear to be known in all cases.
In the years 2003-2005, 295 women died from causes directly or indirectly related to their pregnancy was 295. There were more than 2 million births in this period (p3).
Maternal mortality rates have increased over the past twenty years and the report suggests that changing demographics may be a factor as a growing proportion of births are to women born outside the UK (p6). The health outcomes for many Black and minority ethnic groups remain very poor: Black African women have maternal mortality rates 5.6 times higher than White women; Black Caribbean 3.7 times higher; Middle Eastern 2.9 times higher; ‘Other’ 2.5 times higher; Bangladeshi 2.1 times higher; Indian 1.9 times higher; Chinese and other Asian 1.3 times higher (p30).
The total number of maternal deaths amongst refugees and asylum seeker in 2003-2005 was 36 (p51). In the absence of national figures on the number of refugees and asylum seeker births, it is not possible to calculate the maternal mortality rate.
The higher mortality rate amongst new arrivals is related to the poor overall health of many of these women. They tend to have poor general health and may also have unrecognised medical conditions such as congenital heart disease, HIV/AIDS and TB (p32).
The care provided to some women showed a lack of awareness of Female Genital Mutilation or Cutting (FGM/C). For one woman, late identification of FGM/C led to an unnecessary caesarean section and may have directly contributed to her death (p81). Migration trends have led to increased rates of FGM/C amongst pregnant women (p33).
At least five of the women who died had travelled to the UK in order to obtain health care, and were classed as ‘health tourists’ (p34). This is a new group for CEMACH reporting.
Cultural practices and attitudes of male partners were flagged as a causal factor, and were particularly important for women who spoke little or no English. There were several instances of a husband not seeking medical care when advised to do so or when it was manifestly necessary (p35).
Most of the women who suffered domestic abuse had reported this to a maternity health professional. 81% of women who were in abusive relationships and died of direct or indirect causes had suboptimal antenatal care: late booking, poor attendance, or no antenatal care (p39).
One instance of death from unsafe (illegal) abortion was recorded. This is the first such death to be recorded since the early 1980s. The woman had not been in the UK for long but spoke English well. She requested a termination and was referred for a surgical termination. She subsequently attended an Emergency Department and died as a result of unsafe abortion. The reviewer speculated that she had sought an unsafe abortion because of cultural factors or coercion (p95). The possibility that she had been asked to pay was not considered by the reviewer, although, as a new arrival, she may have been ineligible for free NHS secondary care.
There were several examples of unsatisfactory interpreting arrangements. Five women who were murdered by their partners had the abusive partner as their interpreter (p176). In one case, diagnosis of tuberculous meningitis was delayed as the husband was acting as the interpreter (p137). An asylum seeking woman who died from a complex set of conditions had her young son translated for her (p138). 34 of the 295 women who died from direct and indirect causes spoke little or no English, and very few had access to translation services (p34). Disturbingly, a GP reported that interpreting was a particular problem in his practice as there was no agreed source of funding for interpreters (p225).
Suboptimal antenatal care is a high risk factor. Late booking, poor attendance for antenatal care or no antenatal care was present around 20% of women who died from direct and indirect causes. Of the women who died, women from Black and minority ethnic groups were disproportionately likely to have had suboptimal care. Suboptimal care was experienced by 35% of women who did not speak English, 40% of Black African women, 57% of Black Caribbean women and 25% of Middle Eastern women, compared to 17% of White women (p32). It is important to note that the percentages relate to very small numbers of women.
In one instance, a woman who spoke no English attended her GP early in pregnancy, and was referred to the local maternity service. Her booking appointment did not come through until she was five months pregnant (p80).
One of the top ten recommendations relates to migrant women: Recommendation 4: All pregnant mothers from countries where women may experience poorer overall general health, and who have not previously had a full medical examination in the United Kingdom should have a medical history taken and clinical assessment made of their overall health, including a cardio-vascular examination at booking, or as soon as possible thereafter. This should be performed by an appropriately trained doctor, who could be their usual GP. Women from countries where genital mutilation, or cutting, is prevalent should be sensitively asked about this during their pregnancy and management plans for delivery agreed during the antenatal period.
G. Lewis (ed) 2007. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mother’s lives: reviewing maternal deaths to make motherhood safer – 2003-2005. The Seventh Report on Confidential Enquiries into Maternity Deaths in the United Kingdom. London: CEMACH  |
