When pharmacist Ifeoma Onwuka, known to her friends as Laura, went into hospital to have her daughter, she and her husband hoped the delivery would go smoothly, and that they would soon be able to take their new arrival home to meet her siblings.
Onwuka’s labor was induced at James Paget University Hospital in Great Yarmouth in the UK, about 140 miles northeast of London, in late April 2018. Things progressed quickly and there were soon signs that her baby was in distress, causing staff to begin preparations for an emergency Caesarian section, but Onwuka’s daughter was born in the recovery room.
Shortly after the birth, Onwuka’s condition began to deteriorate, according to the family’s lawyer, Tim Deeming; she began to bleed heavily, and was taken into surgery where attempts were made to stem the loss of blood. Hours later, and only after a second consultant had been called in, she was given an emergency hysterectomy. The mother-of-three died three days later.
The coroner, Yvonne Blake, said an expert had told Onwuka’s inquest that the delay to surgery contributed to her death, since acting early could have controlled the bleeding.
Black mothers have worse outcomes during pregnancy or childbirth than any other ethnic group in England. According to the latest confidential inquiry into maternal deaths (MBRRACE-UK), released Thursday, Black people in England are four times more likely to die in pregnancy or within the first six weeks of childbirth than their White counterparts.
Deeming said Onwuka had been considered a high-risk patient because of her age – she was 37; her ethnicity – she was a Black British citizen, who was born in Nigeria; and because she had lost twins during a previous pregnancy.
Onwuka was found to have developed an amniotic fluid embolism (AFE), a catastrophic complication of pregnancy in which amniotic fluid or other debris enters the mother’s bloodstream, Deeming said. This can lead to fatal reactions, including cardiac arrest or excessive bleeding. According to one study, those from “Black or other minority ethnic groups” are more likely to die or have permanent neurological injury from the condition.
Blake took the step of issuing the hospital and the General Medical Council with a “report to prevent future deaths” over the handling of her care, warning of “a lack of leadership and overview on Ms. Onwuka’s care.”
Deeming said that: “Even though AFE is a rare condition, there are national guidelines and all hospitals should have clear plans and training in place for such situations given the data.” For example, Blake discovered that there did not need to be two consultants present to conduct the hysterectomy that could have saved Onwuka’s life.
“How can we prevent this happening to another family when we know that ethnicity and the other risk factors mean [AFE complications]… can be prevented,” Deeming asked. The family is waiting for a response from the hospital.
In a statement to CNN, the hospital said it had been “greatly saddened by the death of Mrs Onwuka, and we would like to offer our sincerest condolences to her family for their loss.”
“As there is an ongoing legal claim, we are not able to comment further at this time,” it added.
The MBBRACE-UK report, which charts maternal deaths in England found that between 2016 and 2018, maternal death rates were 34 per 100,000 among Black women, compared to eight per 100,000 among White women, 15 per 100,000 Asian women and 25 per 100,000 mixed race women.
Such differences have existed since MBBRACE began tracking maternal deaths in 2014, covering the 2009 to 2012 period, and likely long before. The improvement since 2019’s report, which showed Black people were five times more likely to die during childbirth, provides little solace for campaigners, who say research or targets designed to help solve the problem remain near non-existent.
“Health professionals were aware of this for a long time, yet the conversation on disparity was not happening in the public sphere,” said Tinuke Awe, co-founder of the campaign group FivexMore, which was named after the disparity highlighted in a 2018 MBRRACE report, and is calling on the government to improve maternal healthcare outcomes for Black women.
The issue gained prominence last June, when Black Lives Matter (BLM) protesters demanded a reckoning for racial injustices, at a time when Black people and members of other minority ethnic groups were being disproportionately affected by Covid-19 .
In September, opposition Labour Party leader Keir Starmer urged Prime Minister Boris Johnson to commit to an investigation into Black maternal mortality – saying it was an example of the structural inequalities that “sadly persist” in the UK.
Constellation of biases
The outcomes for Black people are similar in the US. In 2018, Black people in the US were three times more likely to die during pregnancy or childbirth than their White or Hispanic counterparts, with a maternal death rate of 37.1 deaths per 100,000 live births, according to data from the US Centers for Disease Control and Prevention (CDC).
Experts have noted that the racial disparity in maternal deaths in the US remains, regardless of the mother’s income and education level.
There is no simple answer for why such inequality exists in the UK, according to Marian Knight, the MBBRACE report co-author and professor of maternal and child population health at the University of Oxford. “Potentially, one of the explanations is that there is a constellation of biases,” from structural biases around ethnicity, to a lack of culturally appropriate care, or, in some cases, complicating factors around immigration status.
On top of that, she said: “You’ve got the added bias of being female,” since women’s healthcare and research is not as well funded as other areas.
The MBBRACE report does not look into specific causes of maternal death according to ethnic groups, which campaigners say makes it harder to pinpoint why the death rate for Black people is so much higher. “There are too many different reasons and we don’t even know why – we need to get to that point,” said Awe from FivexMore.
Knight said more research was being done, but that pregnancy research in general is underfunded and research gaps on Black female health outcomes in the UK are a reflection of structural biases faced by those working in obstetrics.
Another reason may be that Black people are more likely to develop conditions such as high blood pressure, or to be obese than other ethnic groups. Obesity increases a person’s risk of developing complications during pregnancy, including high-blood pressure and pre-eclampsia.
The differences in overall health and chronic illnesses between Black and White parents does not adequately explain the high proportion of poor outcomes, say some health practitioners. Social determinants such as implicit biases, socioeconomic status, a person’s physical environment, or levels of stress, also play a part.
A lot of conditions could be driven by social determinants, Hannah King, a midwife who is part of the Midwives Against Racism collective, told CNN.
She noted the “weathering hypothesis,” published in 1992 in the National Library of Medicine, which described conditions faced by Black Americans. It proposes that racial disparities could be bad for one’s health – that social and economic disadvantage can lead to an earlier onset of disease and other health problems, she says.
These disadvantages can include living in poverty or even one’s immigration status – affecting groups like asylum seekers and migrant women who are considered a high-risk for pregnancy-related death, Rosalind Bragg, the Director of UK charity Maternity Action, told CNN.
The annual MBRRACE report does not include details on the immigration status of the non-UK citizens who died. But according to the latest report, the highest proportion of deaths among non-UK citizens came from people born in Africa (36%).
The overall maternal death rate for those born in the UK was 8 out of 100,000 mothers. That rate was 7 out of 100,000 for mothers born in Nigeria, 27 out of 100,000 for mothers born in Bangladesh and 49 out 100,000 for mothers born in India.
The British government has introduced fees for some migrants accessing NHS services. Even though the law says women should not be refused maternity care, the charges – part of what is known as the “hostile environment” for asylum seekers and migrants – effectively deter them from attending maternity care, Bragg said.
It is a view shared by Knight, who says sometimes hospitals are unable to address the specific needs of the vulnerable – such as lacking an interpreter for those who do not speak English – which could lead to them dying from preventable causes.
This year’s MBRRACE report notes that a number of women who died “were Black or other minority ethnicity women who did not have English as a first language.” The language barrier “seems to have been magnified as the women became more unwell, because of their inability to express themselves or misinterpretation by healthcare workers of different cultural expressions of illness,” it added.
A growing body of US research suggests the biases of health professionals play a further role in these bad statistics. Studies have shown that Black patients are in some situations prescribed less pain medication than their White counterparts. And a recent article in the New England Journal of Medicine attributed unequal treatment in part to “enduring racist cultural beliefs and practices.”
In the UK, a 2013 study found minority women reporting a poorer overall experience of maternity care compared to White women.
Racial bias “both implicit or unconscious and unintentional, can hinder medical consultations, [and] negatively influence treatment options,” ultimately resulting in Black women avoiding treatment,” Dr. Christine Ekechi, an obstetrician and co-chair of the Royal College of Obstetricians and Gynaecologists’ race equality taskforce, told CNN in a statement.
That’s a view shared by Sandra Igwe, founder of UK social enterprise the Motherhood Group, who says she has heard a number of “horror stories” of Black people struggling to be heard or believed while receiving care.
During the birth of her first child, Igwe said she felt she was callously treated by midwives even though she told them repeatedly that she was in agonizing pain from her contractions. At one point she said she began vomiting, but “all I could remember was that they were more frustrated with me for expressing my agony,” she said.
Jacqueline Dunkley-Bent, NHS England’s Chief Midwifery Officer, told Parliament last July that the NHS had much to do “in relation to stereotyping,” adding that “every health professional [should] think about unconscious bias and think how that might influence the consultation with women and their families.”
King says those biases exist right from the beginning of doctors’ training, in medical school, where “everything is on White mannequins or textbooks or White patients, so you can’t recognize things like low blood oxygen saturations or cyanosis on darker skin tones,” she said.
While giving evidence, Dunkley-Bent told the parliamentary committee that there is no national target to reduce the poor maternal outcomes for Black women.
When asked by CNN why no such targets had been set, a spokesperson for the Department of Health and Social Care said: “We have launched a new oversight group to monitor how the health service is tackling maternal inequalities.”
They added that: “No woman should have to worry that the color of their skin will impact their pregnancy and we are taking steps to make sure Black and ethnic minority women get the right support and best possible maternity care.”
But change is not happening fast enough, say campaigners.
Knight, the report’s co-author, pointed out that for every death, there are 100 more women who are severely ill.
“I just don’t feel like enough is being done,” Awe said. “I now have a daughter, I’ve got friends, I’ve got sisters, I’ve got people I care about who will one day [have children]. Just by virtue of being Black, are they more likely to die?”