Individual biological and behavioural factors

Although limited, evidence from the UK has suggested the role of individual biological and behavioural factors in producing excess unfavourable outcomes among some groups of ethnic minority mothers. For example, the confidential enquiry into maternal deaths showed a particular susceptibility to aggressive forms of pre-eclampsia among Black African mothers who died, although the underlying genetic or other pathophysiological mechanisms were poorly understood. The same enquiry also noted significant associations between amniotic fluid embolism fatality and Black or other minority ethnicity. In addition, there were higher representations of obese or overweight Black African and Asian women among maternal deaths for whom body mass index (BMI) data were available . Similarly, findings from the nationally representative UK Millennium Cohort Study have indicated a higher incidence of pre-pregnancy obesity and overweight among Black mothers and pre-pregnancy underweight among South Asian mothers . However, UK studies have failed to link individual factors such as age, BMI, parity or pre-existing maternal medical conditions, such as hypertension and diabetes, to ethnic disparities in severe maternal morbidity as postulated from other countries such as the United States .

Evidence on the role of biological factors in ethnic inequalities in neonatal and infant outcomes in the UK is restricted to certain conditions and outcomes. For example, fatal congenital anomalies are established as a leading cause of excess infant deaths among mothers from some ethnic groups compared with the general UK population . Babies born to mothers of Pakistani origin are four times at a higher risk of deaths from congenital anomalies, representing about 90 extra deaths per year in comparison to White British mothers . Both old and new studies have shown that consanguineous or first cousin unions are responsible for a significantly elevated risk of congenital abnormalities in babies of Pakistani origin . Although genetic predisposition to preterm birth and a higher susceptibility to genitourinary tract infections such as bacterial vaginosis during pregnancy among Black women compared with White women have been indicated from the US , there is no evidence to support this among Black women in the UK, either those born in the country or those born abroad.

Behavioural factors resulting from a process of cultural change or ‘acculturation’ involving the adoption of customs, norms and practices of the host country may also act as potential contributors to differences in perinatal outcomes between first and subsequent generations of migrants. For instance, Hawkins et al. reported that health behaviours such as smoking in pregnancy and duration of breastfeeding that can potentially lead to maternal morbidity and affect neonatal outcomes worsened among ethnic minority mothers with increasing length of residency in the UK . The likelihood of engaging in unhealthy behaviours during pregnancy and after childbirth tended to be higher among UK-born ethnic minority mothers compared with migrant women irrespective of socio-demographic circumstances . However, a more recent study found no significant change in patterns of negative health behaviours such as smoking and alcohol consumption among ethnic minority mothers according to the length of residency in the UK, despite a linear trend in improved socio-economic circumstances . The notion of selective migration involving healthy women who are less likely to engage in negative health behaviours than the host population, known as the ‘healthy migrant effect’, could also be a plausible explanation for favourable outcomes among migrant mothers compared with subsequent generations.

Maternity and wider policy context

The evidence of the impact of UK policies on addressing inequalities in perinatal health outcomes is relatively sparse, although policies explicitly provide for flexible services tailored to the needs of individual women, especially those who are vulnerable and disadvantaged. Maternity services have long been urged to adopt a woman-centred approach that is accessible, efficient and responsive to changing needs, ensuring choice, access and continuity of care . Elements that directly relate to the health of migrant and disadvantaged women are also evident in the UK policy. For example, the National Institute for Health and Care Excellence (NICE) has published specific guidance on ‘women with complex social factors’ including recent migrants, asylum seekers and women who speak little or no English, with explicit recommendations in areas of service organisation, training for health-care staff, and information and support . The Standards for Maternity Care report have highlighted measures for addressing the needs of ‘women with social needs’ as part of Standard 7. The measures that have direct relevance to migrant mothers include establishing inter-agency arrangements for women from disadvantaged groups to ensure adequate support and benefit from other agencies; providing flexible, accessible and culturally sensitive services to motivate all women to engage with maternity services; and providing interpreting services for women whose first language is not English .

On a broader level, policy initiatives such as the Inequalities in Health Report , Race Relations Amendment Act and the Race Equality Scheme have all underscored the importance of creating health and social care services responsive to ethnic diversity, proactively setting out a high-level vision for reducing health inequalities and promoting health equity. The overall health equality focus gained further momentum with the government’s White Paper ‘Equity and Excellence: Liberating the NHS’ and the subsequent Health and Social Care Act . Although not directly referring to ethnic inequalities, the White Paper indicated pregnancy as a unique opportunity to engage women to improve life chances and to tackle cycles of disadvantage. The reformed National Health Service (NHS), focused on making services more directly accountable to patients and local communities, have explicitly committed to reducing differences in health outcomes and experiences between communities. The reduction of persistent inequalities in health is also a key focus in the UK Department of Health’s Public Health Outcomes Framework .

On an implementation level, regular and effective assessments of strategic health needs and audits of health equity offer opportunities for commissioners to accurately map the diversity of their childbearing population and to understand the needs of disadvantaged women in order to balance investment on par with differing levels of need. Independent local advisory committees known as Maternity Services Liaison Committees and service user organisations such as HealthWatch with representations reflecting the ethnic, cultural and social mix of the local population provide opportunities in principle to ensure that services reflect the needs of local maternal populations and are acceptable to them. Although few, there are examples of innovative approaches for maternity care provision from some areas where there is a high population density of migrants to address the health needs of vulnerable and socially disadvantaged women .

Overall, there are salient aspects in UK maternity as well as wider policy initiatives to support the needs of ethnic minority groups including migrant women. However, it has been argued that the integration of migrant health into broader policies and the ethnicity focus has led to some ambiguity about the needs of newly arrived migrants along with a lack of clarity about rights and entitlements according to immigration status . Recent evidence also suggests that fluid rules regarding entitlement to care for certain migrant groups tend to cause confusion for health-care providers and associated problems in health-care provision .

Intersections between social determinants, ethnicity and migration status

Social determinants constitute conditions in which people are born, grow, live, work and age . There is well-established evidence on the role of social determinants in explaining disparities in health outcomes . The significance of social determinants on ethnic differences in overall health outcomes is relatively well established, although it continues to be debated . The link between migration and disadvantage is well known, with migrants, especially those arrived recently in the country, likely to be living with fewer resources in deprived neighbourhoods characterised by degraded and polluted physical environments and reduced access to appropriate services . The socio-economic circumstances of ethnic minority mothers in the UK, including foreign-born mothers, appear to be diverse. Analysis of the socio-economic characteristics of mothers in the nationally representative Millennium Cohort Study found Pakistani and Bangladeshi mothers to be the most socio-economically disadvantaged among all ethnic groups with low levels of English fluency and distinctive patterns of family formation. The same analysis showed stark differences between migrant and second generations in higher-level qualifications among some groups, such as Black African and Indian, with higher proportions of migrant mothers having no higher-level qualifications. Less educated mothers of Black African origin were more likely to have been first-generation migrants to the UK, largely from Somalia, Nigeria and Ghana. Nearly half of the Black Caribbean and Black African mothers were living in disadvantaged wards with a relatively high incidence of lone parenthood. Further, foreign-born mothers were more likely than UK-born mothers to be in households where only native languages are spoken .

Studies on direct associations between ethnicity/migration status, socio-economic factors and adverse outcomes have mainly focused on neonatal and infant outcomes, and they have demonstrated marked socio-economic gradients with significant differences in distributions between White and non-White groups . For instance, analysing data on all singleton live births in England and Wales in 2005–2006, Oakley et al. found that the prevalence of preterm birth, low birth weight and small for gestational age increased with increasing levels of deprivation. Further, as levels of deprivation increased, mothers tended to be younger, less likely to be married or living with the father, and more likely to be foreign born with an ethnic minority status. They also found that babies of Asian, Black or other non-White ethnicity tended to have higher levels of deprivation . Using data from a nationally representative cohort study based on a multidimensional measure of socio-economic status involving household income, housing tenure, occupational class, education, maternal employment status and lone parenthood, Kelly et al. (2009) found that socio-economic disadvantage has a strong explanatory role for the excess incidence of low birth weight among Bangladeshi, Pakistani, Caribbean and African babies . Another UK study found significant links between deprivation and marital status and excess preterm births in Afro-Caribbeans . Analysis of the Millennium Cohort Study data indicated ethnicity coupled with socio-economic circumstances as factors for poor health and health-care use among mothers in some ethnic minority groups even after adjustment for the country of birth or the length of residence .

Some ethnic groups in the UK have shown puzzling associations, however, in patterns of socio-economic disadvantage and outcomes, as seen elsewhere, hence supporting the argument that social disadvantage alone cannot explain ethnic disparities in birth outcomes . For example, parents of Bangladeshi infants have a similar socio-economic profile to the parents of Pakistani infants, whereas infant mortality rates differed significantly between these groups . It has also been indicated that improved socio-economic circumstances for mothers in some ethnic groups do not always correspond with better health outcomes . Social determinants are difficult to quantify, and some of the variations between and within groups could be attributed to the varying methods of assessment and the complex array of risk factors involved in the socio-economic spectrum. For instance, in a comprehensive review, Blumenshine et al. (2010) found variations in socio-economic effects on birth outcomes among different ethnic groups depending on the measure and the outcome that was examined . It has also been indicated that indicators of socio-economic position may be non-comparable across ethnic/racial groups . The cumulative impact of deprivation across the life course and the possible interaction of socio-economic factors with ethnicity-specific characteristics have been posited as possible explanations for observed differences among groups from other countries, but existing UK evidence continues to be limited in this regard. Overall, it would appear that there are strong links between higher levels of social disadvantage and the excess risk of unfavourable perinatal outcomes among migrant and ethnic minority mothers in the UK. However, the pathways in which social determinants interact with ethnicity- or migration-related factors to produce excess adverse outcomes remain poorly understood. This in turn indicates the need for well-designed interventional studies in this area.

Access to and utilisation of good-quality maternal and perinatal health care

Timely high-quality health care can maximise health outcomes for mothers and babies, and it may have the potential to offset some of the social disadvantage . Several studies have suggested differential access to and utilisation of services among ethnic minority mothers in the UK, in particular among recently arrived migrants, refugees and asylum seekers with variations in care initiation, quality and content . For example, a recent study exploring the needs of migrant mothers found that new migrants were less likely to book into maternity services within the recommended 12-week period or to attend follow-up appointments regularly . Analysis of health-care use among migrant mothers in the first wave of the Millennium Cohort Study showed that 7.1% of mothers born abroad had no antenatal care at all, compared with 2.4% UK-born mothers. Among all the ethnic groups, highest proportions of mothers having no antenatal care were among Pakistani and Bangladeshi groups . Another cross-sectional survey reported that foreign-born women were over four times more likely to initiate antenatal care late compared with UK-born women . Women born outside the UK are also less likely to have been offered or attended antenatal classes, or to receive quality advice on healthy lifestyle factors and adequate support with breastfeeding . These findings are consistent with those reported from other countries that migrant women as a whole are more likely to receive inadequate prenatal care than receiving-country women with the risk of late or inadequate utilisation differing by country of origin .

UK studies have also indicated direct links between excess risk of poorer maternal outcomes among ethnic minority and migrant women and late or no access to health services . Although little or no engagement with maternity services has been associated with maternal deaths for many years, the most recent report showed that a quarter of the Black Caribbean (25%) and Pakistani (23%) mothers who died accessed antenatal care after 22 weeks’ gestation or had no antenatal care at all in comparison with 11% of White women. On a positive note, the same enquiry indicated generally good access to maternity care for Indian women as well as improved access for Black African women compared with the past . Differential access to maternity care has also been posited as a plausible explanatory factor for excess severe maternal morbidity among ethnic minority mothers compared with White British women .

A variety of individual, contextual and structural factors have been implicated in the late and/or inadequate access and utilisation of maternity services for ethnic minority women in general. For instance, a recent systematic review from the UK that explored the views and experiences of ethnic minority women on the barriers to and facilitators of the early initiation of antenatal care identified various individual-, family-, social- and health service-related aspects that affected their care pathway . These factors included a number of elements such as lack of a fixed abode; preference for local services that are either unavailable and/or inaccessible; lack of joined-up services and difficulty in navigating through the services; inability to access information; perceived impersonal and insensitive nature of the health system; women’s as well as professionals’ lack of knowledge regarding entitlement to care; women’s lack of knowledge about available services, purpose of care and choices available; professionals’ failure to direct women to appropriate care and poor relationships with health professionals; and individual knowledge, culture, motivations and beliefs .

Analyses specifically focusing on late and/or inadequate access and utilisation of maternity services for foreign-born women have identified more or less similar factors responsible, but they have increasingly highlighted the linguistic concerns of recently arrived migrants. For example, analysis of the Millennium Cohort Study data showed that the strongest predictors of no antenatal care for migrant women were younger maternal age, lower or no educational qualifications, no previous employment, lower occupational class and living in a high ethnic minority density ward . Although there is little difference in the maternity care needs of migrant and non-migrant women, migrant women are shown to be less positive in the UK as well as other countries about their care compared with non-immigrant counterparts .

The importance of effective communication, particularly between health-care professionals and parents, is indicated to be a prerequisite for quality in maternity care by policymakers, providers and women themselves . Both previous and recent studies have highlighted the linguistic concerns of migrant mothers in their contact with maternity services and the lack of adequate provision of effective language-support services . Although there is a statutory obligation to provide interpretation services for patients who are unable to speak English, stark inadequacies exist in the provision of these services including failure of the interpreters to attend appointments or their inability to understand medical terminology; failure from professionals in booking interpretation services; lack of interpreters for migrants speaking uncommon languages; and inappropriate use of family members to interpret . Although UK-born status and the resultant language competency and familiarity with the health-care system have been perceived as an advantage in care provision by both health professionals and UK-born mothers , difficulties between care providers and mothers due to inadequate cultural sensitivity, racism, stereotyping and/or inappropriate provider attitudes are shown to affect access as well as the quality of care for migrant as well as UK-born ethnic minority mothers . Immigration status has also been indicated to be one of the most important factors in determining maternity experience, with its impact on women’s rights and entitlements, and in particular the level of agency that the immigration status tends to mediate .