Research and analysis

Confidence in maternity care services: engagement with ethnic minority women and maternity staff

Published 28 August 2025

Executive summary

A 2024 report by MBRRACE-UK found that in the UK, women from Black ethnic groups were almost 3 times more likely to die in childbirth than White women. Women from Asian ethnic groups were twice as likely to die in childbirth. These disparities appear to be consistent with previous years, and remain worrying in the UK maternal health space. This has resulted in significant media attention. It has also prompted inquiries from civil society, research bodies and parliamentary groups. 

All maternal mortality represents personal tragedy. One consequence of such tragedy, as noted in the many reports, is the lack of trust ethnic minority women have in the NHS. Many ethnic minority women said how a lack of trust can lead to different choices for their maternity care and how they felt unsafe to give birth in hospitals in England. For example, a 2023 report by the NHS Race and Health Observatory found that Black women are fearful of giving birth in the UK. It found that they have more stressful birth experiences. Some also choose to “go back to their homeland for the birth because they felt they were more understood there.”

We know that a lack of trust can lead to a negative impact on ethnic minority women’s outcomes and access to public services. The then Equality Hub – now the Office for Equality and Opportunity (OEO) – researched the drivers of confidence in maternal care services in England to gain evidence from ethnic minority women on their experiences of using maternal care services. This was supported by evidence from a rapid evidence review of recent work in this space.

The exploratory qualitative research ran under the previous Conservative government from January to May 2024. It involved a series of focus groups and in-depth interviews with ethnic minority women and maternity staff across:

• Birmingham
• Bradford
• Bristol
• London

Participants were asked a series of questions through a semi-structured topic guide. The OEO analysed 46 responses from ethnic minority women and 25 from maternity care staff. 

The main aims of the research were to:

• identify the most recent evidence from the academic literature and independent research bodies 
• identify the drivers of confidence in using maternal care services in England by listening to ethnic minority women and healthcare practitioners
• understand the impact this can have on clinical outcomes

This research will feed into the government’s work to improve maternity and neonatal care for women and babies, including tackling the stark inequalities that persist.

The research found that ethnic minority women particularly value building relationships with maternity care staff. This is to ensure their experiences, culture and religious needs are taken into account. These relationships were affected by:

• continuity of care, where women see the same midwife throughout their pregnancy
• feeling that they are being listened to
• feeling that their choices are understood

These factors help women feel empowered and in control during their pregnancy journey and to self-advocate without explaining their circumstances repeatedly. Building relationships with women helps maternity staff to be more empathetic and compassionate. It enables them to be better equipped to understand and address concerns, and gain the woman’s trust.

Migrant women can find it harder to use maternity care services if their English is poor, or if interpreters are not available. This is also the case for women whose first language is not English.

Ethnic minority women felt that midwives with the same ethnic background could be more empathetic and compassionate to their concerns. In some cases, they felt they had a greater ability to understand and address them. For example, women raised how ethnic minority staff were better able to recognise how medical conditions manifest in different ethnic groups and skin tones. 

Local community organisations can be better placed to reach ethnic minority women. Where NHS England (NHSE) worked with local community organisations and the voluntary and community sector (VCS) to shape services, women felt an increase in confidence in their maternity care journey.

Women and some maternity staff feel there is a lack of clinical training and guidance for providing care to a diverse patient population. This includes misreading how people can express pain, or how different conditions present. It also includes how cultural or religious needs should be taken into account.

Ethnic minority women are likely to be influenced by:

• social media 
• information they get from friends and family 
• local community organisations 

This is because they often find information from the NHS less relatable or applicable to their circumstances. This informal information is vital to their perception of, and decisions around, the maternity journey.

Main findings 

Findings have been grouped into 4 overarching themes. While we discuss these individually, they are not mutually exclusive. In our concluding section, we discuss how themes interact and reinforce each other, creating a cumulative impact on women’s confidence in accessing maternity care services.

1. Relationship building between ethnic minority women and maternity staff

1a. Continuity of care

One of the most important factors identified to build positive relationships between ethnic minority women and maternity staff was continuity of care. Ethnic minority women who had the same midwife throughout their care felt more in control of their pregnancy, comfortable discussing their concerns and, by receiving continuous advice by a member of staff who understood their circumstances, were able to lead the direction of their care and more easily trust advice. For example, women who had positive experiences mentioned instances when midwives provided relational care, such as offering direct lines of contact, such as a phone number, and listening to concerns. 

Both ethnic minority women and maternity staff also raised that continuity of care, and in particular ensuring the same midwife throughout pregnancy, could create a safe space for women that enabled open conversations about sensitive issues, including points of cultural difference. For example, a few ethnic minority women raised how abortion is not an accepted or recognised practice in many cultures (an issue particularly raised by Somali women), while others had a preference to be cared for by female clinicians due to their religious background and practices. These topics were described as difficult issues to raise when women lacked a relationship with their midwife or care provider.  

Conversely, many ethnic minority women expressed how a lack of continuity of care could cause feelings of frustration. For ethnic minority women who may be less familiar with the NHS maternity services or who perceive the maternity services in England to be focused on White women, having the same midwife throughout antenatal appointments helped them to build a rapport and confidence in their care provider. For example, a number of women from the Black and Mixed ethnic groups in Bristol raised how they found it emotionally hard to repeatedly explain themselves and their medical notes to a different member of staff, sometimes receiving conflicting advice. 

Some women shared how they felt judged because of their cultural or religious needs, a feeling that was exacerbated each time they had to ‘explain themselves’. One Black African woman said how she only saw the same midwife twice (a woman is usually offered between 7 to 10 antenatal appointments) and found it frustrating to repeatedly go through the same questions with different staff. 

“I don’t have the time and energy to explain things all over again. I will have to explain the same things again and again to different members of staff, it does not help.” (Black African mother)

“A mother who had a stillbirth does not want to start every appointment every time with ‘I had a stillbirth’. In the end, they get so sick of saying it, they just stop saying it.” (Black maternity staff member)

Discussions with maternity staff also reiterated that continuity of care helps ethnic minority women to build a rapport with the maternity staff and feel more in control of their pregnancy. In Bradford, maternity staff raised how good relationships help women with a higher risk pregnancy to feel more empowered and in control of their care in face of unexpected circumstances (for example, this was particularly felt when there is an urgent decision needed, for example a change in birthing plans). 

The value of a good relationship was illustrated by an example of a woman who did not want a C-Section in spite of being told it might be a good option. The healthcare practitioner explained “the mother was empowered enough to say ‘I’m in the UK, I want to make the decision myself’.” (Birmingham maternity staff member)

In contrast, many women stop sharing their concerns when they have to repeat their stories at each appointment, an adverse impact of a lack of continuity of care. In turn, midwives – who may have limited time to read the full pregnancy notes – may miss crucial information and possible preventative action, multiplying the risk of an adverse outcome. Here, limited time with women was also raised as a barrier to delivering relational care. 

Maternity staff shared how spending time with women allows for a stronger emotional connection to be built, with staff becoming empathetic and compassionate to women’s concerns. This was particularly important for interactions with ethnic minority women who may not be aware what their options are, and already experience certain levels of distrust. It can also help maternity staff to dispel ethnic minority women’s myths more effectively. 

For maternity staff, limited capacity to spend time with women and feeling overworked also led to stress, exhaustion and impacted their ability to empathise. A lack of empathy, due to lack of time, could also have a negative impact on how women feel seen by staff. For example, ethnic minority women in Bristol raised how they perceived care as lacking empathy and understanding, which discouraged them to share their concerns of the fear of being judged. Both staff and women felt that this lack of relationship-building, and subsequently sharing of information, can have an adverse impact on women’s clinical outcomes.

“You need established relationships, mother-led with choice, not withholding of options” (Bradford maternity staff member)

“Everyone wants continuity of care but that can be a misnomer, continuity of care in the ante-natal stage, that’s where it’s really important” (Bristol maternity staff member)

“No compassion, the ‘service’ part is missing from the National Health Service.” (Birmingham mother)

While time to build rapport is crucial, maternity staff (particularly in Bradford and Birmingham) raised how staff shortages have a negative impact on the implementation of continuity of care models. For example, a practitioner in Bradford raised how continuity of care models had to be prioritised in areas with high levels of deprivation and diverse populations to ensure relationships were built with the most vulnerable women. 

Finally, time to build rapport with other service providers was also raised as an issue in delivering adequate care. For example, maternity staff shared that continuity of care resulted in more effective communication between maternity staff and other medical professionals, such as GPs and doulas, with staff taking time to understand the woman’s medical history and taking steps to ensure notes were shared between prenatal, birth and postnatal services. This aligned with our findings that many women feel there is a severe lack of communication between service providers throughout the pregnancy journey.

1b. Feeling listened to 

Women from different ethnic groups across all 4 locations raised feeling dismissed, their concerns not being taken seriously, and instances when their pain was not believed.

Ethnic minority women repeatedly raised instances of feeling consistently dismissed and not being listened to when raising their health concerns to the maternity care staff.

There was a perception that maternity staff did not seek to understand their previous medical history, leading to a feeling that health complications could have been prevented.

Ethnic minority women also felt that they were not involved in the decision-making process during their pregnancy, leading to a feeling of not being part of their own birthing plan. 

For example, an ethnic minority woman in Birmingham shared how she didn’t feel listened to during the decision-making process that led her to be induced for labour. She feared her medical notes had not been read by staff and while she repeated her medical history several times, she still did not feel heard. 

“traumatic, unheard, ‘shut-up and sit down, get on with it’ attitude” (Birmingham mother)

Maternity staff also recognised that ethnic minority women’s perceptions of not being heard,  listened to or understood can have a significant impact on their confidence in the services. 

In Bradford, a staff member shared how staff are required to make an assessment of pain levels over the phone to determine women’s access to the labour wards. This can often lead to a perceived unfair assessment on the level of a woman’s labour pain, delaying their access to immediate care and later on, confidence that staff midwives understand their needs.

In Peckham, a staff member raised how ethnic minority women’s referrals to specialists are often delayed when their concerns are not listened to by GPs and other health practitioners, which could delay timely preventive action.

Another maternity staff member raised that ethnic minority women do not feel listened to when they make complaints, often feeling ignored until the senior management gets involved.

A doula in Bradford shared how doulas often have to actively advocate and ‘speak for’ women who are not being listened to by staff, reiterating women’s concerns to ensure they receive the care they need. It was strongly felt that advocating for women had a direct impact on babies and women, with an example provided by a doula of a neonatal death following the end of a doula’s support: “Women want to trust midwives and doctors, but services are failing them over and over again.”  

Maternity staff also raised how healthcare providers often fail to ask important wider questions or listen to women when they raise concerns that are beyond their immediate medical care. For example, ethnic minority women’s wider circumstances such as their financial situation, vulnerabilities (such as abusive relationships) or involvement with social care have a significant impact on the woman’s pregnancy experience. Staff shared how such issues can often be ignored by other staff when raised or, if there is no relationship or confidence between the woman and staff, be hidden by women. 

Some positive experiences mentioned by ethnic minority women involved maternity staff taking steps to listen to their concerns throughout antenatal and postnatal appointments. 

In Peckham, a midwife shared how her particular job meant she had the opportunity to build relationships with the women by actively listening to them. She described an incident when she spent an hour listening to a woman who had had no contact with maternity staff for over 6 months, taking steps to address the woman’s concerns and understand her experiences.

1c. Feeling understood

Appropriate cultural training and guidance

Many women from Black ethnic groups perceived that maternity staff are only trained to treat White patients and, as a consequence, fail to recognise symptoms of jaundice or on black or brown skin. Several women raised how conditions were not being diagnosed by White midwives leading to delayed medical action, such as late diagnosis of a Black baby with jaundice and a Black woman with preeclampsia. 

This issue was also raised by maternity staff who shared how mandatory training and some of the National Institute for Health and Care Excellence (NICE) guidance^{[footnote 1]} does not address different presentations of common conditions among ethnic minority women, while others had concerns around the lack of training relating to ethnic minority babies. For example, clinical indicators such as the Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score^{[footnote 2]} were raised as inappropriate to measure the health of Black or Asian babies.

Cultural training and awareness also emerged as a theme, particularly among London maternity staff. Some staff felt that the NHS information provided on health issues, such as gestational diabetes and diet during pregnancy, are based on western norms. As an example, a local midwife created her own diet guide to avoid gestational diabetes specifically for Black Caribbean women. Some staff also raised how antenatal education often has a White middle class focus, with Black women deemed ‘non compliant’ when they can’t relate to the guideline.

“The system was not built for ethnic minority mothers. Even the training did not include Black and brown babies, different food, dialects etc.” (London maternity staff member) 

Perceptions and stereotypes 

Most Black African, Black Caribbean and Mixed White and Black Caribbean women were highly aware of the possibility of being stereotyped or perceived as angry or difficult by maternity staff. For Black ethnic women in particular, this led to tailoring their behaviour to avoid being perceived as ‘loud’ and ‘difficult’. Similarly, many Muslim women shared how maternity staff made assumptions on their ability to speak English based on their attire and appearance, causing them to feel judged and dismissed.

“[There was an] assumption in maternity services that I couldn’t speak English because I would attend appointments with my husband and I wear a headscarf.” (Pakistani mother)  

Some maternity staff also felt assumptions were made by some staff about certain ethnic groups, such as the perception that Black women are ‘strong and resilient’ or ‘loud, aggressive and angry’, or how Asian women ‘don’t complain’ and can ‘be difficult’ when they do complain.

“The existing narrative needs to be broken. ‘Nice White civilised patient’ ‘Difficult Brown, Afro-Caribbean patient’. (Maternity staff member)

Religious beliefs not considered

A number of examples were raised of instances where women felt there was a lack of understanding of their religious beliefs. Many Muslim women shared how they felt their requests for female clinicians and sonographers were treated as an inconvenience: “as a veiled woman, consideration should be given to dignity and preserving modesty.” 

In one particular example, a woman in Birmingham shared how difficult it was for her to adhere to her religious practices when her baby was stillborn because the standard process did not account for her beliefs. The lack of emotional support for her religious practices made the woman feel that her religious practices were not respected by the maternity staff.

On the other hand, when there was religious inclusion it resulted in a better experience for women. For example, one woman shared how getting a Muslim counsellor had helped her to resolve her miscarriage trauma and raised how women from ethnic minority backgrounds may “hide or pull back a bit” in sharing their stories if the counsellor was White.

1d. English proficiency and a lack of qualified interpreters

A recurring theme with both maternity staff and ethnic minority women was the adverse impact of low English proficiency and the shortage of qualified interpreters available in NHS maternity units.  

Some women (particularly from Asian and Somali ethnic groups) raised concerns about the availability and quality of the interpreters, and the significant impact this had on their ability to understand what was happening around them. For example, a woman explained how she was not given an interpreter and did not understand, or consent, to critical medical decisions. Following medical complications, she felt she underwent forced sterilisation during her pregnancy experience, which caused significant trauma, shattered her trust and shaped all future interactions she had with the NHS. 

Another woman shared how she was given the wrong interpreter due to a shortage of interpreters who understood her dialect, which significantly impacted her ability to make informed decisions. Many women raised that due to the lack of interpreters, they often relied on family members to interpret for them. This led many women to feel that they were not in control of their care and lacked the full understanding of the options and advice given by maternity staff. In contrast, when offered appropriate interpretation services, women described feeling much more confident about their options and in control of their maternity experience. 

“Specially trained maternity interpreters are a Rolls Royce service that is seldom offered” (Birmingham maternity staff member)

This issue was also a recurring theme for maternity staff, with particular concerns expressed about language barriers, shortages of qualified interpreters and ethnic minority women  feeling apprehensive about using interpreters known personally to them. We found that these factors can have an adverse impact on the clinical outcomes of new migrant women. For example, a maternity staff member in Bradford shared an instance where a Black African woman, who faced significant language barriers, did not understand that she had to take antibiotics and was not given interpretation services. The staff member perceived this played a role in her early death at 34 weeks pregnant. 

“Language barriers create confusion that can have catastrophic outcomes.” (Bradford maternity staff member)

In Bradford, some maternity staff also shared how some women feel apprehensive to use interpretation services if they know the interpreter or if they are male, due the fear that their personal issues will be shared in the wider community. Similar issues were raised when family members (usually partners or husbands) acted as the interpreters, along with fears raised by maternity staff that husbands may not relay the full information, making judgements of what may be necessary for women to be aware of. Without appropriately trained interpreters, maternity staff struggled to develop meaningful relationships with women and mitigate potential misunderstandings.

However, there were suggestions and examples of good practices being implemented by NHS trusts to overcome this barrier. For example, an English for Speakers of Other Languages (ESOL) tool with a focus on maternity terminology is being developed in Bradford, and Voluntary and Community Sector (VCS) organisation is also leading ‘Better Start Bradford’ to create an additional ESOL scheme targeted at wider health issues. 

1e. Self advocacy

Advocacy was identified by ethnic minority women and maternity staff as important to overcoming barriers faced by ethnic minority women in maternal healthcare settings, and improving clinical outcomes. The positives of self-advocacy were, however, often reflected on with regret, with many participants noting that it should not be necessary as women should be listened to and respected outright.

Many ethnic minority women mentioned self advocacy in their stories, either citing it as the reason they were able to have a positive pregnancy experience, or expressing regret at not advocating for themselves when faced with difficult pregnancy scenarios. 

For instance, a woman in Peckham felt she had a positive experience because she advocated for herself, even in spite of having complications during pregnancy. She felt strongly that women have ‘to verbalise it’ to have a positive birthing experience. She explained how doing her own research (mainly through television and instagram midwives), preparing her own birthing plan and crucially making sure it was read and followed by the maternity care staff, helped her have a positive outcome. 

This was supported by many other women, who felt that self-advocating could help them avoid negative outcomes, perceiving that they can easily be ignored with care becoming more like a ‘tick-box exercise’ if they did not self advocate.

“I was a good advocate for myself. I knew exactly what I needed. I knew that if I did not self advocate I would be pushed aside.” (Pakistani mother)

Comparatively, multiple women who had less positive experiences, felt that they would do  more research and self-advocate in future. One woman mentioned that she would be ‘more over the top’ and advocate for herself if she got pregnant again, having experienced a difficult pregnancy due to her sickle cell disease. Another woman also shared how she would take a different approach in future pregnancies as, following her first pregnancy, she is better equipped to deal with healthcare language, has a clearer understanding of her rights and what are her choices: 

“I didn’t realise that, if you don’t connect with your midwife or you feel they don’t understand you, you can ask for another midwife to provide your care” 

A strong feeling of needing to self advocate and proactively prepare as a Black or Mixed Black woman before interacting with NHSE appeared to be driven by a high awareness of the ‘5x more’ statistic^{[footnote 3]} or, in case of Asian women, driven by previous negative pregnancy experiences. 

Many women took steps to prepare and ‘become pros going into it [NHSE services]’, including doing their own independent research in order to overcome the perceived risk. Some women reflected that this made their pregnancy stressful, feeling a need to prepare themselves for worse outcomes: 

“I had to tell my husband what to do in case I did not make it, as I knew it was likely”

Self advocacy, however, was not always seen to be enough. For instance, one woman whose child passed away, felt that her negative experience and outcome still happened in spite of her advocacy. She explained how she clearly expressed her preferences to staff and did extensive research to help sustain her complex pregnancy, keen to carry to term, but that she felt dismissed, overhearing staff warn each other to ‘be mindful’ of her because ‘she does her research’.

It was not just women who emphasised the importance of advocacy. Some maternity staff were of the opinion that had they not advocated for women in their care, there would have been worse clinical outcomes. 

In Birmingham, we were told by a midwife about a woman from the Black ethnic group who had an extensive postpartum tear which required stitches. The woman could not advocate for herself due to high levels of pain and the midwife felt that no one, including the consultant, took notice of her, repeatedly asking her to ‘sit up’. The midwife explained that she had to advocate for the woman to make the other staff realise that she was in a lot of pain. Other maternity staff suggested specific tools or a lead midwife to help advocate for ethnic minority women. They felt this would help women feel listened to and more involved in decisions about their care.

2. Ways of working among maternity staff can affect women’s confidence in maternity services

2a. Diversity

We heard mixed views on the need to be cared for by those who share the same ethnicity or cultural background as the women.

Some Black women (particularly in Bristol and London) felt particularly strongly about this issue, and shared their concerns of being stereotyped by a non-Black midwife. In particular, women felt that a Black midwife would understand them better as they have the everyday experience of being a Black woman. We were told how having a Black midwife made one woman feel happy and welcomed. Another explained how the absence of Black nurses on the delivery ward made her fearful. 

Other Black women felt differently about this issue and raised how feeling empathy and compassion from their maternity staff was the most important aspect of relationship-building and receiving good maternity care. However, it was recognised that although these women were happy with a midwife that did not share their ethnicity, some women felt that compassionate care was provided by those who shared their ethnic background. Many women felt these staff were better able to empathise and understand their experiences, concerns and preferences. 

“I remember the only midwife after my labour that helped me was Black and she was telling me what I had to do. Post care may be different for a Black woman” (Black mother)

Other Black women also noted there are clear differences in care based on the ability of  non-Black midwives to recognise the different ways medical conditions can manifest in different ethnic groups and skin tones. As previously mentioned, we heard numerous examples of missed diagnosis, including preeclampsia and babies with jaundice. Specific pre-existing conditions were also considered. For example, one woman who had sickle cell anaemia credited her Black midwife with saving her life because she understood the implications of the condition during pregnancy. 

Some women, particularly those from the Asian ethnic group, were not overly concerned about the ethnicity of the maternity staff providing their care. This was as long as they were qualified and aware of different cultural practices, such as a preference for female clinicians. There was still an acknowledgment that there was a need for better diversity and representation at more senior levels across the NHS. In particular, some Black women expressed concerns about the lack of Black clinicians. 

“maternity staff need to represent the communities they serve” (White British maternity staff member)

While diversity was seen as important, having maternity staff from an ethnic minority group was not necessarily perceived to improve clinical outcomes in every context. For example, maternity staff in Birmingham raised how there can be prejudices and tensions between races and cultures of any background. They shared documented cases of misogyny and bullying by doctors of Asian ethnicity against non-Asian ethnic minority women.

2b. Power dynamics

Between different maternity care staff

Maternity staff and some women shared that ethnic minority midwives were sometimes ignored by their peers. They shared how this issue was exacerbated due to the hierarchy between professions, which resulted in poorer care to women and sometimes was expressed through bullying-like behaviour to both staff and patients.

“Some staff aren’t even civil to each other, so what about a person who doesn’t speak English or doesn’t have a partner with her?” (Birmingham maternity staff member)

“There is a power imbalance in maternity services. Obstetrics and gynae have the highest rates of staff bullying and women don’t feel empowered to complain. There is [also] hierarchical access from GPs to maternity.” (South Asian maternity staff member)

This power dynamic between staff was also perceived by some of the women. One woman raised how her Black midwife felt ignored:

“She was really upset that her advice wasn’t listened to – I told her it was not her fault… They were just not listening to us” (Black mother)

Another woman shared how her midwife, despite being experienced and knowledgeable, often feared speaking up to her peers.

Some maternity staff raised that this issue is wider than maternity services, and is a challenge across the management level of NHSE. They also shared how they felt their ideas to make meaningful changes to practices in order to improve outcomes for ethnic minority women were often ignored or dismissed as too costly without full consideration. In particular, some raised they felt that senior managers do not see the need for positive changes to be made to improve women’s experiences. 

Between maternity staff and women 

Some women also mentioned an imbalance in the power dynamics between staff members and women. This impacted their ability to self advocate and take the lead in their care. For example, women from across ethnic groups said they often felt they could not question decisions due to a hierarchical attitude towards knowledge: “I’m the doctor, I know better”. A number of these examples involved major medical procedures, such as having labour induced or a Caesarian section, where women felt they were told what would happen to them, without being given a choice. One woman described: “[the consultant] looked me dead in the eye and told me this [her preference] was irrelevant.” 

There were other instances where women felt this imbalance directly led to worse outcomes for their babies. In Peckham, a Black woman shared how she was advised to terminate her pregnancy but chose not to do so due to her religious beliefs. From then onwards, she felt medical staff repeatedly criticised her religion and considered her ‘difficult’, demonstrating a lack of compassion or understanding of her decision.   

From maternity care staff’s perspective, the power dynamic between maternity staff and women could often leave women feeling ‘let down’, where they had to ‘give up power’ when entering healthcare spaces and when engaging with staff. However, others raised that there are wider factors that can shape the dynamic between women and staff, including how being overburdened can lead to displays of negative behaviours towards women. This included taking less time to hear women’s concerns, giving curt responses or using negative body language, which could be perceived as indirect, subtle or unintentional discrimination. 

2c. Data and research

Many maternity staff raised concerns with gaps in the data and research relating to ethnic minority maternal disparities. This included research into critical cases to identify patterns of comorbidities, and genetic factors and how they shape outcomes for ethnic minority women.

Maternity staff felt that understanding these factors and patterns can help inform preventative action to mitigate against the risks these conditions pose. For example, maternity staff in London shared how the creation of new midwifery specialisms for critical cases has revealed comorbidity patterns by ethnic group, such as early insight showing Asian ethnic women are more likely to present with stroke, while Black women present with cancer and cardiac disease.

Staff also felt collaboration between independent research bodies and delivery partners is able to identify effective interventions to reduce maternal health disparities.

Staff also raised issues with the quality of NHS ethnicity data, which was described as poor. For example, the NHS data collection is based on 2001 Census categories of ethnicity, despite the fact that the 2021 Census data is available and ethnicity categories have changed. 

Some maternity staff raised the need for better collaboration with other bodies, such as the NHS Health and Race Observatory, to develop, trial and evaluate specific interventions to support Black and Asian women and reduce maternal health inequalities. 

2d. Collaboration with community organisations

Both the women and the maternity staff suggested that building collaborations between community-led organisations and NHS services can improve the care provided to women. When discussing the reasons for this, many women mentioned that existing NHS services were not suitable or inclusive. One woman described how she went to antenatal classes but they were “no use” and that she “got a better picture from friends and family.” This was echoed by women in other groups who raised that there is a specific issue with prenatal classes for Black women: 

“I went to a class that just didn’t make sense for me. I asked the teacher and they just said I’d need to find something else – it was money wasted” (Black mother)

As a result of negative maternity experiences, a number of women mentioned seeking out community organisations for support. Women noted that community organisations often made a difference by providing them the information that is easily accessible, and relates better to their circumstances and perspectives. For example, some women shared how their involvement with ‘Approachable Parenting’ (a Muslim-focused organisation) gave them the support and knowledge needed to better self-advocate. 

Given these benefits of community organisation support for ethnic women, many maternity staff recognised that the NHS needs to collaborate with the voluntary and community sector (VCS) and local authorities, in order to share knowledge and improve outcomes for vulnerable groups. For example, one maternity practitioner emphasised how collaborating with VCS organisations could help drive engagement with ethnic minority women at the grassroots level, helping the NHS to better understand their barriers to building confidence in maternity care services. In particular she felt this was important as VCS staff were often able to access specific communities of each ethnic minority group, understanding their unique experiences and barriers. Other benefits include learning what works, identifying the specific needs of a community and sharing best practice.

Maternity staff outlined a number of areas where local engagement and peer support could  assist in better information sharing and the resources available to women. For example,  maternity staff in Birmingham mentioned how women do not receive pre-pregnancy counselling, with healthcare professionals like GPs not providing enough information as they are pressed for time. 

In some NHS trusts, collaboration with local organisations is already in development. As discussed earlier, maternity staff in Bradford spoke about work with the VCS to provide ESOL, including a tool with a focus on maternity and a wider ESOL scheme for health. These are designed to provide support for pregnant women and to help them communicate with their midwife and feel more in control. 

Similarly, in Bristol the development of a health innovation network is taking a grassroots-driven approach. The network will trial ‘maternity champions’ in local communities who will work with the NHS to help bridge gaps in knowledge and support. In Bradford, many community doula services are free. Staff shared how NHS midwives are ‘over the moon’ when they see a doula arriving at the labour ward to support a woman as they are trained to work with maternity staff to provide the best birthing experience for women as possible.

3. Confidence was affected by information accessed through social media and friends and family

3a. Social media

One of our findings, seldom discussed in the academic literature, was the dual role of social media in informing decisions and influencing perceptions. Women said that negative media stories were often shared through social media (such as Facebook, Whatsapp and TikTok) and caused feelings of fear, anxiety and a greater mistrust of NHSE. Many women, from a variety of ethnic backgrounds, mentioned how they learned about local stories and tragedies through social media. 

For maternity staff, this can be a cause of concern:

“The media has increased levels of mistrust and specific stories spread quickly across communities. In Bradford currently, people are hearing about a 31 year old ethnic minority mother and her baby who recently died shortly after labour and birth.” (White British, maternity staff)

Many maternity staff considered social media to be problematic and possibly even dangerous. One maternity practitioner described how social media can influence ideas of motherhood, with those influencing having little qualifications and knowledge. As an example, she felt there is a romanticisation of pregnancy, birth and motherhood and gave the example of the growing ‘freebirth narrative’. Her biggest concern with social media, however, was confirmation bias: 

“You see what fits your narrative” (Bristol, maternity staff member)

On the other hand, many women described using platforms such as TikTok and Instagram to access information in a way that made them feel empowered. One woman discussed how she did her own research, engaging in social media platforms and speaking to other women and doulas. This had a direct impact on her birthing plan – she found that she did not need to be induced, and that she had a choice and could ‘ask why’, which led to feelings of empowerment and more control. 

“There is a page called ‘Pop That Mumma’ that provides lots of video advice and 1-to-1 packages if you want tailored advice… You want midwives that show passion – you can find a lot of it on Instagram and Facebook.” (Black mother, Peckham)

“I did my research after seeing the One Born Every Minute documentary and realising that things would be even more difficult as an ethnic minority mother. I used a lot of instagram midwives – such as ‘badass birthing mothers’ – for advice, especially home and water births” (Black mother, Peckham)

3b. Family and friends

Ethnic minority women often cited how their family, friends and community played a role in how they accessed information and feelings towards pregnancy. Some ethnic minority women felt that the information they received from friends, family or neighbours was the main source of maternity information rather than the NHS. This raised concerns about the accessibility and focus of NHS maternity information for ethnic minority women. 

Women shared their sources of information, which included ‘word of mouth’, hearing about maternal experiences or stories in the local community and advice from friends and family. 

“you speak to other mothers and friends and family to know what to expect. What is okay or not. You then notice a few things – that you can say no or ask more questions.” (Bristol mother)

The experiences of family and friends that the women talked about were not necessarily negative, and not all women who participated had a negative experience. One woman explained that although she had heard about negative experiences accessing maternity care from NHSE from others, she ignored these and felt confident because of a positive relationship with her midwife and consultant, where she felt listened to and had ‘excellent’ communication.

The role of family and friends, as well as wider social networks, was also recognised by maternity staff. Maternity practitioners mentioned to us that often women are afraid to ask questions to professionals and instead ask their friends or family for advice. Maternity staff acknowledged that one of the reasons for this could be the information provided by the NHS around maternity care services is not always accessible. 

“Information is provided in a way that almost seems like the audience is middle-class mothers… [ethnic minority] mothers won’t access this information, they rely on family and community” (Bristol maternity staff member)

Some maternity staff in Bradford felt that more could be done to provide information and resources to improve maternity education. They mentioned the importance of community doulas in enabling ethnic minority women to get access to information, as these doulas often represent the communities they serve. 

They also spoke about ‘maternity circles’ in Bradford which aim to provide women access to information on different services, and are piloting a campaign to help support women learn things like how to approach GPs, understanding a formal healthcare setting and how to read basic English keywords to be able to navigate hospitals.  

4. Other indirect factors impacting ethnic minority women’s confidence in maternal health services

Other problems, barriers and concerns were raised by women and staff that affect women’s confidence in maternal health services in an indirect way. A number of women explained how their confidence was higher when they had been receiving regular home visits, whether this was in England or abroad. For example, one woman explained that although she can walk to the hospital for appointments, it was better in her last pregnancy when she was visited at home as it felt more personal.

Maternity staff were also particularly aware of the practical barriers many women face including social and financial barriers such as not being able to afford to travel to their appointments. For example, one woman was expected to travel many miles for daily appointments and was considered difficult when she refused because she did not have the time or ability to do so. In one Trust, there is an attempt to increase phone appointments, and encourage home visits to check why patients were missing appointments if they missed more than 2. 

“[Hospital] based staff have an expectation that the women will arrive at their appointments, they don’t consider that the woman might have no money for transport.” (Bradford maternity staff member)

Another issue was the need for women to bring their older children to appointments. Maternity staff in Bradford explained that while there are ‘strict rules’ about women bringing other children to appointments, staff are flexible to offer the best support for the woman and not turn her away. This was confirmed by a Bradford woman who praised her team for the support and help she received with her older child during appointments. Other indirect barriers, such as literacy and digital exclusion, were also discussed. 

“Assumptions are made, that mothers have access to the internet, that they can read.” (Black maternity staff member)

Conclusion

Our research found there are a number of interrelated and cumulative factors that shape the confidence of ethnic minority women when accessing maternity care services in England. These factors varied significantly based on the different ethnic groups and to a lesser extent, geography. 

A strong theme present throughout all engagements was the need for compassionate and empathetic care that enabled women and staff members to build strong relationships. 

We found that strong relationships enabled women to feel more in control of their pregnancy journey, listened to and confident that they understood their options. In more practical terms, our research identified practices that mattered to ethnic minority women and staff to build these relationships. These include, but are not limited to:

• having the same midwife throughout pregnancy
• a direct line, such as a phone number, to maternity staff
• clarity on woman’s medical background, for both women and staff
• easy access to appointments, and (when needed) access to NHSE leaders to raise concerns 

We heard many examples of how strong relationships between women and maternity staff – developed through these practices – had a direct impact on the outcomes of both women and babies, allowing for immediate and preventative action to take place. 

While there are findings that can be applied to all women (regardless of ethnicity), our research found points of cultural and ethnic difference that acted as specific barriers to creating these relationships for ethnic minority women. These included:

• lack of clinical training and guidance to provide care to a diverse patient population
• misreading or disregarding the different ways in which people can express pain
• inadequate interpretation services
• feeling unrepresented by the workforce, particularly in terms of leadership
• ingrained distrust before accessing services due to media reporting on tragedies and ethnic disparities, alongside stories by families and friends 

Some women and staff felt these barriers, and the resultant poorer outcomes for ethnic minority women and babies, indicated the presence of racism and discrimination in NHSE. Our research found that these factors, and the interaction and cumulative effect of these, can build or erode ethnic minority women’s confidence in accessing maternity care services and directly affect outcomes for women and babies.

Cumulative effect during women’s use of maternity care services

Below is a list of points of contact women have with maternity services. It describes the types of interaction they may have, and is based on real experiences. It shows how there can be a cumulative effect (positive or negative) each time a woman accesses a service during her maternity journey.

When a woman discovers she is pregnant, her GP is usually the first point of contact

Positive interaction

The GP surgery provides clear, accessible early pregnancy health advice to the woman, and makes notes of any specific needs, such as a translator. They are given contact details for the midwifery service and an outline of what to expect and what information the service will ask for. 

The woman feels cared for and prepared to start her maternity journey.

Negative interaction

The GP surgery brusquely provides the contact details of the midwifery service. The woman feels as though she has imposed upon the GP and taken them away from higher priority patients.

The ‘booking in’ appointment with a midwife

Positive interaction

The midwife arrives at the woman’s home with a translator ready if needed. She explains how she is the woman’s primary contact during her maternity journey. As well as the health and pregnancy information collected during this appointment, they talk through the sequence of appointments, what to expect and any particular requirements that will be needed. These are all noted down to share with other services. 

The woman is pleased to have a specific contact and has been able to get reassurance regarding potential risks, such as gestational diabetes.

Negative interaction

The midwife is not aware of the need for a translator, so the husband has to help. The woman is given a number to call if she has any queries – she is told to leave her name, number and query and someone will get back to her. The midwife does not ask about any particular requirements. No information is shared with other services. She is given leaflets in English about potential risks but the midwife does not go through them.

The woman feels overwhelmed by the information and has many questions but is unable to convey them to the midwife. She feels confused and uncertain about what happens next.

The dating scan at the hospital

Positive interaction

The hospital is aware of the woman’s requirements and makes the necessary accommodations. The sonographer clearly explains the process and next steps.

The woman feels reassured that her needs have been considered and she has been listened to.

Negative interaction

The woman arrives at the hospital to find that the sonographer is male. She requests a female sonographer but is bluntly told there is not one available today. The hospital staff do not try to accommodate her needs or rearrange her appointment for when a female sonographer is available. 

The woman feels belittled and judged by the hospital staff. She decides not to make a complaint as she does not want to be considered ‘difficult’.

16 week midwife appointment

Positive interaction

The midwife explains the scan and test results. The woman explains she has been feeling very tired and a bit dizzy. The midwife suspects anaemia and provides an iron supplement.

The woman is confident that the midwife is listening to her and will support her over the next few months.

Negative interaction

A different midwife is working today and she has not had time to read the woman’s notes. She tries to explain the scan and test results but the husband’s medical language and understanding is limited. The woman explains she has been feeling very tired and a bit dizzy. The midwife brushes off her concerns saying all pregnant women get a bit tired.

The woman doesn’t feel reassured but accepts the midwife’s assessment, as she has the medical qualifications.

Additional midwife appointments

Positive interaction

As well as completing the required checks and tests, the midwife always makes sure to ask the woman how she is feeling, enquires after her wellbeing and provides relevant and accessible advice when the woman has questions or concerns.

The woman feels comfortable discussing how she is feeling and her apprehension regarding the birth. The woman and midwife develop a birth plan which includes ‘plan b’ options as well.

The woman feels reassured and understood.

Negative interaction

The woman has a different midwife at each appointment. The midwives run through their checks and tests, ask cursory questions about how the woman is and reiterate standard lines when asked for advice. The woman has been told she should develop a birth plan but doesn’t really know what that entails.

She is still very tired and dizzy but feels as though no-one is taking her concerns seriously. She is worried that she is anaemic but thinks that because of her skin colour, the midwives can’t see it. She feels as though she is just something to be ‘processed’ and that the various people she has engaged with lack compassion and empathy.

Labour

Positive interaction

The woman has been having strong but infrequent contractions for most of the day. She phones her midwife who talks her through how labour should progress and when she should call the hospital. The woman feels confident in her midwife understanding her situation so goes on to explain how painful the contractions are and that ‘something doesn’t feel right’. 

The midwife makes arrangements for the woman to attend an urgent appointment at the hospital to check how labour is progressing. 

The woman feels that she is being listened to and taken seriously.

Negative interaction

The woman has been having strong but infrequent contractions throughout the day. She calls the midwife advice line but gets an answer machine – she leaves a message. A midwife calls her back after a few hours and advises not to call the hospital until the contractions are very frequent. The woman explains that the pain is really bad when she does get a contraction and she is scared. The midwife dismisses the woman’s pain and tells her not to go to the hospital until she is in established labour.

The woman is concerned that she did not explain herself well enough because of her lack of English. She feels frightened and abandoned.

Post-natal ward

Positive interaction

The hospital midwives check up on the woman and baby regularly. The woman is encouraged to breastfeed and is shown ways to do this. At one check the midwife notices the baby’s eyes look a little yellow so she orders a jaundice test. The test comes back positive and the baby is treated. While this delays the woman’s discharge, she is relieved to know her baby is getting the treatment needed.

Negative interaction

The woman is struggling to breastfeed but the midwives do not have time to provide any support. She thinks the baby does not want to feed. The woman has been asked once or twice if everything is ok to which she just replies ‘yes’ even though she is feeling overwhelmed and emotional. She’s not sure if she should bother the midwives with her concerns about her baby being sleepy and not feeding well as she’s always been made to feel that she is overreacting.

As the examples illustrate, each interaction a woman has with maternity services is an opportunity to develop a strong, respectful and trusting relationship..

Acknowledgements

The Office for Equality and Opportunity (OEO) would like to thank the local community organisations, services and partners for their diligent work in helping to organise focus groups and in-depth interviews with the ethnic minority women and the healthcare practitioners across the 4 locations.

OEO would also like to thank all the ethnic minority women and healthcare practitioners who gave their time to participate in our research.

1. National Institute for Health and Care Excellence (NICE) provides guidance around the routine antenatal care that mothers and babies should receive. ↩

2. Health score for a newborn baby 5 minutes after birth based on ​​appearance, pulse, grimace, activity and respiration. ↩

3. This was based on the MBRRACE 2018 report that found that Black women were 5 times more likely to die in or shortly after pregnancy than White women. Figures in the latest MBRRACE report indicate women from Black ethnic groups are almost 3 times as likely to die in childbirth compared to White women.  ↩