Identifying and quantifying the problems of maternal inequality

In recent years, there has been a growing focus on the inequalities that are driving global disparities in perinatal outcomes within a range of populations and across multiple settings. Where reductions in maternal mortality over time are observed, they are associated with access to good quality reproductive health and maternity care, whereas conditions that create barriers to sexual and reproductive health services are where inequalities flourish.

The UN 2024 report on the state of world population2 has highlighted ‘the uncomfortable truth’ that progress in improving sexual and reproductive health ‘ has not been enjoyed equally’. The report tells us that although some barriers to healthcare have come down over time, this has mostly been for those easiest to reach, leaving those most marginalised within our societies experiencing the least improvement.2 These most marginalised groups are often those who are in a minority relative to their community, subjected to discrimination, living in a conflict setting, trapped in poverty or are unprotected by reproductive and human rights. Rather than assuming that progress will continue over time and simply rely on progress following an upward linear trajectory, it is important to remember that reproductive rights require ongoing protection; change in attitudes, social and structural discrimination, shifts in political ideology and ongoing power imbalances can erode or dismantle these rights.

Discovery of data and understanding of the intersectionality of inequality

To draw attention to the consequences of inequality, greater awareness of perinatal outcomes is required and in recent years improved data surveillance has led to observations of the size and nature of inequalities in differing settings. A report from the USA in 2023, which looked into circumstances contributing to pregnancy-related death, determined that discrimination contributed to 30% of deaths,3 and reports from UK maternal mortality surveillance have highlighted disparities by maternal ethnicity for over 10 years4 with the most recent noting that Asian women were two times as likely to die, and black women were four times as likely to die when compared with deaths in white women in the perinatal period. These sobering statistics have served as a call to action and illustrate that high-income countries are not immune to the issue of maternal inequality. In recent years, charities and activist groups have been advocating for improvements to maternity care for black women and other minority groups have been raising awareness through representation of experiences. Black women were over-represented in those admitted to hospital with confirmed SARS-CoV-2 in pregnancy in the UK,5 6 and the global surveillance that came with the SARS-CoV-2 pandemic further highlighted inequalities, again shining a spotlight and raising questions about why some groups were suffering the worst outcomes unequally. The pandemic raised awareness of many aspects of societal inequality and the murder of George Floyd in the USA in May 2020 initiated a global antiracist movement, which saw protests in the USA and many countries across Europe bringing with it a new discourse about structural and individual level bias and discrimination.7 In August 2020, the American College of Obstetrics and Gynecology led a joint statement for collective action addressing racism with many US-based reproductive health organisations and in September 2020, the International Confederation of Midwives also released an antiracism statement.8 There seemed to be a positive shift towards top–down drivers for change.

However, racial inequality is not the only disparity that requires our attention. Other broader determinants of health9 remain as powerful as ever in influencing all health outcomes, including maternal and foetal health outcomes. Household wealth, for example, affects access to maternal health services.10 Cultural, language, geography, disability and underlying prepregnancy chronic health conditions (which are more prevalent in some groups of women) all impact on maternal health outcomes and women who experience any combination of these factors are even further disadvantaged. Intersectionality (combined or multiple disadvantages, primarily in relation to protected characteristics)11 can create or compound inequality. Furthermore, a complex relationship exists between intergenerational socioeconomic advantage and health literacy.12

Disappointingly, despite long-standing efforts to highlight the multiple well-established contributors to inequality, the evidence suggests that it continues to grow.13

Seeking effective solutions while reflecting on personal action

As nurses, midwives and health professionals, what can we do to reduce these inequalities and what might be effective? A recent systematic review of interventions to reduce inequalities in maternal and child health in low-income and middle-income settings found that studies were limited, but where there was evidence for impact was with outreach and community level improvements in healthcare together with increased human resource.14 The opportunity to receive perinatal care from a known caregiver via a model that promotes continuity of carer has also been suggested as a way to build trust, break down barriers and support those otherwise affected by inequalities.15

Organisations are encouraged to take an intersectional approach to maternity care practice and provision and to identify and understand structural inequality and thereby minimise its effect.11

Advocate for and drive the necessary change

The Surgeon General’s Call to Action to Improve Maternal Health16 offers detailed suggestions as to how women, their families, their communities and the organisations serving them can contribute at microlevel, mesolevel and macrolevel to shift practice towards greater accessibility, increased inclusivity and reduced inequality. Specifically, the Call to Action suggests healthcare professionals should support women to access maternity care and address racial and other disparities by offering services that are culturally and linguistically appropriate, underpinned by self and situational awareness.

Throughout our upcoming blog spotlight, we will hear from those working in practice to address inequality and in considering the maternity workforce, as well as hearing from those driving the discovery of new data and insights. Through further understanding, each of us can reflect on our own position and potential to reduce inequity, through identifying the gaps, building knowledge, working towards effective solutions and driving the change.

Ethics approval

Not applicable.