Woman's Hour - Black women are five times more likely to die in pregnancy, birth or postpartum than white women. Why?

Episode Date: July 15, 2019

Black women in Britain are now five times more likely to die during pregnancy, birth or postpartum than white women. This is according to the latest study from MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK). And the risk has been increasing year on year. On today’s Woman’s Hour we concentrate on these disturbing statistics – released late last year, but receiving very little attention.We discuss why this could be happening with Elsie Gayle, an independent midwife and nurse with 30 years’ experience in the NHS; Daghni Rajasingham, a consultant obstetrician who speaks for the Royal College of Obstetricians and Gynaecologists; Jenny Douglas, the founder and chair of the Black Women’s Health and Well Being Research Network and a senior lecturer at the Open University; and Mars Lord, a doula.We also hear the birth experiences of some of the many women who contacted us, and are joined in the studio by Remi Sade, a writer and podcaster, and Candice Brathwaite, the founder of Make Motherhood Diverse.And we look at historical attitudes to black women’s bodies in obstetrics and gynaecology. Deirdre Cooper Owens is a Professor of History who explores how the field of gynaecology developed through the experimental treatment of black slave women in the American south. She is professor of history and medicine at the University of Nebraska-Lincoln and the author of Medical Bondage: Race, Gender, and the Origins of American Gynaecology.Presenter: Jenni Murray Producer: Helen Fitzhenry Interviewed guest: Elsie Gayle Interviewed guest: Daghni Rajasingam Interviewed guest: Jenny Douglas Interviewed guest: Candice Brathwaite Interviewed guest: Remi Sade Interviewed guest: Mars Lord Interviewed guest: Deirdre Cooper Owens

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BBC Sounds. Music, radio, podcasts. Hello, this is Jenny Murray welcoming you to the Woman's Hour podcast for Monday the 15th of July. In today's programme we concentrate on disturbing statistics that show black women in the UK are five times more likely to die in childbirth than their white counterparts. The figures were released late last year but received surprisingly little attention. Well, today we'll ask why this is happening to so many women. To what extent is it the result of unconscious bias or prejudice or maybe assumptions made from historical evidence of black women's role in the development of obstetrics and gynaecology.

Are such women simply expected to be able to get on with it, as Loretta was? The consultant came into the room after we raised the alarm again. She confirmed that I was nine centimetres dilated and that we needed to go to the birth suite. We pretty much were told by the bidwife to basically get our stuff out of the ward and take it with us. I was expecting to have a wheelchair, like I'd seen the other ladies on the ward who were about to give birth. They were wheeled into the birth suite.

I wasn't provided that at all. By this time, I had still not had any pain relief. Well, the numbers which came out last November have been rising for some time, and the mortality rate for black women is much higher than for any other ethnic group, although Asian women are twice as likely to die as white women. Well, how were the figures collected, and why do some people within the medical research community believe they may simply be the tip of an iceberg?

Well, Dagny Rajasingham is a consultant obstetrician who speaks for the Royal College of Obstetricians and Gynaecologists. Jenny Douglas is the founder and chair of the Black Women's Health and Wellbeing Research Network and a senior lecturer at the Open University. And Elsie Gale is a midwife and nurse with 30 years experience in the NHS. Elsie, how surprising are these figures to you? I am very concerned about these figures because ever since 2001, I have been observing them myself. When I attended the Embrace report on the 1st of November 2018, I noted a rise from three times more likely to die to five times more likely to die for women of African descent. And Asian women had basically remained the same. It really concerns me as a woman myself of African descent, because within this country,

where we have good quality midwifery care, well-trained midwives and a really good support system in the obstetric world that we should be having these figures. What we heard from Loretta at the beginning is so basic and so shocking that you know pain is ignored, there was no wheelchair, even when she was nine centimetres dilated. Why could such a thing happen? Well, I have been able myself to journey having little pots of money to look specifically at the voices of women. So women of African descent appear to complain bitterly about not being treated the same as everybody else. They say they are ignored, their voices are not heard,

and even when surveys are done and they are asked their opinions, one woman said to me, well, why should I take part in any more surveys? They take our information and we hear nothing. Dr. Ipdet, what do you reckon we learn from this mortality rate about the risks black women are facing in childbirth? The statistics are awful and you'll know that this is part of the Embrace report. We've had a confidential inquiry in this country for decades. The figures are shocking and the rise is there. And it is a complex problem in terms of

medical conditions that women may have, the risk factors that they may enter pregnancy with, the fact that none of us in this country really plan and prepare for pregnancy as we probably should, to be in the best possible health. But regardless of ethnicity, that is true, surely, that no woman prepares, and yet the mortality rate for black women is so much higher. Why? It is. So the variation, there are several potential reasons for it that are being looked into in detail by Embrace. One of the differences may be the fact that with certain ethnic groups, we get certain conditions that predispose in pregnancy

to really poor outcomes and, in some cases, mortality. But the problem is complex. We have an interplay of socioeconomic factors. We have, as Elsie has just very eloquently said, this issue of not being heard. Jenny, what sort of attention would you say has been paid to what's a rising mortality rate by policymakers or practitioners? I would say that very little attention has been paid by policymakers and people who are planning services and commissioning services.

It was for that reason, many years ago, 2011, that we set up the Black Women's Health and Wellbeing Research Network. I was very concerned that although this is not just in relation to black women and maternal mortality, but in relation to a whole range of health issues, black women are having poorer health. And it seems to be persistent. And we don't seem to have any focus on looking at why this should be so. We've had some research on breast cancer that shows that black women are likely to have more aggressive breast cancers, we've had research about hypertension and stroke, we've had research about mental health. But what we seem to have is small pockets of disparate research. And we set up the network to try and bring together

researchers working in different spheres in relation to black women's health. And how successful have you been at achieving that? We've brought together researchers. We've had a number of seminars and conferences. What we possibly need to do much more of is lobbying politicians, service providers and practitioners to make sure that we start to see changes in service provision. Because maternal mortality is, the issue is urgent and it's getting worse. And we can't see anything that is being done to actually try and address this. How aware, Dagny, would you say the medical profession has been of these statistics? So the statistics have been there.

They've been publicly available. They're part of our continuing professional development. But I think Jenny raises a really important issue. These are systemic issues that we haven't addressed systemically. The professionals are aware of it. And we are there are certain things that we're doing to try and improve it. But my fear is that those are things that will take time to come to fruition. What are you doing to try and improve it? So you will know that we now in this country have the first chief midwifery officer, Professor Jackie Dunkley-Bent. Her agenda is very much on continuity of carer. And we know that when

women have continuity of carer, that is continuity of carer from a midwife or a team of midwives, that their outcomes are better. We don't have the resources to provide continuity of care for every woman, so we should be focusing them on these groups that we're talking about. I'll say something you said really struck me. You said we make or break people in maternity care. What did you mean by that? The first 1,001 days of a human being's life impacts them forever. So starting from the moment of conception until the age of two sets the life course. So we actually

have to begin to care for women, whoever they happen to be, before conception, and then we give them a humanised style of care so that they can actually journey well through childbirth, through the pregnancy, the labour, the birth, and then supporting them at least for six weeks after so that they can then nurture their babies to the best of their ability. You see, a humanised form of care is what you would assume would be a given. Why isn't it? The NHS, it is struggling, I think. This is my own observation.

A lot of doctors are leaving the profession. Obstetrics is a very challenging profession in terms of the litigation. The organisations in which people have to work are very stretched. Midwives are walking, they're voting with their feet, so they may go to work, they don't get a coffee break, they don't get a lunch break, nor a tea break, they can't even go to the loo sometimes and when they go home, which is often late, their wee is orange. Jenny, how much trust do you think women have in the service? Because I think from what Elsie has found, a lot of women are saying, no I'm not going to go into the system. I'll give birth on my own at home. Yeah, I would agree that from the research that's out there, a lot of women are losing trust in the system. A lot of women have had poor experiences. And I know we probably don't want to mention it, but a lot of black women experience racism and discrimination.

There are a whole raft of assumptions made about black women, about black women's ability to cope with pain, not listening to black women. And I think that until we start to take an approach that recognises the complexity of the lives of black women, we're not going to be able to develop appropriate services. Well, Jenny, Dagny and Elsie, for the moment, thank you all very much indeed.

If we look at the history of the development of obstetrics and gynaecology, some of the answers to 21st century mortality rates may lie in the 19th century. There's clear evidence that pioneering doctors in America used female slaves to perform experimental procedures such as caesareans and removal of the ovaries on women who were poor and powerless.

Deirdre Cooper-Owens is Professor of History and Medicine at the University of Nebraska-Lincoln and the author of Medical Bondage, and she joins us from America. Deidre, how did the research on women who were slaves begin? Thank you for having me. It really began over a decade ago when I was writing my dissertation and found a line in a book by scholars Janetta Cole and Beverly Guy Sheftal that was a really brief mention of James Marion Sims, who was known as the father of gy the United States, and also being a doctoral student at UCLA, I had never heard of experimental research on enslaved women in particular. And as

I started to dig a bit deeper, I saw that James Marion Sims had in fact been included in a cohort of white medical men in the 19th century, many of whom were Southern slave owners who had a vested interest in trying to restore the reproductive health of enslaved women so that the engine of slavery could continue. Especially after the transatlantic slave trade had been banned by the United States Constitution in 1807, there was even more emphasis on trying to have what slave owners called natural increase. Now you use the term in the book, medical superbody. What do you mean by that term? Medical superbodies is really a fraught term. I wanted it to be because there are a lot of racial fictions that were inscripted by doctors and scientists.

You know, we call them natural historians centuries ago who had ideas about black people's distinctiveness. So, for instance, black women were more masculinized. They were more primitive. And so even someone like Thomas Jefferson, considered one of the great founding fathers of the United States, wrote in his only book that the reason people of African descent look the way they do, and he talked about prognathesis and their skin complexions, is because African women wanted to mate with orangutans, whether than form sexual partnerships with their own men. And so when you have the leading thinkers writing about Black biological distinctiveness in this way, there is a particular way that physicians begin to think about, examine, treat, and write about Black bodies. And so there is an idea that Black people can withstand more pain, especially Black women during childbirth. And yet at the same time, there will be these notations and ideas also about Black women that somehow they're biologically inferior to white women's bodies. And it really

was this racial fiction because these doctors never gave up the practice of choosing to experiment on black bodies to cure everybody, including white ones. How was the work of these American gynecologists, obstetricians viewed by others in the medical profession at the time? It changes over time. Initially, when you had someone like Ephraim McDowell, who is considered the father of the ovariotomy, so he did pioneering experimental work to remove diseased ovaries, typically tumorous ones. When he published his findings based on his experimental research, largely on enslaved women, he was ridiculed at first. And a part of the ridicule coming from a leading British surgeon in, I believe it was the Lancet, Dr. Johnson essentially says, well, of course these women could undergo cutting because their bodies can bear pain the same ways that dogs and rabbits can.

And so there was a kind of ridicule, right? This would be expected because these women were negresses, as they were called. And then you have, and that was in 1809 to about 1817. But by the 1840s and 50s, when someone like James Marion Sims does this kind of experimental research, and there is a record of success in terms of the surgical cures, all of a sudden he's lauded globally. He really becomes an international figure within the rise of gynecology and obstetrics. What impact would you say these early pioneers had on the way Black women are treated in the maternity services today? Oh, the legacy that they left was really one of

medical racism. And so much of what they learned in the 19th century, believing in the biological distinctiveness between black people and white people, believing that women were a subset of men. So, for instance, women in general, regardless of race, don't experience a lot of pain around surgery because they don't have a lot of nerve endings in the upper vaginal area. I mean, all of those kinds of things that these men were learning in the 19th century have unfortunately followed in terms of the medical curriculum in the 20th and 21st centuries. And so when you have leading hospitals coming out of really elite universities, like the University of Virginia, for instance, in 2016, serving their students, their residents, even some physicians about their ideas of black patients. You tend to have a lot of these old racist ideas mired in a kind of old school racial science. You know, once again, black people don't experience pain. It doesn't matter the age, the severity of the condition. Black people have thicker skin, thicker blood. I mean,

there are all kinds of ideas that when black people, especially women, request pain relieving medicines, they are thought to be addicted to drugs. And so there is a particular way that I am really trying to show that racism is still a public health crisis. And so often people talk about the ways that blackness becomes the kind of culprit in maternal morbidity conversations. But it's not blackness. It's not the person's hue or race.

It really is the racism that emanates from a medical field that was literally founded on the wombs of enslaved women. That's the problem. I think you have actually had some experience of this, of pain in this context. What happened to you? I couldn't have imagined that 10 years after first beginning my dissertation research that I would be undergoing in vitro fertilization. And so I remember being on a wait list. I lived in Manhattan at the time

in New York and going to what was considered one of the best fertility specialist centers in the city. And the doctor really having a wonderful bedside manner. And I remember he told me I had a condition called cervical stenosis. And essentially that meant that my cervical opening was closed. And so he would have to open it. Now, I don't have children. I wasn't personally familiar with what that process meant. So he told me I would have to get my cervix dilated. And I should take at least a Motrin or two. So a pain relieving aspirin that's typically used for menstrual cramps about 15 minutes before I arrived. I took Tumotrin. I came. And after the speculum, the duckbill speculum that was also perfected on

enslaved women by James Marion Sims in the 19th century, once that speculum was inserted, the doctor held my cervix in his hands and he took a metal dialer. What that means is a long metal rod with a metal brush, and he essentially bore a hole or an opening into my cervix. I had never experienced that kind of pain in my life. This happened for 15 minutes. I screamed, and I remember a nurse just kind of looking at me as if I was somehow, you know, getting on her nerves. And then the doctor left and the nurse left, told me to stay, keep my legs elevated for 15 minutes and to walk over to the next hospital for the HSG, which is another diagnostic exam. My body had responded so negatively to that that I was swollen,

and so he couldn't perform the HSG diagnostic exam. But I do remember when I walked to the hospital after having to clean myself, find supplies in the office, a Black nurse was there. And I remember not really saying much, but she knew that I was in distress. And she was really the one who said to me, you know, so she just tried to talk to me. She said, oh, the doctor tells me you're a doctor. And I said, yeah, a historian of medicine, not an MD. And we kind of talked and she said, you have to write about this. And I said, well, I'm a historian. I write about dead people. And so she said, you have to write about this. And so in the forward, excuse me, in the afterward of my book, I included really as a meditation of unfortunately being a symbolic representation of those mothers of gynecology that I talked about, that nothing about my status mattered in terms of the way that I was treated. Deidre Cooper-Owens, thank you so much for joining us.

And I have to tell you, there is a group of women sitting in this studio, all listening to you, and we are all coming out in very sympathetic pain. Thank you so much for joining us this morning. You're welcome. Thank you for having me. Well, it's clearly not unusual for it to be assumed that a black woman will feel less pain than a white one, and that she'll be able to cope with whatever labour throws at her. We've spoken to new mothers and a new midwife, and there are only a few of the dozens of responses we've had to our requests for you to get in touch. So I was induced and I was kind of left on a ward and it wasn't just me there was another woman we were basically laboring by ourselves through the night no one

ever came in to check in and it got to the point where I was in so much pain and I couldn't kind of call for help all I had was my phone And I called my husband and told him to come back to the hospital, went to the bathroom because I felt like I needed to have a poo. And I felt my little boy's head. So I got rushed down to the labour suite where I gave birth about 10 minutes later. That experience wasn't great, but I didn't really think that was kind of down to anything other than, you know, just kind of stuff, not really checking in. And as I say, there was another woman in the same position as me. so my little boy was born he was very small he was um five pounds ten I also lost a lot of blood so we were told that we needed to be kept in to monitor

me and to monitor him and on the ward I discharged myself because of how bad things were basically no one came to check on us um I was offered water periodically asked if he was feeding and that was it and opposite us there was a white couple and they had nurses and midwives come in and you know kind of talk to them they were sat with them just having a general chat on an ipad kind of recommending different like breast pumps and things like that and me and my husband had absolutely no one say anything to us other than offer us water and because I'd lost a lot of blood I was feeling very woozy there's one point I was sat on the bed holding my son and I literally felt like the room was turning and I had to give him to my husband because I didn't feel safe to continue to hold him feeling in such a state it basically got later

and I think it was basically like 10 o'clock where you know visitors had to leave and I didn't feel safe to be alone with my little boy because of how bad I was feeling and the fact that we'd had no support literally we just got offered water a handful of times and that was it no one did any kind of checks on my son other than the general kind of check he had off ward after he was born and no one did any checks on me at all and so it got to midnight my husband was still there I was really scared that he was going to get asked to leave so I decided to discharge myself. A consultant came in she was like yeah you're going to need birth sleep I had to basically walk and I just found it kind of outrageous that I mean I'm literally about to give birth and you're just making me carry stuff when everybody else that I'd seen on the ward had been given a wheelchair

all the other women I had seen were white and then it was me that was the only black girl when I got to the birth suite we kind of got abandoned again so my partner's trying to help me get onto the bed and stuff and I'm literally in so much pain by this time I still had no pain relief I just remember everybody kind of came in and then they realized the baby's heart rate was dipping because he'd had the cord wrapped around his neck so they had to basically rush me into theatre. I do remember them saying that if I am put under and my partner can't be in the theatre room with me which was fine but they sort of just left him there and he wasn't told any more information so for at least an hour or two hours he was just thinking what's

happened to both of us he didn't know anything um the type of surgery i had and the amount of anesthetic i was given i was reacting to it quite badly with being sick so they promised that they'll give me antipsychotic medicine but i never received that so again we're forgotten about we eventually got taken back to the ward i was just thinking i don't know how busy the hospital was but this was really bad because you know seeing other women they seemed to be treated and responded to quite quickly and perfectly and then when it came to me everything was just going wrong then the next day one of the nurses was literally um you seem to be fine we're going to discharge you my partner looked at her and basically said no way she can't walk so how do you expect her

to be discharged the way she made me feel it was almost as if I was a burden asking to stay in hospital for another day. But because at the time I lived in a block of flats, it had stairs, there was no way I could have walked up the stairs with the type of surgery that I had. I'm a newly qualified midwife working for the NHS, so my eyes are still quite new to this environment. Although I have been practising as a student in the maternity wards for the three years preceding my qualification. I've often felt that black and minority ethnic women and families were treated differently by maternity staff, whether it's by offering a single room to white British families more often than to non-white ones or by not actually offering the same amount of information to women based on their ethnicity. I may myself hold my own bias and treat people differently and I hope conversations like this may help prevent that. Well how truly widespread are these kind of

experiences? Dagny stays with us and we're joined by Remy Sade who's a writer and podcaster about being a young mother and Candice Braithwaite is the founder of Make Motherhood Diverse. Candice what was the response to your expressions of pain during labour? Non-existent to be honest the clip version of my birth was I was induced which I find to be quite common amongst women of colour. And it was 19 hours of induced labour to only dilate to two centimetres. By that time, I wasn't allowed to get off the bed or take in any food or fluid. And I was like, I can't physically bear this pain anymore. And they wanted me to do a further 12 hours.

And I was like, I sign out and I pushed for a c-section and I as we were being wheeled down I remember the surgeon saying let's hurry this one up because I was meant to be home two hours ago and that I only hold that with me as the story develops so I'm discharged the next day um as the about three days in I'm starting to feel worse not better and I understand it's a c-section but I'm sweating through two-hour mattress I'm feeling really dizzy different midwives are coming to see me every day and I'm telling them how I feel but it's being written off as oh you're a new mum you don't understand understand, you know, this is very normal. One night, we're so exhausted, new parents,

I fall asleep with my daughter on my chest and I'm awoken by the most horrific stench. And the smell woke me up, that's how bad it was. And I thought, my word, I know they said new babies, poo really stinks. And as I stood up, I felt fluid slide down the top of my thighs and when I pulled my tracksuit bottoms open it was black pus oozing from my c-section wound I'm blue lit back to the hospital I'm all I'm thinking about is my baby she's only three days old an hour later surgeons rush into the room they're like we're taking you down to surgery right now. I'm like, what's wrong? They're like, you're slipping into septic shock.

And if we don't sort you out now, you will not see tomorrow. My daughter was born on the day my dad died. And he died of sepsis. And I remember thinking, I kept telling you I didn't feel well and everyone kept... Candice, that is just so awful. What have been the reactions of your midwife who I know so happened to be black?

She was really apologetic. I had a black midwife, an Asian midwife, and a white midwife. I had three of them. And she was really apologetic, as were everyone. And I think at the time the trauma was just so overbearing because after that I was separated from my daughter for four weeks. So I didn't get back into her life until she was five weeks old. And it was just apology after apology, but also a very please don't sue us type vibe.

Trying to apologise without accepting responsibility for what had happened. And then once I did start to unpack the trauma, all that stood with me was hearing that surgeon say let's hurry this one up how different do you honestly think it might have been if you had been white completely different completely different I've had a friend who recently had a child via emergency c-section and she whatsapped me in the morning because we work together and she said I'm really scared and I actually responded saying don't worry you're white you will be fine. Rennie how were you treated as you went through the antenatal period by consultants and midwives? Originally my consultant was horrific so because my Bmi was high but my bmi wasn't over the threshold of being able to labor as i chose i was still referred to a consultant or referred to

see my consultant who let me know that my child would probably be born with shoulder dystocia so they should probably just book me in for an elective C-section. I wasn't even in my third trimester. Like that conversation shouldn't have happened. Also, because of my age and as you mentioned, socioeconomic status, I think they assumed that I was just unaware of my options. And then I saw a consultant midwife who said to me that black women have a curvature in their spine, which means that they have a predisposition to difficult labours, which was also something that I just don't think I needed to know. But how true was that? I don't know. The truth is I don't know and the truth is that most women of a certain socioeconomic status

regardless of race don't know certain things but usually the information they are armed with is quite different and so I think that that had a lot to do with it. Let's just ask Dagny. Dagny, is there anything to support that assumption? So there are differences, ethnic differences in the pelvic shape of women. But I think your point is the information you were given,

the way you were given it, and the timing of that information just was not appropriate. And I also think if you know that there are differences in the pelvic shape, then make a service which provides varied types of care instead of providing a service which is a one size fits all when you as healthcare professionals are clearly aware that that cannot be distributed equally among different types of women when our bodies, as your medical research has shown you, does not respond the same way to all types of care.

How did it happen in the end? Because you wanted a home delivery. Yeah, so after that conversation with those two health care professionals, I was absolutely petrified. I was also aware of the birthplace study and I knew that as a first-time mum there was a slightly increased point something percent risk to a child being born at home but for mothers there was no increased risk and so I chose to go down the home birth route also because it meant that I would have continual care by my midwives if I was under the care of a home birthing team. My consultant remained the same. I ended up going into hospital for something else as an emergency and I met an obstetrician who was a black woman and that completely changed my whole experience as a pregnant person.

And so I basically fought and I was like, I want to change my consultant and at 32 weeks I did. And she didn't really change the information, but her delivery changed a lot. However, when I went into labour, my midwives were overrun and unavailable and there were other women labouring. So because of that, I got given a midwife who I didn't know. She came to my home. I was in active labour. I had a birth pool in my house that I'd

arranged myself. I was in labour for about, I think, 18 hours. And then when I went into more active labour, I decided I wanted an epidural. I wanted to go to hospital. And the ambulance came to my house and then I was like, I need to push. And I'd dilated from five to nine or 10 centimetres in about an hour. So they were like, right, you can't leave. You can't go to hospital. You can't get an epidural. I was pushing for about an hour. My daughter's head was not coming through the birth canal as it should have. At that point, things went very haywire. I was put in an ambulance. Somebody injected me with something, one of the paramedics. I was rushed to hospital. And then when I got to hospital, long story short, I was cut with like, you know, the episiotomy

stuff with no anaesthetic. I was screaming and I said, I can feel you cutting me. I was injected with some local anaesthetic, and then I was cut again. And it was horrific. It was one of the worst experiences of my life. Dagny, how well are difficult, high-risk pregnancies prepared for and handled? I suppose it depends on the services and the service providers and where you're having a service and what sort of the higher risk pregnancies that you deal with, you tend to deal with them better.

And when I say better, I'm talking about technically a lot of what we're talking about here is that really important, as Elsie said, human side of these experiences. Having an episiotomy without any pain relief should happen very, very, very, very rarely. It's a difficult thing to think about how do we provide these, as you have very clearly said, bespoke services. A one-size-fits-all isn't the way maternity services should be provided. And to some extent, I think in the trying to have guidelines so that we know what we should be doing in most of the time means that there are groups of women who are not catered for because they aren't the middle of that normal distribution curve in terms of what

generally tends to happen and so making tailored and bespoke services and guidelines is important and it comes back to Jenny's point about where's this information where's the research and how do we use it and do we inform the guidance or do we do it for the majority and therefore we end up having potentially the situation that we're talking about how much of a problem is the whole bmi question i mean we we know that a lot of women are overweight these days whether they're black or white or whatever color they are how easy is it for you as a professional to judge how difficult it's going to be for a woman to give birth naturally if she's very, very obese? So the data around BMI and groups of women is very clear. If you have BMIs above a certain amount, a BMI of 20 to 25 is the normal range. And with each increase in BMI, and especially so after 35,

and more so after a BMI of 40, you do have an increased risk of pregnancy complications. And that's throughout pregnancy, getting pregnant, high rates of miscarriage, high rates of problems with the baby, high rates of problems in labour and after labour. So it is a real risk. And our duty of care is not to ignore that real risk. A woman who has a higher BMI also has a higher risk of having diabetes,

a higher risk of hypertension, and both of those relate to poorer pregnancy outcomes as well. Can I just add, I had a lower BMI than 35, and I ended up losing so much weight in my first trimester that I was told to try and maintain my weight and when my daughter was born she was born with a cord around her neck and so I understand what you're saying about you know the care being tailored but also I think that even when looking at external factors such as BMI and all of those things there needs to be an

awareness about the changes that happen in a woman's body because women aren't weighed throughout their pregnancy. They're weighed at the beginning of their pregnancy. And so your birthing experiences might not be reflective of what a healthcare professional originally expected it to be. And that's a personal judgment. Well, Remy, Dagny and Candice, thank you all very much for the moment. Now, what can a black woman coming into her pregnancy and hoping for the best in antenatal care, delivery and postnatal care on a par with any woman of any other ethnic origin do to ensure that she doesn't suffer from prejudice or the assumption that she's tough enough to cope with whatever happens.

Well, Elsie Gale and Agni Rajasingham are still with us and we're joined by Mars Lord, who's a doula. Mars, you're there to support the woman and sometimes the couple if they both need support. How often do you find yourself suggesting things could be done differently or done better by the professionals over there? What kind of things have you pointed to? So I've pointed to the black woman that's been told within a few hours of being in the

birth centre that she needs to now go on to the labour ward because there's a possible obstruction because she's had no progress and yet she's been in the birth centre for less than four hours. I've been in the birth centre with white women for 18 hours before that conversation even starts. And I wish I could say that it's something that surprises me, but I find when I'm working with black and Asian clients, they're finding it much harder to get into the birth centres. They're finding it much harder to be listened to.

So how well do you reckon they have been served as black women in the antenatal period? It's very difficult to talk about how race affects you in the antenatal period if we just keep it isolated to that. We live with our daily microaggressions, etc. We live in a society that's systemically and structurally not set up for us. So when it comes to the antenatal period, I talk to my clients very much about what they can learn. The internet, I think, has been an absolute lifesaver for black women because suddenly we're beginning to hear that ours isn't the only isolated story. When you have a woman that is talking to a midwife about breastfeeding support

and seeing a group of white women being shown into a room where they get breastfeeding support and she's told, I'm sure you need to get home for your other babies when her first baby that she has just given birth to is in the neonatal unit because there's an assumption that because you are black surely you must have multiple babies from multiple partners waiting at home and why would you want to breastfeed? So, Elsie, significant numbers of women, as you've observed, are opting for births at home by themselves. If they're hearing those kind of stories, how could they be made to feel safer doing it either at home or in hospital,

but with medical help? It's very difficult, Jenny, if I am honest. And one of the ways that I have had to start working because I myself have observed the disparity in treatment, irrespective of whether the women are professional or not. I experienced similar sort of treatment myself when I was expecting one of my children. My work now and the work of many midwives who are associated with the group Midwifery Conversations, what we are doing is working with women to support them in terms of what ought to be happening. We're helping them to find the information,

to understand the systems within which they are receiving the care, and to help them to access when they need to. So, for example, if they're having a problem with getting a scan or getting their voice heard, then we might direct them to a senior midwife in the system rather than complain to pals or somebody. So it's really about helping them to traverse the system and achieve the help that they need, whatever that is. What about the obstetricians? To what extent does the obstetrician feel he or she

is there as an advocate for the woman or are you simply somebody who steps in if there's a problem? So I have and always will, as an obstetrician, consider myself as an advocate for women. And I think that's a professional responsibility that both midwives and obstetricians have. This issue of how do we address what is a huge and listening to the stories very disturbing problem is complex and I think there is something about the way we educate professionals there's something about the way we train them there's something about the way we get them to hear voices like

this so the maternity voices partnerships is one way throughout their careers not just at the start but throughout the careers to understand the impact of saying something in a certain way or a phrase or a gesture and how that stays with some women for a long long time. Mars, Dagny mentioned earlier that we now have a chief midwifery officer in England. She's black. Yeah. And she's keen on continuing care. Yes. What difference will she make? I think she'll make a huge difference. I have one concern and not about continuity of care, because I think continuity of care is so important. And it's one of the things that we doulas offer, because we meet our clients often really early within pregnancy, is if your carer is someone who works and operates with implicit bias, and they are your carer from

beginning through to the end, how does that serve the black woman, the Asian woman who is trying to, using Elsie's word, traverse this system? How are we going to travel through the system if the person who we are supposed to trust Can we say some? There are one or two that, but, you know, let's not point fingers. But we're working with a system that was not designed for us. It's a white patriarchal system. It's a white male system. That's what the medical system has been set up for. The fabulous Sheila Kitzinger, when she talks about birth, says that birth should be like the female orgasm, but is mostly treated like the male orgasm. Hold, hold, push.

There's no fluttering. There's no opening. There's no allowing the woman's body to do what it does because it's all about times, measurements, etc. And when you work within a system that has a set way to do things amongst a huge number of women who are not generic, then we're going to have problems. Well, Miles, Lord, Elsie, Gail, Dagny Rajasingham and everyone else who's contributed this morning, thank you all so much for being with us. And of course, we do want to hear from you. Let us know if you have had good experiences or if you had bad experiences. We really want to hear from you.

We're at BBC Women's Hour on Twitter and Instagram, or you can email through the Women's Hour website. Bye-bye. Hello. Sorry to interrupt your content consumption, Bye-bye. are joined by a brilliant guest to discuss the bewildering pursuit of adulthood. We talk sex, jobs, rejection, jealousy, sex, all with help from BBC Radio 4. That's the Grown-Up Land podcast. Make sure you subscribe on BBC Sounds. I'm Sarah Trelevan, and for over a year, I've been working on one of the most complex stories I've ever covered.

There was somebody out there who's faking pregnancies. I started, like, warning everybody. Every doula that I know. It was fake. No pregnancy. And the deeper I dig, the more questions I unearth. How long has she been doing this? What does she have to gain from this? From CBC and the BBC World Service,

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