Dismantle structural barriers to improve reproductive healthcare for racially minoritised women

Over the past decade inequities in reproductive outcomes among racially minoritised women have increasingly become a part of public health discourse. This is largely because of widespread advocacy efforts led by organisations such as Five x More1 and the Reproductive Justice Initiative.2 It is an area that was the subject of a feature in the 2020 BMJ Racism in Medicine series,3 and it is just as relevant in this series, five years later. If we are to tackle these inequities, it is crucial that decision makers understand the complex, structural drivers of reproductive health inequality.

One of the key statistics—often at the forefront of this discourse—is the disparity in maternal mortality between black and white women. In the UK, women of black ethnicity are twice as likely to die during pregnancy and the neonatal period as white women, and the maternal mortality risk among Asian women is also higher than in white women.4 This is just the tip of the iceberg—racial inequity stretches across the entirety of reproductive health. Risk of miscarriage is 40% higher among black women than white women,5 and black women in the UK have higher rates of repeat abortion.6 Racially minoritised women are more likely to undergo abdominal (rather than laparoscopic or vaginal) hysterectomy as treatment for benign conditions compared with white women.7 Black women in the UK are less likely than women of other ethnicities to have IVF cycles funded by the NHS, and both black and Asian women have lower IVF birth rates than white women.8 Similar patterns of inequity are seen across a range of reproductive outcomes, showing that structural barriers are affecting the health of racially minoritised women in a range of ways. Despite this, the interventions that are commonly proposed often take an individual, rather than structural, approach.

In 2021 draft guidance from the National Institute for Health and Care Excellence that proposed a lower threshold for induction of labour among women of “black, Asian, and minority ethnic backgrounds” was met with widespread criticism9 from a range of organisations including the Royal College of Midwives and the Royal College of Obstetricians. A binary stratification of interventions based solely on race or ethnicity implies that the increased mortality experienced by racially minoritised mothers is because of an inherent physiological risk factor shared by all women who do not identify as white. Given that there is no biological underpinning to racial categorisations—particularly when considering categories as large as “black, Asian, and minority ethnic”10—it is inappropriate for any intervention based around individual risk to be considered as part of the effort to improve maternal mortality among black and Asian women.11

One challenge, when attempting to tackle racial inequity, is the lack of diversity of expertise among those who design health policy. A system that works in silos will always find it challenging to make progress in improving a complex structural problem. To fully understand the structural racism woven through the reproductive health system, we need discussions that include political theory, medical history, and social justice. Reproductive coercion and injustice were built into the practice of Western colonialism,12 and the legacy of these atrocities persist in modern reproductive health. Until recently J Marion Sims, a surgeon who experimented on enslaved women without anaesthesia, was uncritically celebrated as “the father of modern gynaecology.”13 Confronting inequities in maternal mortality requires an acknowledgment of this history and its effect on the experiences of minoritised women. Examples include the continued use of pulse oximeters that do not accurately record oxygen saturation in darker skinned patients14 and under-prescription of pain relief because of healthcare workers’ belief that black people have higher pain thresholds.15

In addition, the differential reproductive health outcomes experienced by racially minoritised women cannot be tackled without a better understanding of medical misogyny. As with structural racism, structural misogyny has been inherent to reproductive medicine for hundreds of years.16 While there has been increasing investigation into biases that affect women’s health, very few have taken the ethnicity of patients into account.

The Hughes report investigated the life changing injuries experienced by thousands of women after the fitting of vaginal mesh. The report identified epistemic injustice (mistrust of a person’s words as a result of their identity characteristics) as a contributor to the harms experienced by the women involved.17 Given that racially minoritised people are more likely to experience epistemic injustice,18 greater recognition of this type of experience through the lens of race and gender may help us gain a better understanding of the persistent inequities in reproductive health.

A full understanding of equity in reproductive health requires an intersectional approach. Intersectionality, a sociological framework originally described by law professor Kimberlé Crenshaw, describes the heterogeneity caused by intersections of social positions (such as race, gender, socioeconomic status, and sexual orientation) and the effects that these intersections have on social experiences.19 This framework is particularly relevant to reproductive health, an area that is inextricably linked to race, gender, and sexual orientation, and to broad religious, social, and political structures. Intersectionality should, therefore, be integral to reproductive health, with a range of perspectives being presented throughout medical training, and a range of expertise being incorporated into the design and implementation of policy. If we want to achieve reproductive equity, we need to stop looking for single interventions and start examining the myriad barriers that prevent minoritised people from achieving the highest standard of reproductive health.