Diversity & Equality in Health and Care Open Access

The maternity care experiences of black women in the United Kingdom (UK): a systematic review

Gloria Chukwuji^*, Nasreen Ali and Chris Papadopoulos Institute for Health Research, University of Bedfordshire, UK
^*Correspondence: Gloria Chukwuji, Institute for Health Research, University of Bedfordshire, UK, Email:

Received: 30-Jul-2024, Manuscript No. IPDEHC-24-21043; Editor assigned: 01-Aug-2024, Pre QC No. IPDEHC-24-21043 (PQ); Reviewed: 15-Aug-2024, QC No. IPDEHC-24-21043; Revised: 20-Oct-2024, Manuscript No. IPDEHC-24-21043 (R); Published: 27-Oct-2024

Introduction

Maternal health disparities represent a pressing public health issue in the United Kingdom, particularly affecting Black African and Caribbean women [1-3]. Statistics reveal that Black African and Caribbean women are approximately twice as likely to experience stillbirths and other severe complications during pregnancy and delivery [1,3]. Additionally, these women report lower satisfaction with maternity services and more negative interactions with health professionals, which can exacerbate stress and adversely affect both maternal and neonatal health [3-5].

Several interrelated factors contribute to these disparities. Limited access to quality prenatal care is a primary concern, often stemming from socioeconomic challenges such as lower income levels, higher unemployment rates, and inadequate housing conditions prevalent within Black African and Caribbean communities [6-8]. Language barriers further complicate access to essential services, as many women may have limited proficiency in English, which can hinder effective communication with service providers and building trust and understanding [9]. Cultural insensitivity and a lack of cultural competence among healthcare professionals also play critical roles, leading to misunderstandings, mistrust, and feelings of alienation among Black African and Caribbean women [3,10].

Discrimination and implicit bias within the healthcare system significantly undermine the quality of care received by these women. Experiences of racism, whether overt or subtle, can deter women from seeking necessary medical attention and adhering to prescribed care plans, thereby worsening health outcomes [3]. Organisational factors, such as fragmented care, a lack of continuity with healthcare providers, and difficulties navigating the maternity system further impede the ability of Black African and Caribbean women to receive consistent, culturally appropriate, and person-centred care [11,12]. The impact of these disparities extends beyond immediate health outcomes. Poor maternity care experiences can negatively influence the social and emotional development of children, as well as the overall well-being of families [7,13]. The intergenerational transmission of health inequities underscores the urgent need to address the root causes of these disparities to promote improve long-term health-related outcomes [6,7,13]. While existing research highlights various barriers faced by Black African and Caribbean women in accessing maternity care, there remains a lack of comprehensive synthesis that consolidates these findings to inform targeted interventions. This systematic review seeks to bridge this gap by collating and analysing primary research focused on the maternity care experiences of Black African and Caribbean women in the UK.

Aim

The aim of this systematic review was to synthesise evidence on the experiences of women from Black, African and Caribbean backgrounds in the UK when accessing maternity care services.

Design

A systematic literature review study design was employed. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines were followed for this review. The process involved a comprehensive identification and assessment of both published and unpublished reviews. The approach was informed by the collective experience of the authors and adhered strictly to established guidelines for conducting and documenting systematic reviews. This rigorous process allowed for the evaluation of the quality of available evidence, a succinct summary of outcomes, and an assessment of the robustness of various conclusions through cross-comparisons [14].

Search Methods

Selection Criteria

The scope of this review includes research studies published between 2010 and 2022. The inclusion criteria required that studies be written in English, based on primary research, and focused exclusively on the UK population. Particular emphasis was placed on both qualitative and quantitative research exploring the maternity care experiences of women of Black African and Caribbean ethnicity in the UK. To ensure relevance, certain exclusion criteria were applied.conducted outside the UK were excluded, as were studies that did not specifically focus on women of Black African and Caribbean ethnicity or those that diverged from the topic of maternal care experiences.

Search Strategy

A literature search was carried out using the required computerized databases, including PubMed, PsycInfo, CINAHL and SocIndex. The Boolean operator “OR” between words and phrases with different meanings as well as the Boolean operator “AND” were used to combine concepts in order to narrow the search. The search technique used pertinent search phrases on studies related to black, African and Caribbean women’s experiences receiving maternity care in the UK and they are as shown Table 1 below. The titles and abstracts of the papers identified were then screened against the inclusion and exclusion criteria (Table 1).

Table 1: Keyword search string as listed by component search term category

Data Extraction

Relevant data were extracted from the studies manually. Data were extracted and entered on a Microsoft Excel spreadsheet. The data extraction headings were as follows: Author(s), year of publication, journal title, article title, study aim and objectives, study design, participants, study location, sampling technique, study size, data collection method, data analysis, key findings, and conclusions.

Quality Appraisal

Following data extraction, the Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the quality and rigor of the included studies in order to gauge the potential strength of the findings of the current review. Knowledge of appraisal techniques allows you to examine published papers with an eye toward systematically assessing their credibility, applicability, and results. The MMAT serves as an essential assessment instrument specifically tailored for the appraisal phase in systematic mixed studies reviews. These reviews encompass a range of study types, including qualitative, quantitative, and mixed methods studies. The tool enables the evaluation of methodological quality across 5 categories of studies: Qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies [15]. A second member randomly checked 50% of the papers and found full agreement.

Screening

The initial screening of the initially identified papers assessed their suitability before delving into a more comprehensive review of their content using a predetermined strategy. This approach involved iterative consultations among the research team to pinpoint studies of interest warranting deeper exploration. GC, in collaboration with NA, conducted this iterative process, with subsequent validation and consensus on suitable studies for further investigation by NA and CP. After the initial studies were identified, duplicates were manually removed. This was followed by an initial screening of the papers based on their titles and abstracts, adhering to the established inclusion and exclusion criteria, which led to the exclusion of additional papers. Manual searches also uncovered potentially relevant sources of grey literature. Once potentially relevant papers and additional grey literature items were identified, a more comprehensive extraction of information from each paper or item was undertaken. The goal of this data extraction was to support the intervention mapping process, enhance the synthesis of data and findings, and facilitate a clearer evaluation of heterogeneous interventions. Both GC and NA reviewed the identified papers against the inclusion/exclusion criteria, and they agreed that the studies clearly met the inclusion criteria.

Quality Appraisal

The included studies across qualitative, quantitative, and mixed methods domains displayed positive indicators across key evaluation criteria. All of the qualitative studies that were looked at-Goodwin et al., Puthussery et al., MacLellan et al., John, Curry, and Cunningham-Burley, and Konje and Konje met the criteria for clear research questions, appropriate data collection methods, and supported interpretations of findings. In the realm of quantitative studies, works by Peter and Wheeler, Henderson et al., and Raleigh et al. consistently met the assessment criteria [16-23]. They showcased clarity in research inquiries, suitable data collection approaches, and robust statistical analyses. In the context of mixed-methods studies, the assessment of Henderson & Renshaw revealed a comprehensive alignment with evaluation criteria [24]. This study had good research questions, good data collection methods, good integration of qualitative and quantitative parts, and good interpretation of the combined results, all while following the quality standards of each methodological tradition (Table 2).

Table 2: Summary of study quality appraisal using mixed methods appraisal tool (MMAT)

Narrative Synthesis

The results were analysed using narrative synthesis, as a meta-analysis of the quantitative data was not possible due to significant heterogeneity across the studies. This narrative synthesis was structured around the key themes of access to maternity services, barriers to care, and service utilisation, allowing for a detailed exploration of these themes within the context of Black African and Caribbean women’s experiences in the UK.

Results

Study Identification

Electronic searches from PubMed, PsycInfo, CINAHL, and SocIndex yielded a total of 618 citations. The titles and abstracts of the papers were checked, and there were 71 duplicates and 532 that did not meet the inclusion/exclusion criteria. After being obtained directly from the data sources, the remaining 15 papers were retrieved and evaluated for inclusion in the review. Furthermore, 6 pieces were omitted because they did not address the topic of interest. Therefore, nine studies were included in the review because they met the inclusion criteria (Figure 1).

Figure 1: PRISMA flow diagram depicting the selection process of studies for systematic review

Analysis of Included Studies

Description of the Included Studies

The studies included in this systematic review were based in the UK. The analysed data was collected from a diverse sample of women across cultures to better understand their expectations of and satisfaction with, the maternity care they received. There have been only 4 studies that looked at what changes would be needed to make maternity care more accessible for black, African and Caribbean women in the UK. Observational, cross-sectional, and retrospective studies were conducted to gather quantitative and qualitative data on black communities’ use of maternity care services in the UK. Researchers in the UK gathered information about the maternity care options available to black. African and Caribbeanwomen, as well as the obstacles that prevent them from using those options. Study Design and Sampling Peter and Wheeler used a mixed method including both qualitative and quantitative approaches to study the challenges black, African and Caribbean women in the UK face in obtaining maternity care, and Henderson et al. employed a quantitative approach and a retrospective study design and a secondary data analysis of national maternity survey using descriptive analysis in 2010 [21,24]. John, Curry, and Cunningham-burley conducted qualitative research, and Raleigh et al., Konje and Konje, Knight et al. conducted quantitative research [19,20,23,25]. Puthussery et al. conducted an in-depth qualitative study where participants 34 participants were interviewed, while Goodwin et al., carried out an ethnographic study using a semi-structured interview, and MacLellan et al. did a qualitative study using thematic analysis [16-18]. As previously mentioned, a portion of the research utilized retrospective and observational designs, while others were cross-sectional studies [19-21,24]. Questionnaires were used in all quantitative research, whereas in-depth interviews and focus groups were the primary data collection methods for qualitative research.

Study Participants

All of the participants were female. Peter and Wheeler’s study included 1,300 black, African and Caribbean women [21]. In the study by Henderson et al., a total of 24,319 female respondents filled out the survey and their study in 2017 included 4578 women with 47% response rates [24]. The study by John, Curry and Cunningham-Burley, included 16 women mainly in the Scottish health board area. Pregnant or recently delivered women of African American, Asian, and other minority ethnicities were recruited for the current study by Raleigh et al. [19,23]. Puthussery et al. interviewed 34 UK-born women of black, African and Caribbean origin [17]. Goodwin et al. conducted their study with 9 migrant Pakistani women and 11 midwives in the Pakistani community and MacLellan et al. utilized 20 study participants out of which 7 were white British while the rest of the participants were of black, African and Caribbean backgrounds There were 2 Arabs and 7 black Africans or people of African descent [18,25]. There was also one black Caribbean person, one Asian Indian, one Asian Chinese, one Asian Bangladeshi, and one Asian Pakistani. Only nine of the women were pregnant at the time of the study, while the other 7 were mothers. Konje and Konje held 2 focus groups with 5 to 6 women, speaking both English and Somali, with the help of an interpreter [20]. A full summary of the background information, methodological details, and key findings of the included studies is presented in Table 3.

Table 3: Summary of included articles

Narrative Synthesis

There were significant variations in the reporting of data on empirical evidence on black African and Caribbean women access (barriers and enablers) to maternity services in the UK, their experiences with maternal care services, ways of improving maternal care services for black women. As a result of which it was challenging to compare data across the studies.

Empirical Evidence on Black Women access to Maternity Services in the United Kingdom

Black, African and Caribbean women are more likely than white women to report negative contacts with healthcare workers; these interactions, which are frequently based on racial biases, have a detrimental impact on their experiences of care, as demonstrated by the included research. Henderson et al. stressed that maternity care was significantly lower in quality for women of Black, African and Caribbean originthan for white women [24]. In addition, John, Curry, and Cunningham found that the current SARS-CoV-2 epidemic may further exacerbate racial disparities in maternal outcomes and access to prenatal care, and Burley’s research sheds light on the unique challenges faced by women of Black, African and Caribbean backgrounds during pregnancy [19]. Results and experiences of maternity care were found to be poorer for these women, single mothers, and those who finished school at a younger age. To the likes of Raleigh et al. experienced more macroaggressions while receiving medical attention than Asian women did [23]. Due to the clinical, social, and cultural complexity, all ethnic groups received biased care [25]. The availability of maternity care for Somali women in the UK was investigated by Konje and Konje [25].

Barriers to Maternal Care Services

In addition to the problems already mentioned, all of the studies also found difficulties in providing maternity care. Research by Konje and Konje, MacLellan et al. identified ineffective communication, lack of continuity of care social determinants, racism and unplanned bias as some of the experiences that lead to worst health outcomes amongst women of black, African and Caribbean origin [23,25]. Challenges in navigating the UK maternity system can arise for women who have a large number of specialists involved in their care or who are not fluent in English [25-31]. Organizational elements, as well as various personal and community factors, have been identified by Konje and Konje as stumbling blocks to women accessing maternity care [25]. Some examples include having faith in God or community elders, avoiding medical help out of fear, or believing what other women say about their own experiences.

Maternity Services and Systems

Women from Black African and Caribbean backgrounds have not seen an increase in access to or satisfaction with maternity services over the past decade or more, even though policy can affect changes in maternity care. These Women of reported that they did not feel valued as individuals by the maternity care system, as found by research by MacLellan et al. internalized racism is a persistent problem within the maternity care system, as stated by John, Curry, and Cunningham-Burley [19]. According to Peter and Wheeler, several black, African and Caribbean women felt the maternity system was unfair because of the difference in treatment they received from medical staff compared to white women or even their white relatives [21].

Strategies for Improving Maternal Care Services for Black African and Caribbean Women

After reviewing the available literature, women reportedly suggested a number of strategies to increase access to and the standard of prenatal care [20]. Several suggestions were made, some of which dealt with improving communication, understanding cultural differences, and providing better service. The women who participated in the research agreed that an established figure in the community leading or participating in a discussion specifically for women would be an effective way to spread the word. According to Peter and Wheeler, educating and raising awareness about the health issues disproportionately affecting black African Caribbean women benefits healthcare providers, maternity care workers, and patients [21]. MacLellan et al. suggested that in addition to creating laws aimed at promoting equality and eradicating racism, correlated community hubs and continuity of care in prenatal services are necessary [18]. Peter and Wheeler contend that more representations of people from Black, African and Caribbean backgroundsin medical media and educational materials would improve the quality of care provided to patients. According to Henderson et al., social support and integration act as moderators, allowing for greater insight into the experiences of women who do not speak English [21]. John, Curry, and Cunningham-Burley argue that better maternity care should be the primary focus of efforts to reduce racial and ethnic health disparities [19]. They also argued that eliminating ethnicity-based disparities in maternal health can be achieved through in-depth studies of maternity systems to support the development of effective and robust interventions.

Discussion

This review provides compelling evidence of the ongoing struggles faced by Black African and Caribbean women in accessing maternity care services. The accounts of these women highlighted the widespread and frequent racialised interactions with medical professionals throughout the maternity care continuum, indicating that current satisfaction with care does not adequately reflect their access to these services [17-22]. The findings revealed the pervasive nature of racism within UK maternity care services [21]. The experiences of Black African and Caribbean women are marked by racial inequality, which is both institutionalised by NHS maternity services and perpetuated by certain clinicians within these services, as demonstrated by studies conducted by Khan, MacLellan, Peter, John, and Konje [18-21,31]. MacLellan et al. noted a paradoxical inversion in the allocation of limited maternity resources, where those most in need, particularly women from ethnic minority backgrounds, receive the least support [18]. This review builds on previous work by illustrating how healthcare staff who fail to understand or attend to the needs of Black African and Caribbean women can prevent some of the most vulnerable individuals from receiving necessary care [25].

According to Henderson et al., women from ethnic minority backgrounds across all groups reported negative experiences with maternity care [22]. The study demonstrates that nonwhite women generally receive lower quality maternity care compared to their white counterparts. John et al. further emphasised that ethnicity-based health disparities influence health outcomes and access to services across various prenatal care settings [19]. Black African and Caribbean women in the UK have identified significant gaps in their access to maternity care [16]. Women of African descent expressed dissatisfaction with maternity care, noting that government regulations and health recommendations often conflict with their cultural and religious practices, as reported by NHS England [8]. The cultural preferences of Black African and Caribbean women are frequently judged harshly, creating additional barriers to accessing maternity care in the UK [19]. Henderson et al. found that Black African and Caribbean women were significantly more likely to book late for maternity services due to systemic inefficiencies, compared to white women [22]. Research by Peter et al. and John et al. indicated that some Black African and Caribbean women were not fully aware of the importance of maternity services [21]. The authors suggest this may stem from uncertainty about their legal status in the UK, cultural pressures, and a lack of familiarity with the country’s healthcare system. Additionally, Konje et al. noted that Black African and Caribbean women expected resources available to them in their communities to be prominently displayed in maternity and community centres [19-20].

Women from ethnic minority groups have disproportionately borne the brunt of the inadequacies within the UK’s technological birthing system, which is frequently underfunded and understaffed [32,33]. The technocratic approach, which emphasises clinical tasks and safety measures over patientcentred care, has been linked to adverse psychological and social outcomes [32,34]. Recognising the particularly severe impact of this approach on ethnic minority women as evidenced by MBRRACE mortality and morbidity statistics-the Continuity of Midwifery Care (CMC) policy was developed [18]. Initially a response to broader concerns about the maternity care system, CMC models have increasingly been targeted at ethnic minority women in an effort to address these disparities and improve their care experiences. This shift reflects a growing awareness of the need for tailored interventions to mitigate the systemic inequities that pervade maternity care [18]. Concerningly, this situation persists despite the publication of numerous national policy documents and local programmes aimed at improving the pregnancy experiences and outcomes for Black African and Caribbean women [22]. Addressing this issue requires sustained efforts to recruit and retain midwives [35]. Nazroo et al. observed that during times of resource scarcity, caregivers may feel compelled to distance themselves from their patients [36]. This distancing is particularly concerning when it involves providing care to groups perceived as “other,” such as racialised communities. As a result, inequalities are not only produced and maintained but also become widely accepted as the norm, often viewed as a reflection of broader structural issues in the context of limited resources [18]. Khan emphasises the necessity for maternity services to engage actively with local communities and stakeholder groups to better understand their socio-cultural needs and enhance cultural competence [31]. To effectively eliminate health inequalities based on race or ethnicity, maternity services must be supported through the development and implementation of comprehensive, transparent national health policies and guidelines [18-22,31]. Although a few regulations make general references to Black African and Caribbean women, these regulations often lack the specificity and depth required to address the unique needs of these women and their communities.

In terms of the quality appraisal results, similarities were observed across various study types in the emphasis on clear research questions, appropriate data collection methods, and robust analyses [37]. Consistent with existing literature, the assessment underscores the importance of aligning methodological approaches with research objectives, whether in qualitative, quantitative, or mixed-methods studies [38]. However, differences emerged in the additional evaluation criteria employed in various systematic assessments. The existing literature highlights different aspects of study quality or utilises alternative assessment tools, thereby offering diverse perspectives on what constitutes methodological rigour across different study designs. As such, future research in this area should prioritise the development of more standardised and universally applicable criteria for assessing methodological quality. By harmonising assessment tools and criteria across different study designs, researchers can ensure more consistent evaluations of study rigour, ultimately enhancing the reliability and comparability of research findings.

This study had several limitations. The evidence synthesis relied solely on primary qualitative and quantitative studies, which were inherently limited by their scope, methodological quality, and presentation. The inclusion of both scholarly articles and reports from charities and public policy sources introduced heterogeneity, leading to variations in rigour and reporting. The exclusion of non-English studies may have introduced bias, and the omission of secondary research methods, such as systematic reviews, could have reduced the review’s comprehensiveness. The focus on UK-based studies further limited the geographical applicability of the findings. Despite comprehensive search efforts, some relevant studies may have been inadvertently overlooked, potentially affecting the completeness of the review.

Conclusion

This systematic review provides critical insights into the barriers, enablers, and maternity care experiences of Black African and Caribbean women in the UK. Inequities in service access and specific barriers deeply affect their maternity care experiences. The review identified actionable strategies to address these challenges, aiming to ensure equitable access and care experiences for these women. It emphasises the need for informed policy development and effective service implementation to improve outcomes. The 10 included studies offer a nuanced understanding of the health disparities faced by Black African and Caribbean women, providing valuable guidance for midwives, researchers, and policymakers in their efforts to reduce racial health disparities and improve targeted services.

Declarations

Funding

There was no public funding for this work.

Ethical Approval

Ethical approval for this systematic review was granted by the University of Bedfordshire.

Conflict Of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgement

Thanks to the University of Bedfordshire library staff for supporting us with the literature search for the systematic review.

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