Inequity in maternity care

From the series: inequity in Dutch healthcare

Beeld door Mirthe de Haas: geboortezorg

The Netherlands is known for the way in which the maternity care system is organized. Unlike other western countries, the Netherlands has a culture in which pregnant people can choose where they want to give birth. Home birth is more common in the Netherlands than in any other western country. The ‘culture of giving birth at home’ has recently even become part of Dutch intangible cultural heritage. It’s thus not surprising that home births still happen frequently in our country. It has been proven that it is safe to give birth to a child in the Netherlands, because the Dutch birth care system is well-organized and professional. Unfortunately, it has also been shown that giving birth in the Netherlands isn’t equally safe for everyone. 

Unfavorable health care outcomes for pregnant people with a migration background
A report from the Dutch National Institute for Public Health and the Environment shows that pregnant people with a migration background, depending on their term of pregnancy, are 30-50% more likely to lose their baby than pregnant people without a migration background. In addition, it even appears that pregnant people with a migration background, compared to pregnant people without a migration background, have a higher chance of dying themselves or becoming seriously ill in the last weeks of pregnancy, during and immediately after giving birth. Black women are most at risk in this regard. Why is that?

The white pregnant person as the norm
There are a few studies that show why Black pregnant people and pregnant people of color (and their children) more often die or become seriously ill during childbirth. One study suggests that maternity care workers are simply not prepared to treat Black patients and patients of color. This is something that I recognize from my experiences as a midwife.
Nurses who don’t visit a Black birthing person or a birthing person of color as often as they would visit a white birthing person, because they assume that pain relief will be chosen anyway. Midwives who provide incomplete information to Black pregnant people and pregnant people of color because they find it difficult to navigate around a language barrier. Gynecologists who don’t ask for permission prior to performing medical procedures, because they don’t see the added value of shared decision-making with someone who may not know exactly how the Dutch maternity care system works. Maternity care nurses who do nothing with a sick baby, because they only recognize the symptoms on white skin… And this is only a fraction of what I’ve encountered in practice. 
Treating the white pregnant woman as the norm makes the birth process of a Black pregnant woman or pregnant woman of color more likely to be unnecessarily medicated or otherwise seen as abnormal. That’s terrible. This is how traumatic experiences, unnecessary medicalization and unfavorable birth outcomes for both the birthing parent and the child come to exist.

Institutional discrimination in maternity care
Discrimination in maternity care doesn’t only occur in the hospitals and midwifery practices in which I worked or did my internships. It’s not a problem of one region, ethnicity or religion. It’s a problem so deeply rooted in maternity care that Black pregnant people and pregnant people of color face it on a daily basis. A distinction is made in the care that they are given by their ancestry alone. An example: anyone who is not from Northern Europe is considered to have a greater chance of developing gestational diabetes. Why? Because of the underlying idea that if you come from somewhere else, you have an unhealthy lifestyle. Without even asking a single question about that, the standard is that all these pregnant people should be monitored extra for gestational diabetes. I think that’s absurd.
The same goes for high blood pressure during pregnancy. Pregnant people with a migration background are automatically considered to have an increased risk of high blood pressure, something that can be extremely harmful for both the pregnant person and the unborn child. It’s believed that this predisposition for high blood pressure is a result of ancestry, a biological disadvantage that everyone who isn’t Northern European carries with them. This is simply not true. In fact, it’s known that depression, anxiety disorders and stress have a negative influence on a person’s blood pressure. We now also know that perceived discrimination has exactly these effects on people. 
I wonder why we still feel comfortable in 2022 with treating symptoms and nurturing polarization, also in maternity care, while we have volumes of evidence and suggestions on how it can also be done.

Better care outcomes possible
There’s scientific evidence that it’s possible to do better. For example, an American study shows that Black babies treated by Black doctors have a significantly lower mortality risk than Black babies treated by white doctors. The same research states that stereotyping and prejudice can play a part in this. It also states that white doctors simply don’t quite know what Black babies need. This sentiment is continued in another study, which argues that Black maternity care workers and maternity care workers of color are necessary to improve the health outcomes of Black pregnant people and pregnant people of color (and their children). That serves as the silver lining, because that means that something can be done about the inequity in maternity care!

More diversity needed in maternity care
We now know that maternity care users with a migration background are in an unfavorable position in the Netherlands. We also know that pregnant people and babies with a migration background benefit from care providers with a migration background. The solution, therefore, seems simple: maternity care needs to be more diverse. The current situation in this country is disproportionate. While about 25% of our society is made up of people with a migration background, only about 5% of maternity care workers also have a migration background. That discrepancy has a long history, starting with where you’re born. Are you born in a neighborhood with a low socio-economic status, do you go to a school with large groups of children where there is little individual attention, and do you end up in an environment where people don’t look further than where you’re “originally” from? Then there is a good chance that you will be taught that you cannot simply become a doctor or a midwife. The inequity in birth care is exacerbated by the inequality of opportunities, which is a persistent problem in this country. The solution? That’s more complex than can be captured in one final paragraph. The more diverse maternity care gets, the better everyone’s health outcomes become. The more diverse maternity care workers are, the more white maternity care workers can learn about the right way to care for Black patients and patients of color. After all, good healthcare outcomes for people with a migration background aren’t the responsibility of Black people and people of color. Good healthcare outcomes for everyone are everyone’s responsibility. If you’re reading this, have a migration background and the ambition to work in maternity care, I’m speaking directly to you: you are needed more than you think. Your arrival will bring about more change than you can possibly imagine! Don’t hold back. We need you. 

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