Black Maternal Health Awareness Week 2022

Caroline Nokes Excerpts

Wednesday 2nd November 2022 Westminster Hall

[Caroline Nokes (Romsey and Southampton North) (Con)]

Thank you—Sir James?

[James Gray (in the Chair)]

Sadly no—not yet. It is in the post.

[Caroline Nokes]

That is a terrible omission. It is a pleasure to serve under your chairmanship, Mr Gray. I thank the hon. Member for Streatham (Bell Ribeiro-Addy) for leading this debate on a crucial issue.

The Women and Equalities Committee has twice held one-off evidence sessions—although there is a slight conundrum in twice having one-off sessions—looking at black maternal health. It has taken evidence from campaign groups, such as Five X More, and experts in obstetrics and gynaecology, yet the picture does not change. Looking at the evidence, we have known that there is a disparity in the health outcomes for black mothers since the early 2000s. For 20 years, we have known that there is a problem, yet still it continues. It has been a huge privilege for me to serve on panels alongside people such as Clo and Tinuke from Five X More, who have done so much incredible campaigning to highlight the issue, as has the hon. Member for Streatham. It is crucial that we begin to see progress; we cannot, 12 months or 10 years down the line, continue to have the same debate.

Raising awareness in Parliament is vital, but what we actually need is Government action. The hon. Member for Streatham made a slight dig about Government reshuffles. I am delighted to see the Minister in her place; this is an issue on which we have engaged before and she takes it seriously. I hope that the Secretary of State for Health will himself grasp the issue, and ensure that we drive it forward to see progress.

We have heard that one of the challenges is data, and the lack of specific data being collected on maternal health outcomes for black and Asian women. I pay tribute to Five X More, which carried out its own experiences survey that included 2,000 women—a huge number—reporting their experiences and findings. The thing that really hits home for me is the repeated use of the phrases, “I didn’t feel listened to,” “We weren’t listened to,” and, “What I was experiencing was being ignored.”

I am loth to say that we sometimes have very gendered healthcare, but look at the evidence. Look at the fact that when there is medical research, it is almost exclusively carried out on men; look at the fact that drug trials are carried out on men; look at the fact that some of the highest backlogs as we come out of the pandemic are in health conditions predominantly affecting women. Whether it is in cardiac, obstetrics or another sphere of medicine, too often the experience is, “I didn’t think they were listening to me.” I am sure every Member hears that from their constituents, and that has been my experience as a constituency MP. I hear from my constituents that, specifically in the area of maternity, “I wasn’t listened to. Nobody paid attention. It was my body, and I knew something was wrong.”

Only last week, I received an email from a constituent who had lost his daughter-in-law moments after she gave birth. He was with his son, helping to bring up a baby and pursue a complaints procedure against the hospital in question. Throughout his email, he kept making the point that they had not been listened to. His daughter-in-law had been a midwife, and even she was not listened to.

Talking to black and particularly Muslim women—I should declare an interest as chair of the all-party parliamentary group on Muslim women—they feel that their voices are doubly ignored, and that there is that intersectionality. Whenever I talk to journalists about intersectionality, they look at me and say, “Please don’t use that word. Nobody understands that word.” It is imperative that we all understand that word. You will be discriminated against if you are a woman, and you will be discriminated against if you are a woman from a black, Asian or other minority ethnic group; when the two come together, as we find in maternity units in particular, women’s voices are not heard or listened to.

When we talk to the Royal College of Obstetricians and Gynaecologists, as the hon. Member for Streatham has done, it calls for specific targets for black maternal health outcomes, and it is right to do so. Although it may be a small number as a percentage of births every year, it is still a significant number. The loss of one mother is one too many.

[Jim Shannon]

It is always a pleasure to listen to the right hon. Lady; she brings lots of wisdom and knowledge to these debates. Ministers in other debates we have had in Westminster Hall, in different positions in the Department of Health and Social Care, have always spoken about the issue of data. The hon. Lady is outlining examples of where data could be used to formulate a Government and ministerial response. Does she agree that the Government really need to grasp the data issue? They can then prioritise their strategy to respond.

[Caroline Nokes]

I thank the hon. Gentleman for his intervention. I did not think he would be entirely able to resist speaking in the debate. He is right: policies must be data-driven and evidenced, but the evidence is there and has been for many years. We are augmenting and adding to that body of evidence the whole time.

I will not be entirely negative, because we have some great opportunities. I was pleased to see Dame Lesley Regan appointed women’s health ambassador earlier this year. I welcome, reinforce, champion and offer anything I can to help the women’s health strategy. Finally, we have one of those, and I pay tribute to the Minister who was instrumental in getting that published. What we now need from the strategy is outcomes. That has to be the focus. What is happening to drive outcomes, and to ensure that the disparities we know exist are recognised, acted on and reduced? Our goal has to be to reduce that horrendous figure of four times as many maternal deaths for black women. We have to improve the outcomes for black babies, so that there is not, as I think the hon. Member for Streatham said, a more than 100% likelihood of stillbirth—

[Bell Ribeiro-Addy]

Increased risk.

[Caroline Nokes]

Increased risk. The hon. Lady is absolutely right to highlight that as an imperative. We must ensure that we reduce the inequity, of which there are many drivers. She was with me when the Women and Equalities Committee took evidence from Professor Sir Michael Marmot, who talks so compellingly about health inequalities and their drivers.

I will not say that there is anything wrong with black women’s bodies—there is not—but we have to look at housing conditions, air quality and the areas where they live. Air quality is a significant driver of poor health outcomes. We have to look at what we are doing around smoking cessation, which is good for not just black women, but all women. We have to look at obesity, which is, again, a crucial factor for all women.

I look forward to seeing, in the remainder of this Parliament, focused and determined action around obesity, smoking cessation and air quality. There are targets on all those things, but—how can I put this gently?—there has been a little backsliding on some of them. Targets have been pushed into the dim and distant future, and there is less commitment around drives to reduce obesity and smoking, which are incredible drivers of poor health outcomes across the population. We should double down on our commitment to those targets.

I hope that in due course—I get fed up of saying “in due course”, which is a standard ministerial answer—to see a White Paper on health disparities. It is imperative that we get that done, and that the women’s health strategy is seen as a driver to ensure that we improve outcomes. First and foremost, I reiterate the calls from the hon. Member for Streatham for targets. I am never a great fan of targets if they are just there for the collection of targets, but if they work, and we see that in many instances they do, we should have them.

We should have time-limited targets, so that in maybe three years we can look and say, “Nothing has changed.” Looking at the data and the evidence from campaign groups, I see that over 20 years, nothing has changed. I do not want to be here in 20 years’ time giving the same speech on this important issue, feeling that nothing has changed. I look forward to the Minister’s comments, and reiterate my congratulations to the hon. Member for Streatham on calling for today’s debate.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Mr Gray. I thank the hon. Member for Streatham (Bell Ribeiro-Addy) for securing this debate. As she highlighted, we had a similar debate recently. I hope that my comments reassure her that we are taking action and making progress in this area.

I take the issue of maternal disparities very seriously; that is why when I was in post previously I set up the maternity disparities taskforce, which has brought together a range of specialists and campaigners. We have heard from groups such as Five X More and the Muslim Women’s Network to hear their views on what is going wrong right now, what systems we need to put in place to improve outcomes and also the experiences of black women in maternity services.

The data shows the disparities in black maternal health. We have heard about them clearly this morning, and I do not think anyone is in any disagreement about the scale of the problem we are facing. As the hon. Member for Streatham said, it is harrowing to hear those figures. The MBRRACE annual surveillance report shows that women of black ethnicity are four times more likely to die from pregnancy and birth compared with white women. I do not think there is a dispute about that; we fully acknowledge it and we want to reverse that trend as quickly as possible.

[Caroline Nokes]

I want to make a quick point about MBRRACE and the data. Data collection remains tricky, with some hospitals not reporting women’s deaths—not necessarily maternal deaths—until up to 500 days after they have happened. Then there is a delay with the medical records and notes, which might indicate the reasons for that. What reassurance can the Minister give that she will work to reduce those times?

[Maria Caulfield]

My right hon. Friend is absolutely right. Although Five X More does its surveys about the experience of women, the data on outcomes is very delayed. When we put measures in place, we cannot see the difference they make until the data comes through, roughly 18 months to two years later, as my right hon. Friend said. That lag does not help us determine whether the measures we are putting in place are actually making a difference. Getting that on track is a key priority for me so that we can accurately measure what is happening.

From the data that we do have, The Lancet series in April last year found that black women have an increased relative risk of 40% of miscarriage compared with white women, and the stillbirth rate in England for black babies is 6.3 per 1,000 births, compared with 3.2 per 1,000 births for white women. That is completely unacceptable, and as the hon. Member for Streatham said, we cannot come back here, debate after debate, without seeing those figures move. One potential cause for optimism is that we do not have up-to-date data on the benefits of the interventions that we have put in place, so it might be better than we think. However, we absolutely need that data, not only to measure what is happening, but to know whether we are heading in the right direction if we set targets in the future.

To reassure Members, I want to clarify the point about not setting a target because the problem is too small. I do not agree that the problem is too small; it is a significant problem. Even if it is affecting one or two women, it is a significant problem, so that is not a reason not to set a target. As the hon. Member for Putney (Fleur Anderson) pointed out, there are multiple factors in why black women often face poorer outcomes in pregnancy and birth, and for their babies. It is a mix of personal, social, economic and environmental factors. Air quality, which the hon. Member touched on, also has an impact on overall health. The maternity disparities taskforce found that being in a lower socioeconomic group has a significant effect on maternal outcomes, and black and ethnic women are often in those groups and so face a double whammy in terms of their likely outcomes.

We cannot just fix this in isolation at the Department of Health and Social Care. That is why I am pleased that in my role for women’s health—I am also the Minister for Women, across the board—I can bring in other Departments, because we need to take a cross-Government approach to this issue. Whether it is the Department for Environment, Food and Rural Affairs on air quality, the Department for Levelling Up, Housing and Communities on housing, or the Department for Work and Pensions on employment, we need to work together so that all the factors affecting black maternal health are addressed in tandem to address this issue.

We know from a health perspective that pregnant black women are more likely to suffer from some chronic diseases that will affect their maternity outcomes, and in particular cause poorer mental health. There are health initiatives that we can put in place to ensure that we improve the outcomes for black women, but that cannot be done in isolation from the other factors that also negatively affect them.

Given the risks that such conditions pose in pregnancy, there is a need for safe personalised care for black women and women from ethnic backgrounds, because the needs of women from each and every community are so different. Just nationally introducing blanket systems will not address some of the problems; there is no one single solution that will improve the statistics and improve the outcomes for women.

The issue is not just the outcomes from maternity services. As we heard from the hon. Member for Streatham, the Five X More survey also reflects the general experience by black women of the healthcare system. Although black women are often at a more difficult point to start with, when they engage with health services they often have a very negative experience. We have seen that in the recent publication of the East Kent maternity report and in the Ockenden maternity review, which highlighted that there is racial discrimination present in some parts of the maternity services.

We cannot allow that to continue, because if we want black women to come and engage with services and to come forward when they have concerns, if they feel that they are not being listened to or if they raise concerns and they are dismissed, why would we be surprised when they do not engage with services in the future? Regarding the East Kent report in particular, I will look at the calls for action on how we improve black women’s experience of the healthcare system and considering how we can address those issues as urgently as possible.

When we consider the actions that we are putting in place, and I will touch on some of the ones that have already started, I am very much a supporter of Professor Marmot’s idea of proportionate universalism, whereby we introduce good services across the country but then we target those people who are most in need; in the case of black maternal health, that is clearly women from the black community. We need to go to them rather than expecting them to come to the health service: we have a universal offer, but ensure that it is targeted specifically at those who do not experience the best outcomes.

On targets, as my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) touched on earlier, we have an issue with data collection across the board in health services, including in maternity services. Black women often experience the worst outcomes, although some of the data that we are seeing is from 2020. For some of the initiatives that we have put in place in the last year or 18 months, we are not yet seeing the benefit of those initiatives in terms of outcomes. I am being very candid here: we have not got a handle on what is making a difference, or on which parts of the country are doing well—as was acknowledged by the hon. Member for Bolton South East (Yasmin Qureshi), the shadow Minister, there are some very good practices in place—and which parts of the country are still not supporting women in the way that women want.

We are working with NHS England, the Office for National Statistics, MBRRACE-UK and the National Neonatal Research Database, because there are also multiple sources of data. We need to pull all the data together and get it as close to real-time data as we can, so that when we introduce interventions and measures we can know whether they work.

As part of the maternity disparities taskforce, I am also keen to make sure that we include black women more in the national patient survey, because the shadow Minister was quite right that we had over 100,000 responses to the women’s health strategy but only a small percentage of those responses came from black and ethnic minority women. That illustrates the problem that we are talking about—that black women do not feel represented, or do not feel engaged with the process. So we have to change things and work is being done to address that situation.

We are introducing some measures. First, we have set guidance that each local maternity system is now working in partnership with women and their families and their local areas to draw up equity and equality action plans. For each local maternity system’s local area, there has to be a plan in place about how to improve the outcomes for women. The plans are agreed by the local maternity systems and the new integrated care boards, which were set up in the summer. They were published last week, so I encourage hon. Members to look at their local action plans to see what they are putting forward and to challenge them if they feel that they are not meeting local community needs. That is why they are done on a local basis: what is appropriate in my constituency of Lewes may be different to what is needed in Streatham, Putney, Leicester East, or Romsey and Southampton North. It is really important that we look at those action plans to make sure that they address the problems that we are concerned about. Every plan is being reviewed by NHS England, which will identify areas of good practice and the support that is needed to drive them forward.

In addition, we have also commissioned 14 maternal medicine networks covering the whole of England, which will ensure that women have access to specialist management. We know that black women are more at risk of high blood pressure, diabetes and sickle cell anaemia and yet many of those risk factors for their pregnancy and birth are not dealt with or managed. The maternal medicines network will bring in specialists so that, at an early stage of their pregnancy, those women can access those specialists to help them manage their pregnancy. They will also be offered pre-conception advice for further pregnancies. We have never done that before. We are targeting the risk factors of black women, and all women who are at risk, to make sure that they get the medical support and advice that they need during and after their pregnancy.

The Department also launched the £7.6 million health and wellbeing fund last year, which is supporting 19 projects throughout England to try to generate best practice guidelines that we can introduce to help reduce disparities. These projects include supporting expectant young black fathers in child development and providing perinatal mental health support for black mothers. If we can get some evidence-based best practice, we can look to roll that out across the country in the coming months and years. There is a lot of work going on.

I will touch on the issue of racial discrimination. It is clearly unacceptable that black, Asian and ethnic minority women feel that the health service is not accessible or not responsive to their needs. There is education and training for NHS staff on health disparities to eliminate bias and racism in obstetrics and gynaecology. The Royal College of Obstetricians and Gynaecologists’ race equality taskforce has developed e-learning cultural competencies. They now form part of the colleges’ members continuing professional development. The Nursing and Midwifery Council is also looking at how to promote and embed equality and respect in professional practice, so that they can create an environment where everyone feels that they can access the services they need. We will obviously continue to look at this with the maternity disparities taskforce, which is bringing in campaigners, experts and professionals to try to drive momentum on this issue.

Data is the key. I can give a commitment here that has been highlighted already. We need that data. We cannot be working with data that is two years old to see if we are making a difference because, if we are, we will not know about it for two years and will not be able to roll out good practice in other parts of the country. In my brief as the Minister for Women, I am aiming to bring that across other Departments as well.

I hope I have reassured hon. and right hon. Members in today’s debate that I am committed to continuing the work to tackle the disparities in outcomes to ensure that everyone has the opportunity to live a long and happy life. I am happy to work with the APPG on black maternal health, which is chaired by the hon. Member for Streatham, because it is only by working together to identify good practice and raising it when things are not working well that we can eliminate the disparity: it is unacceptable that black women are four times more likely to die during pregnancy simply because they are black women.