A pregnant black woman sits on a big doctor's hand. Prenatal medical care and check-up. Psychological and medical vector concept

NICE induction guidelines: is this really a step in the right direction for pregnant women of colour?

Posted by for Life

Newly drafted guidelines from the National Institute for Health & Care Excellence (NICE) propose that all groups at increased risk of complications during birth, including Black and brown women, should be offered induction at 39 weeks. Here’s why that’s a problem. 

For the last couple of months I’ve been monitoring my cycle, as well as taking prenatal vitamins and supplements, like folic acid and q10, to improve the quality of my eggs. I’m also drinking less and attempting to get more active after all of the lockdowns we have endured.

No, I’m not trying to get pregnant, but I am gearing up to freeze my eggs. And, while I have no idea whether I’ll ever meet someone to start a family with, or whether I’ll go it alone one day, I’m already worried about what it will be like to be pregnant as a (mixed) Black woman in the UK.

Black women are four times more likely than white women to die in pregnancy or within the first six weeks of childbirth. Those with a mixed ethnicity, meanwhile, are three times more likely, and women from Asian ethnic backgrounds face twice the risk.

As if these heightened maternal mortality rates weren’t enough to contend with, us Black and brown women are also at greater risk than our white counterparts when it comes to underweight babies, preterm births, and stillbirths. In fact, statistics from the Office for National Statistics show that Black babies have a 121% increased risk of neonatal death, as well as a 50% heightened risk of dying within 28 days of birth compared to white babies.

Black woman holding her pregnant stomach
NICE has recommended that induction of labour should be considered at 39 weeks for women “with a Black, Asian or minority ethnic family background.”

Now, it’s worth noting that fewer than one in 10,000 women die in labour, and the infant mortality rate stands at 3.8 deaths per 1,000 live births here in the UK.

Still, though, the grossly disproportionate figures between white women and women of colour prompted me and many others to wonder just how many more Black and brown women and babies would have to die before the government actually did something about it.

Cue the National Institute for Health and Care Excellence (NICE) publishing its controversial new induction guidelines.

Earlier this month, the advisory service to the NHS recommended that Black and brown women should be offered induction (artificially induced labour) at 39 weeks, as opposed to 41 weeks for those who are overdue. 

And, while it’s a positive step that women of colour are actually being considered for once, I can’t help but feel that we are once again being treated as a monolithic group. Which means that, subsequently, these guidelines will do more harm than good.

“On average, human pregnancy lasts 40 weeks. However, if someone was to go into labour at 39 weeks it wouldn’t be classed as a preterm delivery,” explains Dr Christine Ekechi, a consultant obstetrician and gynaecologist at Imperial Healthcare and spokesperson for racial equality at the Royal College of Obstetricians and Gynaecologists.

This means that, while babies wouldn’t be premature, the NICE recommendation of inducing labour at 39 weeks gives women of colour less agency over their own bodies and birthing experiences. Indeed, as per Birthrights’ response to the news, induction is frequently considered to be more painful by those who have gone through it, and inducing labour also removes options such as giving birth at home or in a birth centre.

“The issue here is that stillbirths can occur at any point through the pregnancy journey for many different reasons,” explains Dr Christine Ekechi.

“We have been able to reduce the frequency of stillbirths that occur in the second trimester and the early third trimester. However, we haven’t been very good at reducing stillbirths that occur closer to the due date.”

She continues: “We are still trying to understand why these stillbirths occur – sometimes it’s problems with the placenta but other reasons have yet to be identified. We also know that Black and Asian women are twice as likely to have a stillbirth, but equally we know if we induce a bit before 40 weeks, we would probably reduce the stillbirths that occur. 

“That being said, using race as one of the markers for induction at 39 weeks, is a very blunt tool. The babies aren’t dying because the mother is Black or brown – but these women may be overrepresented in the other markers for induction like having high blood pressure, a high BMI, or diabetes.”

This overrepresentation in other markers is a clear indicator of how systemic racism within our society has led women of colour to develop risk factors – risk factors which we likely would not have had if we were on a level playing field with our white counterparts. 

And, much like our white counterparts, we should be treated as individuals. Instead, these guidelines further bolster and promote the racial biases within healthcare – both private and public.

A beautiful soon-to-be mixed race mother is in a hospital bed waiting to give birth. Her healthy mother is standing at her bedside in support.
There are concerns that the new NICE guidelines downplay evidence about women and birthing people’s experience of induction, and evidence about long term impacts.

While NICE has framed its proposition as guidelines, or discretionary and optional advice, they are not.  

“Following the landmark case of Montgomery vs. Lanarkshire Health Board (2015), the way that practitioners dealt with consenting patients for operations significantly altered,” explains health litigation lawyer, Jenny Bleasdale

“Legal principles established through case law are binding and they cannot be ignored. The case law on NICE guidelines is likely to have the same effect. When making a decision about how to treat a patient, ignoring and failing to adhere to the NICE guidelines is likely to lead to legal consequences.”

These guidelines, I imagine, will dehumanise women of colour further in the eyes of healthcare professionals. However, if induction saves our babies – there is still the issue of our own lives that has yet to be addressed – it feels as though we are left with no other option.

“I think irrespective of your ethnicity we need to treat pregnant people as individuals and consider their choices,” says Dr Ekechi. 

“It’s important that medical professionals discuss and explain, not dictate, so that informed choices can be made. We need to ensure we don’t generate fear, and leave women of colour worried that their choices have been taken away. This can result in poorer outcomes, as people won’t be willing engage with us.”

I hope and pray that healthcare professionals have the good sense to follow Dr Ekechi’s lead. As a Black woman who’s been gaslit and ignored by medical professionals in the past, though, I have my doubts. Especially as, when asking a renowned gynaecologist why Black women suffer with infertility issues at a greater number than their white counterparts, I was told that “perhaps they don’t follow their doctors’ instructions properly.”

I know all too well how racism plays a huge role in the perception of people of colour and the subsequent care we receive. I can already imagine the undue stress I’ll be under when I’m pregnant, and the self-advocacy that will be needed. I’m already exhausted. But what’s new?

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