This research looks at the experiences of midwives and obstetricians from ethnic minority groups of working in maternity services in England. It also explores their insights into the care of people from ethnic minority groups using maternity services.
We commissioned an independent researcher, Lucy Smith, to carry out this research and write the summary and full report.
Purpose of this research
The purpose of the research was to explore:
- Experiences of people from ethnic minority groups working in maternity services
- Insights that staff have into safety issues and experiences of people from ethnic minority groups using maternity services.
The findings from the research will inform insight and research work with people who use maternity services and with other staff groups. They will also guide CQC’s future approach to inspecting maternity services.
Background and introduction
Maternity services should provide good quality care to everyone who uses them. But there is evidence of inequities in how people from ethnic minority groups experience maternity care and outcomes in England. CQC commissioned this research to find out what maternity staff from ethnic minorities could tell us about these inequities. They also talked about what is being done, and what could be done, to address them.
This was a small-scale piece of qualitative research, conducted in two phases. First, 10 interviews with midwives from ethnic minority groups working in England (in summer 2023). The findings from these interviews fed into CQC’s annual State of Care report. Second, 10 interviews with obstetricians from ethnic minority groups (in autumn/winter 2023). The staff who took part were from Black or Asian backgrounds.
Findings from the research
1.What are the key issues and challenges experienced by staff from ethnic minority groups while working in maternity services?
- Maternity staff identified a backdrop of differential treatment for staff from ethnic minority backgrounds, which has a big impact on their experiences of working in maternity services.
- Some reflected on a hierarchy of experience according to whether they are British-born or UK-educated: being British-born, speaking English as a first language and being educated in the UK made life easier than for those who are educated elsewhere.
- Interviewees described a culture in which it is normalised for people from ethnic minority groups to tolerate discrimination from colleagues, including in terms of how work is allocated, and in terms of not being made to feel like part of the team.
- Several midwives noted that midwifery is a small sphere (compared to nursing), where it is easier for staff to ‘get away with’ perpetuating an exclusionary, ‘cliquey’ culture; and that this culture becomes more entrenched within a small group and harder to call out and challenge.
Staff reported experiencing microaggressions from colleagues, such as racially stereotyping language - and often a lack of awareness, or claimed lack of awareness, around this. For example, use of the word ‘aggressive’ to characterise Black women (both staff and women using maternity services), and then if called out on this, denying that it is an issue.
About a White staff member, they will say ‘that person is so passionate’ and when it’s a Black person, it is called aggressive. Even though those two people are saying the same thing.
- They felt that staff from ethnic minority groups had to work harder to prove themselves, than their White counterparts. Midwives perceived that they had less opportunity to develop and progress, compared to White colleagues, and both midwives and obstetricians felt that they were less likely to be represented in leadership and managerial roles.
Midwives and obstetricians talked about the fear of speaking up about unfairness towards themselves or to people using maternity services. When they did, they could find themselves ignored, dismissed, or even punished by negative treatment (such as not being given opportunities). Issues were ‘swept under the carpet’, or addressed only superficially, showing a lack of genuine accountability either by individuals or the organisation.
If you complain or raise a concern, it’s always, ‘we are sorry that you are having this issue and we are working on it’. If a White colleague complains it is escalated very quickly to highest management. When it’s an ethnic minority person it is swept under the carpet. Like if you complained about unfair workload, or bullying and harassment – they just say, ‘oh we are sorry, let’s investigate it – it might not be racism, it might not be bullying’.
- Interviewees reported impacts on their wellbeing, mental health, confidence, motivation and career options. Negative experiences can lead to midwives and doctors from ethnic minority groups feeling excluded, undermined and frustrated, and in some cases traumatised. Some considered leaving their profession or, if not British, returning to their home country.
2. What do staff think is being done to address issues for staff from ethnic minority groups?
- Longer-serving staff members reflected that things had improved over time for staff from ethnic minority groups.
- Some staff talked about positive initiatives in their trust, such as the Freedom to Speak Up champion, and staff networks, groups and training.
A few of those interviewed had EDI as part of their role, formally or informally - but cautioned that EDI requires proper resourcing and senior support in order to have an impact, and should not simply be a ‘handing over’ of responsibility.
If you want change – fund things to create change, and show you’re serious.
- However, overall awareness of initiatives was low, and many interviewees did not feel that this issue was a priority for their leaders.
3. What do staff think needs to happen to improve the experiences of staff from ethnic minority groups?
- Staff interviewed thought that increased diversity within the maternity workforce would improve the experiences of staff from ethnic minority groups.
- Increased diversity at senior levels would help to encourage staff from ethnic minority groups to feel able to speak up about discrimination, and provide role models to encourage career progression.
- Staff would like more effective channels for reporting concerns, without fear of being ignored or blamed.
- Support and mentoring for staff from ethnic minority groups, especially those trained outside the UK, would help to build confidence and support integration into the workforce.
More open acknowledgement of the issues, at all levels, was seen as an essential foundation for change. Senior leadership buy in and support is not enough; it may be at middle management level where there is reluctance to acknowledge the problem:
The denial of that fact that racism exists - when you have White managers who are in high positions in the NHS they haven’t had these experiences, they are coming from a place of privilege, it is hard for them to acknowledge. They will say, well that hasn’t happened to me. That contributes to systemic racism in the NHS. It’s not a priority because White managers are not affected by it.
4. What insights do staff have into the experiences of people from ethnic minority groups using maternity services?
- Those interviewed had seen people using maternity services being treated with a lack of respect, not listened to and not given choices in their care.
There was a strong consensus across interviewees that having poor, or no English was associated with worse experiences of care. Firstly, translation is not being used consistently to enable communication between staff and people using services. Secondly, they are seen to be less likely to complain:
Those who don’t speak the language are being treated appallingly because the staff know there will be no comeback.
- Stereotypes and lack of cultural awareness amongst staff were seen to impact significantly on quality of care and help-seeking. Interviewees said that women were judged according to racial and cultural stereotypes, for example, the racial stereotype of Black women as aggressive was reported to be common and not always recognised as problematic by those using it, even when challenged.
- Interviewees had observed misconceptions and lack of knowledge about physical characteristics and symptoms, that affect how staff address clinical scenarios for women from ethnic minority groups. For example, colleagues referring to the ‘African pelvis’; failing to recognise jaundice on Black or brown skin; having poor awareness of sickle cell disease.
Interviewees said that experiences were affected by perceptions around who is ‘entitled’ to care:
I have heard staff say, ‘If they were in their country, they wouldn’t have an epidural.’ There is this sense that women from ethnic minorities should be grateful.
Those interviewed observed the consequences of all of this for those using services. If people do not feel they are treated with respect and valued, they may be less likely to voice their concerns about their health, their baby and their care; they may carry forward fear into to subsequent pregnancies; they may experience long term psychological impacts.
The feeling of judgement affects whether women will seek help, if they feel like something is not right with their body, their baby – they won’t seek help if they feel like they are going to be judged and ignored and treated without respect.
- Interviewees recognised that staffing pressures in the NHS made it more difficult for staff to provide good quality care, across the board. They noted that many colleagues are providing excellent care to people from ethnic minority groups, but more needs to be done where this is not the case.
5. What do staff think is being done to address issues for people from ethnic minority groups using maternity services?
- Some observed improvements in how their trusts have been addressing issues for people using services from ethnic minority groups, over recent years.
- These included staff training in cultural competencies, outreach and engagement with ethnic minority communities, raising awareness of how to complain, and improved access to translation services.
6. What do staff think needs to happen to improve the experiences of people from ethnic minority groups using maternity services?
- Staff taking part in the research thought that a more diverse workforce, reflecting populations using services, would help people feel better understood and cared for.
- More effective channels for patients to report poor care, in ways that they feel safe and comfortable doing so. For example, Maternity Voices Partnerships (MVPs) were seen as a valuable mechanism for patient views to be shared, but MVPs are not necessarily representative of the populations being served, so work is needed to increase diversity on these groups.
- More effective and consistent use of translation, so that people understand information and can communicate their needs and preferences.
- Increased cultural awareness and understanding amongst staff, so that cultural practices can be respected and accommodated.
- Review of education and training, to ensure curriculums reflect how symptoms and conditions may affect and present differently in people from different ethnic groups.
7. How could CQC gain better insights into these issues through the inspection programme?
- Interviewees thought that CQC should speak to people from ethnic minority groups as part of inspections. This should include staff at all levels and people using services. CQC should do this in safe spaces where people feel able to speak openly.
- Look at trust policies on how issues relating to race are dealt with (both staff and patient complaints).
- Look at diversity in the workforce and how trusts are working to increase ethnic diversity.
- Consider ethnic diversity as part of a broader approach to understanding how inclusive trusts are, for their workforces and service users.
- Look for good practice and innovation in relation to improving culture and practice, and support sharing and roll-out.