Black, Asian and minority ethnic women's experiences of maternity services in the UK: A qualitative evidence synthesis

Abstract Aims Black, Asian and minority ethnic women are at higher risk of dying during pregnancy, childbirth and postnatally and of experiencing premature birth, stillbirth or neonatal death compared with their White counterparts. Discrimination against women from ethnic minorities is known to negatively impact women's ability to speak up, be heard and their experiences of care. This evidence synthesis analysed Black, Asian and minority ethnic women's experiences of UK maternity services in light of these outcomes. Design We conducted a systematic review and qualitative evidence synthesis using the method of Thomas and Harden. Data Sources A comprehensive search in AMED, Cinahl, Embase, Medline, PubMed and PsycINFO, alongside research reports from UK maternity charities, was undertaken from 2000 until May 2021. Eligible studies included qualitative research about antenatal, intrapartum and postnatal care, with ethnic minority women in maternity settings of the UK NHS. Review Methods Study quality was graded using the Critical Appraisal Skills Programme tool. Results Twenty‐four studies met the inclusion criteria. Our synthesis highlights how discriminatory practices and communication failures in UK NHS maternity services are failing ethnic minority women. Conclusion This synthesis finds evidence of mistreatment and poor care for ethnic minority women in the UK maternity system that may contribute to the poor outcomes reported by MBRRACE. Woman‐centred midwifery care is reported as positive for all women but is often experienced as an exception by ethnic minority women in the technocratic birthing system. Impact Ethnic minority women report positive experiences when in receipt of woman‐centred midwifery care. Woman‐centred midwifery care is often the exception in the overstretched technocratic UK birthing system. Mistreatment and poor care reported by many ethnic minority women in the UK could inform the inequalities of outcomes identified in the MBRRACE report.


| INTRODUC TI ON
The 'Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries' (MBRRACE-UK) audit confirmed that Black, Asian and minority ethnic women are at higher risk of dying during pregnancy, childbirth and postnatally and of experiencing premature birth, stillbirth or neonatal death compared with their White counterparts (Knight et al., 2020). Published explanations for these inequalities are complex and include a combination of contributing factors: organizational, language and cultural, help-seeking and access barriers (Aquino et al., 2015, Fisher & Fraser, 2020, Henderson et al., 2018, Murray et al., 2010. Much of the evidence comes from international literature rather than the UK specifically and reflects different social, cultural and historical experiences. MBRRACE highlighted the need to review the evidence related to the UK health system.

| BACKG ROU N D
Feeling cared for (Beake et al., 2013;Redshaw & Heikkila, 2011), staff attitudes (Rayment-Jones et al., 2019) and communication (Harper Bulman & McCourt, 2002;Wikberg et al., 2012) have been reported as being important by the whole population of birthing women. Yet experiences of negative stereotyping and lack of 'cultural competence' among maternity staff reveal dimensions of poor care experiences unique to women from ethnic minorities (Jomeen & Redshaw, 2013).
Stereotyping and pre-conceived ideas about women from ethnic minorities negatively impact women's ability to speak up and their experience of care (Hoffman et al., 2016;Puttusery et al., 2008). Such attitudes reinforce a 'Them and Us' approach that expects ethnic minority women to adapt to an insensitive and sometimes discriminatory health system rather than the system being responsive to the needs of the women (Lyons et al., 2008). There is a significant body of literature (largely from the USA) that co-implicates social, economical and political forces in producing the stigma and inequality experienced in negative encounters with health services. These negative encounters include attempts at service engagement being rebuffed (Davis, 2019;Metzl & Hansen, 2014;O'Mahony & Donnelly, 2010).

| Aim
The aim of this review was to synthesize the published qualitative evidence about Black, Asian and minority ethnic women's experiences of UK maternity services in light of the disparities reported in maternity outcomes between different groups of women.

| Design
We used a thematic evidence synthesis method to extend the interpretations offered in the original individual studies included in this review (Thomas & Harden, 2008).

| Search method
We registered our review on the PROSPERO database (MacLellan et al., 2020), followed the PRISMA guidance (Page et al., 2021;Rethlefsen et al., 2021) and used PICO (Population, Interest, COntext) to structure systematic searches for qualitative studies where Population = Black, Asian and minority ethnic women, Interest = Experiences, COntext = UK maternity services (Miller, 2001). The acronym 'BAME' was used in searching due to its consistent use in the preceding 20 years, but in line with recent UK government guidance, we use the term 'ethnic minorities' to include Black, Asian and other minority ethnic people. This update in terminology is an acknowledgement that the concept of 'race' refers to a shared culture and history among a group of people rather than skin colour. While MBRRACE did not include this group in their description of racial inequalities, the inclusion of the experiences of white minoritized ethnicities such as Orthodox Jewish, Gypsy, Roma and Irish Travellers is appropriate to our synthesis (Race Disparity Unit, 2021). Searches were carried out in December 2020 in AMED, EMBASE, PsycINFO, CINAHL and MEDLINE databases, published in English from 2000. This cut-off date was chosen as there was a major change in the maternity system approach in the late 1990s with the Changing Childbirth report, to woman-centred care (Department of Health, 1993, 1997. For full search strategy, see Table 1: Search strategy. In addition, we used backwards citation tracking, Pubmed 'related articles', Google Scholar and research outputs of UK maternity and advocacy charities. Searches were repeated in May 2021 and yielded no additional records (Figure 1).

| Search outcome
We included studies that reported qualitative (interpretive and textual) data about antenatal, intrapartum and postnatal care, with ethnic minority women in primary and secondary care settings. We excluded papers about the experience of asylum seekers and women without recourse to public funds due to their unique financial and immigration concerns. Other exclusions were papers focused on morbidity, child health or the impact of COVID-19. Studies reporting only professional perspectives were also excluded.

K E Y W O R D S
ethnic minority, literature review, maternity, meta-synthesis, UK

| Quality appraisal
Study quality was graded using the Critical Appraisal Skills Programme (CASP) tool for qualitative studies (CASP, 2019). Two reviewers (JM and SC) graded the papers independently, conferred on a random selection of 12 papers, with the third reviewer available to resolve any disparities (TR). While CASP does not advocate a scoring system, the majority of included papers achieved 'yes' on eight domains or more. As recommended by Atkins et al. (2008), papers were not excluded as a result of a low score but were integrated into the synthesis with these concerns made explicit. In all but one instance, the findings of the lower quality papers were corroborated by two or more high-quality papers, adding confidence to the findings. In the single incidence, a confidence statement follows the report of the finding. We also examined the relative contributions of each study to the final analytic themes (

| Data abstraction
We collated records into an Excel database, removed duplicates and screened abstracts for inclusion against the inclusion/exclusion criteria (JM and SC). Full texts were screened independently by two

| Synthesis
Findings and results sections of papers were extracted and entered verbatim into NVivo 12 software to support thematic analysis guided by Thomas and Harden (2008). This began with independent lineby-line inductive coding by two researchers (JM and SC), who then organized the codes into broad descriptive themes for discussion by the full research team to refine. Four major themes have identified that structure the presentation of our synthesis findings below.

| RE SULTS
Searching yielded 131 papers after removing duplicates, with 37 fulfilling our eligibility criteria ( Figure 1). Thirteen of these did not report directly on maternity service experiences, leaving 24 for synthesis (  Ockleford et al., 2004;Puttusery et al., 2010). Among the women who reported their care as fragmented and task focused, they also described feeling the system was unable to engage with the complexity of their lives, with healthcare professionals assuming that they had access to childcare or transport, for example, which impacted women's ability to attend appointments (Birthrights, 2020; Cardwell & Wainwright, 2019;Jayaweera et al., 2005;Moxey & Jones, 2016;Phillimore, 2016). They described feeling judged by healthcare providers when they requested support related to personal safety or resources during their antenatal appointments (Cardwell & Wainwright, 2019;Goodwin et al., 2017;Jayaweera et al., 2005;Phillimore, 2016) and noted that some healthcare providers made assumptions that all women had safe and stable housing (Birthrights, 2020;Cardwell & Wainwright, 2019;Phillimore, 2016).
In two papers, women reported that staff audibly discussed sensitive personal information about them standing just behind a curtain in an open ward (Birthrights, 2020;Cardwell & Wainwright, 2019). Privacy was also an issue: women felt disrespected when staff would keep opening their bed curtains which they had closed to breastfeed or pray (Ali, 2004;Birthrights, 2020;Hassan et al., 2019).
Some papers described targeted services that offered additional support to ethnic minority women (Ali, 2004;Birthrights, 2020;Cardwell & Wainwright, 2019;Jayaweera et al., 2005;McAree et al., 2010), but referral to these charities and mental health services appeared highly dependent on local knowledge of the midwife

| Strengths and limitations
To our knowledge, this is the first attempt to synthesize the qualitative literature from the UK exploring ethnic minority women's experiences of maternity services and we have used rigorous methods (Atkins et al., 2008;CASP, 2019;Karnieli-Miller et al., 2009) (Downe et al., 2018;Karlsdottir et al., 2018;Renfrew et al., 2014). These concepts were also highlighted as necessary for the ethnic minority women who participated in the studies included in our synthesis. However, they are entering the system already facing enormous disadvantages due to structural racism in society, and then there is further damage by more direct forms of racism in maternity care, both of which are not faced by white majority women.
Complaints of a dissatisfying birth experience in this underfunded, overstretched technocratic birthing system are shared by the white majority (Davis-Floyd, 2003;Reed et al., 2017;Scamell & Aleszewski, 2012;Walsh, 2010). The technocratic approach, where clinical tasks and the safety agenda are privileged over personcentred care, has been linked with negative psychological and social consequences (Beck, 2011;Benoit et al., 2010;Forssen, 2012;Reed et al., 2017;Soet et al., 2003). This has stimulated the Continuity However, this is predicated on work to recruit and retain midwives, which is an ongoing concern (Hall, 2021), to reduce the staffing pressures known to engender a routinized, technocratic model of practice (Kirkup, 2021 impact that this has on the experience and well-being of birthing women from ethnic minorities and is thus a necessary core consideration in a woman-centred care agenda (Trepagnier, 2017).

| CON CLUS ION
This synthesis shows that ethnic minority women report positive pregnancy and birth experiences when they are in receipt of kind, respectful and woman-centred midwifery care. However, these experiences are often the exception in the overstretched technocratic birthing system of the UK. The integration of these 24 studies reveals varied and disturbing forms of mistreatment and poor care for ethnic minority women in the UK and it seems probably that these differences in experience are linked to the inequalities in outcomes identified in the MBRRACE report. There is clearly much to be done in education and practice to address these concerns and improve these women's experience of the birthing journey.

ACK N OWLED G EM ENTS
The authors would like to acknowledge Nia Roberts (librarian, Bodleian Health Care Libraries, University of Oxford) for her guidance in developing the search strategy.

CO N FLI C T O F I NTE R E S T
The authors report no financial or personal interests. Myatt comments. All authors accept responsibility for the manuscript.

D E TA I L S O F E TH I C S A PPROVA L
Ethics approval was not required for secondary use of data in this systematic evidence synthesis. This manuscript is an honest, accurate and transparent account of the study being reported that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained. Data extracted from included studies and data used for all analyses are available from the corresponding author on request.

O PEN R E S E A RCH BA D G E S
This article has a preregistered research design available at https://www.crd.york.ac.uk/prospero/display_record.php?ID= CRD42020225758

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15233.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.