How doulas are helping to tackle inequality in maternity care

Research shows Muslim women are more likely to face discrimination during childbirth

A couple plays with their infant on a sofa.
In 2023, maternal research organisation MBRRACE-UK found that the risk of maternal death was twice as high in Asian women as in white women. Photo by Johner Images/Getty Images

Khadija*, 35, from west London, gave birth to her first child in 2015. During labour, an obstetrician informed her that her baby’s head was in an incorrect foetal position, and that forceps might be used to help with the delivery. Khadija said she didn’t want the medical instrument to be used, but an episiotomy, a surgical incision to enlarge the opening for childbirth, was carried out nonetheless.

Khadija said she couldn’t recall medical staff explaining how the incision of her perineum and the posterior vaginal wall would be made. “There wasn’t a conversation about the episiotomy. At no point did they ask me if they could do it. I just remember it happening,” she said.

It was only during Khadija’s third pregnancy in 2022, after she employed the help of a doula, a professional who helps mothers during pregnancy and childbirth, that she learnt that doctors should have asked for her consent and that the procedure might not have been necessary.

“At the time I was lying on my back on the bed. If they were good practising midwives, they should have encouraged me to get up and move around,” Khadija said.

She added: “Then the baby’s head might have moved, and I wouldn’t have needed those stitches, or to go through that healing process. Instead, they chose the medical and invasive route.”

While Black and ethnic minority women are more likely to experience complications during pregnancy and childbirth, doulas can help to reduce risks, according to Tommy’s, the UK’s leading pregnancy and baby loss charity.

Doulas provide expectant mothers and their families with emotional and practical prenatal and postnatal support. Though doulas do not have to complete any training by law and do not administer any medical care, many undertake courses and training programmes, such as those offered by the National Childbirth Trust. Doula UK, a non-profit membership association for doulas across the UK, has around 700 members.

According to a 2023 report from MBRRACE-UK, an organisation that investigates the causes of maternal deaths, stillbirths and infant deaths, Black women are nearly four times more likely to die in pregnancy than white women.

The research, which examined data on more than 240 women who died during or up to six weeks after birth between 2019 and 2021, also found that the risk of maternal death is twice as high in Asian women.

In July 2022, the Muslim Women’s Network, a UK charity working to improve equality for Muslim women, released a first-of-its-kind report on the maternity experiences of more than 1,000 Muslim women from ethnic minority communities. 

Those who took part in the survey were either pregnant or had given birth in the past five years. Researchers found they were 1.5 times less likely to be given an epidural for pain relief compared with the UK average (21% compared with 31%). Additionally, researchers discovered that Muslim women were also 2.4 times more likely to experience postpartum haemorrhage  — heavy bleeding after birth that can be fatal.

Anisah Abdullah, 35, is a London-based doula who has been supporting women for the past 10 years. She described a number of challenges that Muslim women have to overcome at the hands of NHS staff during pregnancy and childbirth.

“At the antenatal stage, there’s an assumption that we are unintelligent and won’t be able to make fully informed decisions, so there is a lot of information that is not always shared with a mum,” she said.

Abdullah said NHS workers tend to prevent Muslim women from choosing how they want to give birth, and have coerced them into undertaking medical procedures against their will.

“I don’t think enough Muslim women know just how much they are up against, and being in that birth room is not the time to find that out. That is your child’s first day on this earth. We want it to be a day that you look back on and smile.”

Tommy’s midwifery manager, Amina Hatia, 48, from Hertfordshire, has been working as a midwife for more than 18 years. She said NHS staff sometimes hold erroneous stereotypes about how Black and South Asian women experience pain. 

While Black women are assumed to be “stronger”, and better able to handle pain, there is a stereotype that South Asian women are unreasonably anxious. These assumptions can have profound impacts, Hatia explained, adding that this could lead to the woman being further along in labour than assumed: “By the time the doctors believe her, it might be too late to give her the epidural for pain relief that she had previously requested.” 

Hatia told me some women experience heightened anxiety around childbirth, which can be linked to poor antenatal care or a lack of information.

That was the case for Samia*, 26, from Essex, who gave birth to her first child in August 2021. In the first six hours in the hospital, she was subjected to three vaginal examinations, which she found extremely distressing. Samia said staff failed to ask for her consent and didn’t inform her that it was an optional examination.

When a midwife came back to examine her a fourth time, Samia had a panic attack. This caused both her and her baby’s heart rate to rocket. “Suddenly a group of doctors rushed in and said you need to sign this form,” she said. “We are going to give you an emergency caesarean because your baby’s heart rate is too high.” 

Samia recalls that a black midwife in the room came to her aid. “I remember that lady so clearly. She kept telling them: ‘She’s fine, her heart rate is going back down’. But no one listened to her. They just made me sign the form and took me in straight away.”

Amy Boning, 41, a Muslim doula based in Derby, says the most valuable aspect of her work is giving clients in-depth knowledge of how best to navigate maternity services.

“My job is to make sure women know they have the right to make decisions about where and how they give birth, and that they have the right to decline tests they don’t want, such as vaginal examinations, which can feel invasive and uncomfortable,” Boning said.

“That knowledge is like a shield because it gives women the confidence to let midwives and doctors know what it is that they want.”

Two years on from the release of the Muslim Women’s Network’s report, the organisation’s CEO, Baroness Shaista Gohir, is rallying the government to change the way the NHS records medical negligence claims.

According to the latest annual report from NHS Resolution — a government-run health authority that handles negligence claims on behalf of the NHS — 13% of all clinical claims in 2022-23 were related to maternity care. Additionally, 41% of total negligence payments (£2.6 billion) in the year up to March 2023 were related to maternity. Given this large number, Gohir believes that recording the ethnicity and faith of people making the claims could provide greater insight into the experiences of Muslim women.

“Not recording this information is another example of systemic discrimination,” she said. “We know that ethnic minority Muslim women are having poorer experiences. As it stands, there’s no way of knowing if they are overrepresented in medical negligence claims.

“If we record that data and we see that a particular ethnic group or faith block is highlighted, we can identify the safety issues and go and put that right.”

*Some names have been changed.

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