In the fourth post of the Birth Trauma takeover, Manna Mostaghim illustrates the importance of using a Reproductive Justice framework to analyse the findings of the Birth Trauma Inquiry Report.
“Evidence suggests that marginalised groups also have a poorer experience of maternity care. As well as ethnicity, deprivation and age, other factors that may affect an individual experience of maternity care can include neurodiversity, sexuality and gender identity. Some factors may, of course, interact”. – Birth Trauma Inquiry Report (2024)
The Birth Trauma Inquiry Report (2024) revealed that, in maternity care settings in England, Black women are “four times as likely” and Asian women are “twice as likely” to die as a result of/during childbirth than white women (Thomas 2024, p. 58). Women living in the “most deprived areas of the UK” experience a maternal mortality rate “twice as high” in comparison to women living in “the least deprived areas” (Thomas 2024, p. 58). Is it because these women spontaneously die in maternity care settings? Is their death inevitable? Regrettable but unavoidable? The possibility of death should not be a predestined fate for some in maternity care settings within NHS England. Despite this, the Birth Trauma Inquiry Report (the Report) acknowledges that maternity care settings in England have not been structured, funded, and staffed to protect all lives equally.
Using a Reproductive Justice Framework
The Report identified that pregnant people should not experience trauma as a result of maternity care settings. But should that be the threshold of good care? A Reproductive Justice framework would argue that a holistic set of sexual and reproductive health rights would allow an individual “the right to have a child; the right not to have a child; the right to parent children in safe and healthy environments” (Ross & Solinger, 2017). Sexual and reproductive health settings should not be required to only avoid bad outcomes, they should actively cultivate good outcomes and good experiences for patients. Good outcomes are to be defined by patient needs and not by the perceptions conveyed by provider paternalism. Patients of sexual and reproductive health services need to be listened to while providers and policymakers listen.
The Reproductive Justice framework was developed by black feminists in the United States, who were frustrated by the myopia of the reproductive rights agenda. The framework adds a dimension to the policy reforms for reproductive rights by acknowledging that some individuals do not “own,” “control,” or make decisions about their body, health, and relationships (Chrisler, 2017). This is because the choices available to some groups of people are predetermined and/or limited by “policies and attitudes directed toward them” (Ross & Solinger, 2017). As the Report acknowledges, maternity care settings in England have profound limitations that prevent the cultivation of informed and full choices from people of minoritised groups. The Report asked patients how to improve services and made subsequent recommendations – but it was demure on identifying and interrogating the basis for persistent inequality in maternity care settings in England.
Adverse outcomes in sexual and reproductive health cannot be rectified without strident policy mandates which reform healthcare systems implicated in adverse outcomes (Valdez, 2021). Access to reproductive health services within the NHS, and the codification of reproductive rights within English Law, has not ensured equal outcomes in maternity care settings across England. A Reproductive Justice Framework highlights that although sexual and reproductive health services and rights are available, they might not be able to be accessed equally because of structural inequalities (Chrisler, 2017).
Missing Information
The Reproductive Justice framework recognises that collecting, analysing and reporting data is the cornerstone of good policy to improve sexual and reproductive health. The Report identified that a “failure to listen”, a “lack of informed consent”, “poor communication”, a “lack of pain relief” and a “lack of kindness” were common factors in subsequent birth trauma (identified in the Report as “key themes”) (Thomas 2024, pp. 14-16). In Chapter 7 of the Report on “Marginalised Groups”, anecdotes on classism, ableism, elitism, racism and homophobia were cited – and racism was explicitly named as a factor that contributed to birth trauma in maternity care settings for patients from minoritised backgrounds (Thomas 2024, pp. 58-65). Studies on maternity care settings consistently identify that these factors disproportionately impact patients from minoritised backgrounds (Onwuachi-Saunders 2019). However, the Report did not measure or report how and when the key themes may have a disproportionate outcome on such people in maternity care settings in England.
The ability to collect, collate and disseminate data for policy reform requires the Report to name the marginalisation it wants to mitigate. But although issues like homophobia are referenced in the Report – homophobia is not named as a source of marginalisation that can contribute to birth trauma. For example, the Report cited an anecdote from Laura-Rose Thorogood, “a woman in a same-sex relationship, [said] when she introduced her wife to the consultant, the consultant’s attitude ‘just switched’, and from that point on the care was ‘unprofessional’...” (Thomas 2024, p. 55). Thorogood also spoke about how homophobia had contributed to the disenfranchisement of their wife’s role in their birth experience, making both feel alienated within maternity care settings. The Report highlights that there is an assumption of heteronormativity in the provision of maternity care and acknowledges the lack of research on the experiences of same-sex couples in maternity care settings (Thomas 2024, pp. 55, 61-62). Despite this, the Report relies on the reader to make an inference of homophobia when it circumvents saying it directly contributed to Thorogood’s experience and trauma.
The analytical dissonance in this report where a report of homophobia is explained but not named would not be permissible within the application of a RJ Framework (Onwuachi-Saunders 2019). Invisible, or obscured, prejudices do not deny the problem, it denies the access to solutions in sexual and reproductive health settings. Homophobia, and other forms of prejudice must be named, so that services, policy makers, and providers can confront it in maternity care settings.
The Audacity of Choice
Complex communication amongst healthcare providers and patients in maternity care settings remains an impediment to the ability to form and enact informed choices. In the NHS England maternity care setting, a pregnant patient who is unable to speak English and who does not have access to a translator will not have the same choices as an English speaker. It has been claimed that if a woman does not speak English, she “is 25 times more likely to die” in maternity care settings within the UK (Mulji, 2024). Similarly, the BBC revealed via a series of Freedom of Information requests in 2023, that “interpreting issues were a contributing factor in at least 80 babies dying or suffering serious brain injuries in England between 2018 and 2022” (Hill, 2023). This culture of complex miscommunication within the healthcare setting has a clear correlation to adverse outcomes for patients and their babies. Within a Reproductive Justice framework, it is a byproduct of a racist system that assumes a monocultural population, and a singular set of needs for a diverse and varied population.
The Report’s 11th Recommendation acknowledges that providing interpreting resources within maternity care settings in England should be a future priority of NHS Integrated Care Boards (ICBs). ICBs function as the local governance structure to provide NHS health services within a specific catchment area. This recommendation would presumably improve the ability of patients to consider information, consider choices, and relay their preferences to healthcare practitioners. However, there is no discussion in the Report on how translation services are going to be funded by NHS ICBs, which are already facing austerity measures and making declarations on the necessity of budget cuts (Campbell & Crerar 2024). The remit of the Report was not to respond to the broader structural issues of the NHS. However, recommendations to improve maternity care services that are made to languish in perpetuity are not useful.
The Report did cite an initiative put forward by Professor Angie Doshani, a consultant gynaecologist and obstetrician, who developed “JanamApp” to communicate information to patients who did not speak English (Thomas, 2024, p. 60). The development of JanamApp is rooted in the practices of Reproductive Justice, as it creates a solution that is economically efficient, whilst acknowledging the realities of patients. However, a reliance on NHS staff to develop tools and resources is not a sustainable solution, nor one that entrenches equity into the health system. It perpetuates inconsistency across NHS ICBs or forces ad- hoc measures via self-sustaining initiatives by staff.
Conclusion
The Report seeks to identify gaps in maternity care services and to help patients develop the capacity to better navigate NHS services. Applying a reproductive justice framework to analyse the report would help to identify, confront, and resolve systematic issues that limit a patient’s ability to navigate NHS maternity care settings. The Report’s refusal to name prejudices that can, and have contributed, to adverse outcomes for birthing people in the NHS, means that the policy recommendations remain underdeveloped. Moreover, it identifies issues within the NHS but refuses to put forward resources to provide actionable results to improve maternity care services. Ultimately, the Report tells us of birth trauma and it provides recommendations – but it remains almost purposely oblivious to the systematic causes of inequity in maternal healthcare.
About the Author
Manna Mostaghim is a researcher on the provision and politics of sexual and reproductive health in the UK and a PhD Candidate at LSE. She is a Trustee of the Reproductive Justice Initiative charity, the Policy Advisor and Public Health Specialist for Ida XR Studio, and a National Executive Committee Member of Abortion Rights. Follow her on Twitter/X at @manna_mstghm
References
Campbell, Denis and Crerar, Pippa. 2024. NHS funding faces biggest real-terms cuts since 1970s, warns IFS. The Guardian. 5 Mar. Online.
Chrisler, Joan. 2013. A global approach to reproductive justice: Psychosocial and legal aspects and implications. William & Mary Journal of Women and the Law 20: 1-24.
Hill, Matthew. 2023. NHS interpreting service problems contributed to patient deaths. BBC. 21 Nov. Online.
Mulji, Yasmin. 2024. We must end the racial disparities in maternity outcomes. The Guardian. 29 Jul. Online.
Onwuachi-Saunders, Chukwudi, Que P. Dang, and Jedidah Murray. 2019. Reproductive Rights, Reproductive Justice: Redefining Challenges to Create Optimal Health for All Women. Journal of Healthcare, Science and the Humanities 9(1): 19–31.
Ross, Loretta, and Rickie Solinger. 2017. Reproductive Justice: An Introduction. Oakland: University of California Press.
Thomas, Kim. All-Party Parliamentary Group on Birth Trauma. 2024. Listen to Mums: Ending the Postcode Lottery on Perinatal Care. 13 May 2024. London.
Valdez, Natali. 2022. Weighing the Future: Race, Science, and Pregnancy Trials in the Postgenomic Era. Oakland: University of California Press.
Zucker, Alyssa N. 2014. Reproductive Justice: More Than Choice. Analyses of Social Issues and Public Policy 14(1): 210–13.
