Neonatal care review highlights ethnic inequalities in healthcare

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The NHS Race and Health Observatory (NHS RHO) has published a review of the medical assessment procedures for newborn babies, finding that these are ‘not fit for purpose’ for many babies from ethnic minority backgrounds.

The Review of Neonatal Assessment and Practice in Black, Asian and Minority Ethnic Newborns investigates 3 main areas of neonatal assessment, namely the Apgar score, cyanosis and jaundice. It follows concerns that the procedures were historically based upon White European babies and are not necessarily suitable for babies from Black, Asian and minority ethnic groups.

Currently in the UK there is a big difference in health outcomes for babies and mothers of different ethnicities.  At present, the highest neonatal death rates are for babies of Pakistani and Black African ethnicity from the most deprived areas. Black women are the most likely to experience miscarriage or a stillbirth, and Black and Asian mothers are more likely to die during or after childbirth than White mothers.

Hannah Carr is a Novum Law Director and specialist women’s healthcare solicitor. Here, she explores the findings of the review, and the issues faced by BAME babies and patients in neonatal care and healthcare more widely.

What is the Apgar score?

The Apgar score test was introduced in the 1950s and is often used as part of the evidence in assessing a baby’s condition after birth.

Each newborn is given an ‘Apgar score’ by maternity staff, who check a baby’s muscle tone, pulse, reflex response, breathing rate and appearance. They give each component a maximum score of two: the lower the overall score, the more likely the baby is to need urgent care.

Traditionally, medics performing the Apgar score also assess the baby’s appearance including whether the baby is ‘pink all over’ with no signs of blue, indicating good blood supply.

The NHS RHO review acknowledges that most healthcare professionals instinctively adapted the check for babies of different racial backgrounds, for example by looking for colour changes around the lips. However, the review did not find a consistent, evidence-based approach, particularly in training where checks needed clarifying. Words such as ‘pink’, ‘blue and ‘pale’ were highlighted as especially unhelpful.

What is cyanosis?

Cyanosis is a bluish hue to the skin or mucous membranes. It is a common finding in newborns, and means that less oxygen is attached to red blood cells travelling round the body in arteries and capillary veins.

Cyanosis can demonstrate a life-threatening illness. Worryingly, medical professionals detecting the condition from babies’ skin colour has meant that some babies were wrongly diagnosed with cyanosis, and other actual cyanosis cases were missed with potentially dangerous consequences.

To avoid the risk of misdiagnosis, the NHS RHO recommends using a pulse oximeter which they note to be more reliable than observing the skin.

What is jaundice?

The review also raised concerns about the ‘subjective nature’ of guidelines for assessing jaundice. Jaundice is another common condition in newborn babies, which is often identified by the yellowing of the skin, whites of the eyes and gums.

Early and accurate jaundice diagnosis and treatment can help prevent serious complications such as kernicterus, which is damage to the brain or central nervous system caused by untreated jaundice.

However, healthcare professionals admitted it was harder to identify jaundice in babies belonging to ethnic minorities. The NHS RHO review highlights that despite awareness that using skin colour to assess jaundice was problematic, this did not always translate into policy changes and training.

Transcutaneous bilirubin (TCB) measurement has been found to be a more accurate method of detecting jaundice than visual assessment alone.

NHS Race and Health Observatory review recommendations

At present, the majority of research and evidence is focused on hospitals rather than in the community where early detection of health conditions in babies could prevent hospital admissions, reduce the treatment required, and avoid long term health implications.

The NHS RHO makes various recommendations for policy changes and additional research to improve practices. It also calls for NHS England to create a national databank of open access images of Black, Asian and ethnic minority babies. These images should be used in the training and education of healthcare professionals and students, and to aid diagnosis.

The review notes that there is also an urgent need for regular education and training for healthcare professionals and students, and better education for families to make sure that babies’ health conditions are not missed.

The impact of ethnicity and race on care

Although the overall focus of the NHS RHO Review is on neonatal assessments, challenges around the quality of care received by patients of different races and ethnicities must not be ignored.

The review highlights potential barriers and facilitators to accessing care for ethnic minority communities.

One such barrier is the communication barrier, where women are seen to face problems in getting information from healthcare professionals due to language differences or inadequate translation. It was also noted that women from diverse backgrounds felt dismissed, ignored, or belittled by healthcare professionals.

The literature and interviews reviewed also revealed discrimination and racism in healthcare. Three specific areas of discrimination were identified, including stereotypes, lack of cultural competence, and inadequate care.

Women reported assumptions about their education and lifestyle, feeling that healthcare professionals labelled Black, Asian, and minority ethnic women as “aggressive” or “difficult”.

Novum Law calls for better healthcare for BAME patients

Hannah Carr is a specialist women’s and maternity health solicitor and Novum Law Director. Through her expert work supporting mothers, babies and their loved ones with medical negligence compensation claims, she has witnessed the systemic failures experienced by BAME people in healthcare settings. This includes the tragic case of Modar Mohammednour, whose wife Rana Abdelkarim died in childbirth as a result of maternity care failings connected in part to her ethnic and cultural background.

Hannah comments:

“What is clear is that healthcare professionals need to provide personalised, culturally adapted. compassionate and safe care to ensure that all parents receive respectful and dignified care.”

“Black and Asian babies have some of the highest mortality rates in the UK, so the assessment tools and language that influence their care must be fit for purpose.  Addressing discrimination in healthcare is vital to improving maternal and neonatal health outcomes.”

If you have any concerns about the treatment you and your baby have received in a hospital or healthcare setting, Novum Law’s specialist medical negligence solicitors may be able to help on a “No Win No Fee” basis.

To find out more information about making a compensation claim, contact us at 0800 884 0777, email or fill out our online enquiry form.

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