Birth Outcomes & Experiences Report

Context

Racialised inequalities in maternal care: UK Context

Maternal health disparities in the UK reveal disturbingly elevated risks for women from minoritised backgrounds, particularly Black and Asian communities. According to MBRRACE-UK, Black women face a fourfold higher risk of maternal death during the childbearing year, while Asian women confront a twofold greater risk than their white women. Moreover, infants born to Black women exhibit significantly higher risks of stillbirth, premature birth, and neonatal death compared to those born to white women. 

The 2021 MBRRACE report identifies crucial factors contributing to maternal mortality, such as heart disease, and emphasises a pervasive "constellation of biases" hindering access to necessary care. Urgent action is recommended to address multifaceted challenges, including the dismantling of racial and cultural biases.

The most recent MBRRACE-UK report scrutinises the care provided to Asian, Black, and White women whose babies experienced adverse outcomes, revealing pervasive issues of poor-quality care across all ethnic groups. The "MBRRACE-UK Perinatal Confidential Enquiry" report for 2023, updated in 2024, critically examines care disparities between Black and White women who experienced stillbirth or neonatal death.

The report identifies significant opportunities for improvement in care that could have positively impacted the outcomes for both babies and mothers. Notably, it revealed that poor quality care, including inadequate interpreting, was a contributing factor to baby deaths across all ethnic groups. 

Insights into the poorest grading of care quality affecting the outcomes for both the baby and mother at different points along the care pathway are provided for each ethnic group. The report identifies challenges in recording ethnicity, nationality, and citizenship status consistently, alongside issues in addressing language needs. It highlights inconsistencies in using independent interpretation services and reveals that routine mental health questions were less likely for women from Black ethnic backgrounds. Barriers to accessing specific care were more common for women from Black ethnic backgrounds, resulting in non-compliance. Complex social risk factors were less systematically recorded for Black women, emphasising the need for more personalized and compassionate care. 

Racialised inequalities in maternal care: Scottish Context

Public Health Scotland's latest report on monitoring racialised health inequalities in Scotland acknowledges that reducing racialised inequalities in maternal health is key to achieving improvements in population health. This report highlights that, in 2022, the proportion of pregnancies registered by the 12th week of gestation was lower for all ethnic minority groups compared to those of White ethnicity, where 94% registered by this point. The lowest registration rate, at 70%, was observed among individuals of African ethnicity. Additionally, the report highlights that living in more deprived areas is associated with delayed pregnancy registration. Pregnant women of African and Caribbean or Black ethnic backgrounds are more likely to reside in such deprived areas when compared to pregnant White women.

Specific challenges facing childbearing refugees and asylum-seeking individuals

In the last twenty years, a growing number of refugee and asylum-seeking individuals, particularly those from racialised backgrounds, have settled in Scotland. Refugees and asylum-seeking individuals face multiple vulnerability factors that place them at risk of loneliness and social isolation, amplifying the risk of adverse health outcomes. The intersection of refugee/asylum status, gender, and racial/ethnic identity further compounds the vulnerability of these women to experience loneliness. 

Refugee and asylum-seeking women in the UK have a higher risk of perinatal mental health problems compared to the general population, holding a much higher risk of postnatal depression and other mental health concerns during the perinatal period. This can include varying psychosocial issues, including social isolation, loneliness, post-traumatic stress disorder, pre and post-migration, and depression, all of which can greatly impact mental well-being.

During this time, mothers also experience the emotional impacts of “family separation, language barriers, precarious immigration status, and unfamiliarity with a host country’s cultures”. Many are also placed in unfamiliar communities without a support system or social network to rely on, greatly compromising their health and well-being. Many experience high levels of stress, depression, and postnatal depression, which can also impact the well-being of young children and may have consequences on healthy early development.

However, the research in this area is limited. Many of the studies that examine maternal mental health amongst migrant women do not distinguish between immigrants, refugees, and people seeking asylum. These distinctions matter because they can highlight the compounding challenges faced by different populations, which can in turn affect service provision.

For many, their experiences of migration and resettlement have been marked by trauma, uncertainty, and dislocation, which can lead to heightened stress and mental health issues during pregnancy. Accessing equitable care becomes not only a matter of physical well-being but a crucial means of emotional support and stability. These barriers to care underline the necessary work of refugee supporting organisations to provide tailored, trauma informed, culturally literate, and appropriate services to this specific population.  

Maternity crisis

The challenges faced by all birthing people reflects a crisis in maternity care and maternity staffing. High numbers of midwives are leaving the profession due to not being able to deliver safe care to individuals in the current system. 

Findings from the 2018 WHELM study revealed high levels of anxiety, depression, work-related stress, and burnout amongst midwives in the UK. This mirrors the RCM Scottish Survey Report 2022, which focused on the significant challenges midwives in Scotland are facing, with safety, low staffing, and stress some of the biggest issues among members. The survey found three quarters had considered leaving midwifery, 41% had not been given access to statutory training during work hours, and half of respondents said their hospital or maternity unit ‘rarely’ had safe staffing levels. 

A recent Care Quality Commission report focused on maternity services also highlighted the desperate need to recruit and retain more midwives, with the Royal College of Midwives framing it as a ‘wake-up call’ to the Government to urgently address years of under-investment in maternity healthcare.

The revelations brought forth in the 2022 Ockenden review and Kirkup investigation, exposing critical lapses in maternity care, cast a shadow not just on specific hospital trusts but on the entire systemic framework. Within each report, the recurring themes of uncompassionate and dehumanised care, insufficient staffing and resources, and diminished morale paint a disheartening picture. These reports demonstrate that these issues are symptomatic of deeply ingrained and interconnected issues pervasive throughout the United Kingdom. 

The COVID-19 pandemic has also had far-reaching consequences, affecting Scotland, the UK, and the global landscape of health for years to come. Its impacts span various aspects of society, including the realm of birth. The Royal College of Midwives’ ‘Blueprint for Better Maternity Care in Scotland’, published in 2021, highlights that the pandemic disproportionately affected socially deprived areas, highlighting deep-rooted inequalities. The pandemic hit the most deprived communities, particularly Black, Asian, and minority ethnic groups, who already face racial inequalities in healthcare.

Healthcare staff, including those in maternity services, endured significant challenges during the pandemic. Recovery for both the system and personnel is essential, with continued support for staff wellbeing and addressing long-term health impacts of COVID-19. These impacts compound the maternity crisis which was already present.

Practice Issues & Discrimination

During the 2021-22 period, birth companions reportedpractice issues or discrimination affecting 37% of 76 recorded cases.

In cases where there were a small number of individuals from the same country, we attempted a comparison by country of origin (see Figure 2). It is worth noting that the sample sizes are not sufficiently large to yield significant results, although the indicative data suggests clients from Pakistan experienced disproportionately higher incidences of discrimination and/or practice issues.

The following themes were identified:

Lack of attention and delayed pain relief

There were several instances where women were not given adequate attention, or their pain seemed to be dismissed.  

"I also had issues with my catheter, because at some point it moved and it wasn't in place. So, I literally slept in a wet bed all through the night. And I got a cold the next morning because when they came to check my temperature, it was high. And that was as a result of me sleeping in a wet bed. My baby cried all through the night, and I was in pain. I couldn't do anything. I was cold, and shivering and I didn't get any attention. Nobody came." (Client testimonial)

[Postnatal ward]: “At 9:00 pm they tried to get [client] to stand and walk. This took several attempts as [client] complained of feeling extremely dizzy when she stood up for the first time after surgery. Eventually [client] walked a few steps. [Client] was feeding her baby and asked for water from one of the ward staff and the staff member became upset and was rude to [client]. When the staff member came back to check on other babies on the ward, they checked every other child except for [client’s]. [Client] was refused pain medication by the same staff member and was told she would get it at "drug time". I advised [client] to report this to the sister in charge of the ward the next day, which she did.” (Companion observation)

“[Client] was experiencing a lot of back pain and was keen to stay off the bed, so I asked a midwife she could have a birth ball. An hour passed, so I asked again if [client] could have a birth ball, which never arrived. I mentioned to the midwife that [client] was now contracting regularly, but she was dismissive of this and insisted [client] proceed with the induction. We waited a while longer and eventually the midwife came to get [client] for the foley insertion. We had to walk down the hall to another ward. As [client] was walking, she was having to stop and breathe through her contractions. The midwife kept saying to [client], ‘I know it’s sore hen, that’s why I’m always telling people it’s best to stay up and moving!’, which was ironic given we had been requesting a ball for hours for that very reason. At no point had [client] ever indicated she wanted to be anything but upright.” (Companion observation)

Inadequate Consent & Communication

Instances were reported where consent was not fully obtained or respected. In some cases, medical procedures were continued despite the mother explicitly requesting them to stop. There were also concerns about inadequate explanations of procedures, such as breaking waters or using a foetal scalp monitor. Language barriers and a lack of interpreters further exacerbated communication issues.

 "Midwives kept pushing [client] to try gas and air. When she eventually tried it, she said she didn't like it and didn't want to use it. But every time she had a contraction, they held it up to her and one point they were close to shoving it in her mouth. I had to grab it from the midwife and say 'No, thank you', reminding her that [client] had declined to use it."(Companion observation)  

"While we were waiting for the anaesthetist to arrive and administer the epidural, the midwife handed me the card that explains all the risks and asked me to read it to [client]. I challenged her on this and insisted it would be more appropriate for her or the anaesthetist to do that. I also asked [client] whether she knew what an epidural is, and she said no — so I asked the midwife to first explain to [client] what it is before getting into the risks. The midwife wasn't doing what I asked so I had to explain not only how epidurals work but also the risks. Even when the anaesthetist arrived, they insisted I read out the risks." (Companion observation)  

"During the third stage, the hormone injection was given without consent. The midwife said, 'I'm just giving you a wee injection to help deliver your placenta', which was then administered before I had a chance to say anything.’ (Companion observation)  

"Following a standard clinic appointment at [hospital], the clinic midwife told her that she would be examining [client with experience of FGM] today. The midwife acknowledged that [client] had not had time to prepare herself for this examination but did not give her the option of postponing it and returning at a later date. [Client] expressed to [birth companion] that she felt unprepared for this examination but was not aware that patients had the right to decline examinations or treatments until she attended an Amma antenatal class. [Client] stated that, had she known she had the right to refuse the examination, she would have felt more comfortable arranging a subsequent appointment for the examination so that she had time to emotionally prepare herself." (Companion observation)

"Not long after [client]'s waters were broken the intensity of her pain rapidly increased. Midwives also started to express concern with the baby’s trace. A consultant was called to look at the CTG – she said the baby’s heart rate was dipping after each contraction and that, although he seemed to be recovering well, they were having difficulty picking up an accurate trace. She advised placing a ‘wee clip’ on the baby’s head.

I asked her to fully explain to [client] what she meant by a clip, because I understood this to be a small screw. The consultant said there are ‘virtually no risks’ to the baby and that it is a very safe procedure. I questioned this, as my understanding was that there were risks, and the consultant said she would return to discuss it later."

“The midwives offered [client] pain relief but she refused. They continued to offer, and she continued to refuse. The midwife then said, ‘Why don't you just have an epidural, there's no points for birthing without it!’. I stepped in and said ‘Excuse me, but she has already said no several times. Did you not hear her?’ The midwife threw her hands up in the air and said ‘Would you want to be like this? She needs pain relief!’. I said calmly that no, I would not like to be like this but that it's [client’s] decision.

The midwife then started suggesting diamorphine, telling [client] it would help her sleep. She asked several times if she would like it to help her rest and eventually [client] passively nodded. The midwife looked at me and said, ‘I think that was a yes, do you?’ I said, ‘If you're not sure then I suggest you ask again’. When [client] eventually said ‘okay’, the midwife left to get the diamorphine and I tried to explain to [client] what to expect. At this point she was in so much pain it was difficult to communicate so I'm not sure she fully understood what was happening. The diamorphine did help to calm [client] but before long she was in agony, and the midwife again started trying to convince her to get an epidural which [client] eventually agreed to.” (Companion observation)"

"[Client] called after 38-week scan saying she was being induced the next day.  She was very afraid that the baby hadn't grown and there was something wrong, but she didn't have an understanding of her choices or really what the issue could be.  We weren't planning to support at the birth, but I went to the hospital at the time of the planned induction. The midwife wasn't explaining her specific situation as she thought this was done already. We advocated for [client] to see a doctor to explain further." (Companion observation) 

“With all examinations, [client] was advised that if she was experiencing unbearable pain she would only have to say ‘stop’ and the doctor examining her would immediately do so. This was not the case on every occasion [client] was examined. [Client] would say ‘stop’ and the doctor would continue with the procedure immediately. After noticing that the doctor had not stopped at [client’s] request, I would then repeat [client’s] request to stop vocally and using a hand to gesture ‘stop’. The doctor would stop then and apologise as well as asking permission to continue.” (Companion observation)      

Restriction of choices and disregard for preferences

Companions observed women feeling discouraged from certain birth positions or place/type of birth (e.g. midwife-led unit, birthing pool). Their birth plans were sometimes interrogated, and their preferences were not always fully respected or discussed. Some companions observed clients being pressured to undergo induction or start using contraception postnatally despite expressing their preferences otherwise.

“We discussed the option of giving birth at the midwife-led unit. Midwife immediately said she didn't think that would be an option for [client] as they won't take anyone on the red pathway. I asked for clarification as to why [client] is on the red pathway. Midwife explained that [client] is considered high risk because of the past trauma she's experienced and the circumstances through which she became pregnant. She said most of their concerns are related to [client]'s mental health and ability to bond with the baby. Midwife said that if [client] hadn't experienced trauma she would be considered a very low-risk pregnancy.

I felt like this was a very one-sided discussion. [Client] struggles with English and the two midwives in the room talked at length about the benefits of giving birth at the PRM without stopping to make sure [client] was understanding. Then when they asked [client] if there's anything they could do to help her feel more at home there, [client] just shrugged and said, 'I don't know, whatever you think.'” (Companion observation)

“Midwife asked [client] about contraception. When [client] said she didn't need contraception and knows how to not get pregnant and that she isn't having sex, the midwife pointed at [client]’s belly and said, ‘apparently not’. This felt judgmental and not at all trauma-informed (especially given that I'm not sure if we know the origin of this pregnancy and if it was consensual).” (Companion observation)

“I mentioned that the midwife in theatre had said [client]’s placenta was ‘huge’. I said she had a birth plan with her and that [client] gave it to the midwife but that they didn't read it. [Client] wanted to see the placenta, which was in the plan, but was not shown to her.” (Companion observation)

 Insensitive and disrespectful behaviour

Instances of disrespectful behaviour by healthcare workers were reported, including insensitive communication, discussing sensitive information within earshot of the birthing person, engaging in unrelated conversations during labour, and exhibiting micro-aggressions or racial/cultural biases. There were also reports of religious beliefs not being considered.

“During labour, the midwife asked [client] (from Malawi) if she had heard of David Livingstone — when she said she hadn't, the midwife said ‘I thought you'd have learnt about him in school! Were you off school that day?’ I found it deeply uncomfortable given the association with colonialism — and even more so because this was all happening during labour.” (Companion observation)

“I felt no respect was given to the birthing environment. When I arrived, the lights were on full blast, radio blaring in the background with high energy music, everyone chatting over [client]. Throughout the day I kept having to turn the lights off, encourage quiet voices, change the music...” (Companion observation)

“Following birth, on the postnatal ward, [client] expressed feeling ‘belittled’ when midwives spoke openly about her in front of other patients in the room. She recalls, ‘I would sometimes hear a midwife and another midwife say, ‘Oh yeah, her partner is not in the UK’, or, ‘She’s a refugee’.” (Client testimonial)

“[Client] said she didn't have a good experience with the doctor. He was very irritable and asked why she was there. She said he wasn't speaking very nicely and seemed annoyed. He said he could do a procedure during the C-section to stop her having any more children. When [client] said she didn't want this, he said they will have to organise contraception as she shouldn't have any more children.” (Companion observation)

Traumatic experiences and misinformation

Some women experienced distressing situations due to misinformation or inadequate explanations of birth processes. This led to unnecessary pressure, stress, and worry during pregnancy and birth.

“The first issue occurred when [client] first presented at maternity services. [Client] was told that ‘most people with FGM require some form of surgery’ prior to or during birth. [Client] disclosed to [birth companion] that this experience gave her some anxiety around ‘being cut again’ despite knowing that women from her family and community back home who have experienced the same form of FGM have given birth vaginally.” (Companion observation)

“When asked by [client’s] friend if baby would likely be born today, midwife responded ‘Yes, there's a time limit on this baby!’ I could tell [client] felt pressured by this, as things were progressing slowly.” (Companion observation)  

Inadequate support and dismissive attitudes

There were reports of inadequate post-birth support, particularly regarding breastfeeding and concerns raised by the mothers. Some women felt that their concerns were dismissed, and they received insufficient support from staff.

“[Client] voiced concerns about the midwifery care post-birth too. She said it was mixed and some midwives were almost dismissive of her concerns about breastfeeding and being visibly very upset. My experience of the midwives in the ward after birth was that they were very dismissive of any concerns I raised about how she was getting on with breastfeeding and the level of support she was getting.” (Companion observation)

“[Client] tried breastfeeding an hour or so after birth. The midwife was supporting but wasn’t very helpful. [Client] was getting frustrated as baby wasn't opening his mouth and I tried to gently say he is learning how to do it and to have loads of skin-to-skin and get to know each other, etc. Also showed her how to express a bit of milk onto nipple. A while later midwife came back saying he needs fed ASAP because of the gestational diabetes, so she could try expressing or "just give a wee bottle for now". [Client] was exhausted and so weak she couldn't hold him anymore so went for the bottle.” (Companion observation)

Issues with Interpreting

In 2021-22, 39% of 100 clients required an interpreter. During this time period, we recorded issues with interpreting in 74% of these cases. This figure was notably higher at the Queen Elizabeth University Hospital (QEH), with issues reported in 85% of cases compared to 68% at Princess Royal Maternity Hospital (PRM).

Three main themes about interpreter provision were identified on the monitoring form: lack of availability of (suitable) interpreters, staff understanding and willingness to use interpreters and technical issues. Below is a summary of these issues as they were reported on Amma’s Birth Outcomes and Maternity Experiences Monitoring Reports.

Availability of interpreters

• Difficult to get a hold of interpreter  
• No interpreter used in maternity assessment and again following birth when client needed stitches
• In-person interpreter requested but not available. Phone interpreter used.
• Waited two hours for an interpreter
• Midwives could not reach an interpreter during the birth. Birth companion had to use LiveLink to obtain consent for Caesarean section.
• No interpreter available with specific dialect
• Client reluctant to speak with male interpreter
• Interpreter failed to show up at appointment
• No interpreter during antenatal appointment which led to client not understanding conversations about induction and should dystocia
• No NHS interpreter available for a specific language. Staff inability/willingness to access an interpreter through other routes resulted in client not understanding serious health issues for several months interpreting.

Inadequate interpreting

• Frustrated client called her daughter to translate when male interpreter seemed disengaged
• Client believed her baby had tumours rather than cysts and thought the baby may have Down’s Syndrome. Client felt this communication was due to inadequate interpreting.  
• Issues with interpreter not understanding due to wrong dialect

Staff unwillingness/inability to use an interpreter

• Interpreter used briefly to explain something and then hung up 
• Amma staff needed to advocate for interpreters to be used 
• Hospital reluctant to use interpreters even to deliver key medical information  
• Interpreters not always used during labour 
• Call handlers in maternity assessment unsure how to phone a client back with an interpreter. On more than one occasion, Amma had to explain how to use Livelink.  
• Maternity assessment staff thought that they were unable to use telephone interpreters to call a client who needed to speak to them on the phone
• Midwife relied on birth companion to translate 
• Repeated reminders not to rely on Google Translate for important conversations relations to interventions and/or consent 
• Midwife continued to use Google Translate even when client asked for an interpreter. When birth companion intervened, midwife insisted Google Translate was fine.  
• Midwife requested to use birth companions’ phone with Google Translate and said this is what would normally be used for interpreting. 
• Staff assumed that because client had conversational English they would not need an interpreter. 

Technical issues

• Phone kept cutting off
• Poor sound
• Faulty service
• The connection was bad despite trying several times 
• NHS phone battery was low and needed to hang up to recharge 
• Very difficult with signal/line to interpreter; many requests to repeat, interpreter suggested calling someone else several times due to connection being so poor. 
• Lack of written translated resources

Key observations from companions about interpreter issues which illustrate the issues identified above include:

“At times it was difficult to get the hospital staff to use interpreters and key medical information was going to be delivered to the client without a translator until I intervened.” (Companion observation)

“Midwife gestured and shouted in English whenever the interpreter wasn’t available. She also insisted certain information had been shared with the client via the interpreter (e.g., dilation amount), but companion heard the conversation in English and knew this to be untrue. Midwife did not give client the opportunity to ask questions whilst interpreter was on the line; birth companion had to advocate for this during a subsequent call.” (Companion observation)

“Called maternity assessment and asked midwife to call back with interpreter. Midwife advised she didn't know how. I talked her through LiveLink instructions. She called back to say she had spoken to [client] and thanked me for teaching her how to use the phone interpreter.” (Companion observation)

“On antenatal ward, [client] asked for interpreter and the midwife got her to type into her phone on Google Translate, even though she was clearly in pain and distress. I asked her to get the interpreter on the phone and she said, ‘This has been working fine.’” (Companion observation)

“On arrival in the labour ward, baby was coming fast. I asked them to get an interpreter, and they said they would, but in the meantime, I used LiveLink on my phone because there was no time to wait.” (Companion observation)

“Later in the birth, the hospital found it hard to get hold of a telephone interpreter and I had to provide one using my phone, when preparing, getting consent, and going into theatre.” (Companion observation)

“[Client] said she had problems with interpreters in the past.  When she had called in the past, she said she had asked for them to call back with an interpreter and no one had called. She said she had been reluctant to turn up at the hospital as she would have to wait for around three hours for an interpreter.  She asked the midwife to clarify what she was told at her last scan two days previously. The midwife explained that the baby has two cysts — one on the bladder and one on the bowel. They don't seem to be problematic. They would like to keep scanning her in pregnancy to see whether they grow. [Client] said that she had been very upset as the previous interpreter had said these were tumours rather than cysts.” (Companion observation)

"When I arrived at the hospital, I was surprised to learn that [client] had already left with a man. This was especially worrying given [client]'s history of trafficking. On top of this, no interpreter was used to discuss the discharge paperwork with [client]. I urged the midwife to call [client] to check that she was safe. She didn't use an interpreter, so I insisted that she phone back with an interpreter. Thankfully, [client] was able to confirm that she was home safe, but the incident raised red flags regarding the discharge process and communication." (Companion observation) 

Rates of Caesarean Sections

In 2021-22, the total rate of Caesarean sections out of 100 clients was 51%. This includes both planned and unplanned procedures (see Figure 4).

In 2021-22, 22% of 100 recorded births took place by planned Caesarean section. In 2021-22, unplanned Caesarean sections accounted for 29% of 100 recorded births.

40% of the individuals who were induced gave birth by unplanned Caesarean section.

Our year-on-year comparison mirrors an overall increase in Caesarean section rates reported for NHS Greater Glasgow & Clyde between 2021-2022. However, it is important to highlight a significant surge in our own figures during this period, which jumped from 38% to 60%. In 2022, the percentage of our clients undergoing Caesarean sections was 18 percentage points higher than the corresponding statistics reported for NHS Greater Glasgow & Clyde. (See Figure 5).

Public Health Scotland's 'Monitoring Racialised Health Inequalities Report' includes rates of Caesarean births in Scotland broken down by ethnicity (see Figure 6), revealing a much higher rate of Caesarean sections amongst African and Caribbean or Black woman than the overall Scottish population. It is worth noting that the rate of Caesarean sections amongst our clients is higher than those reported by Public Health Scotland when broken down by ethnicity.

The Public Health Scotland report also states that the higher proportion of Caesarean births seen amongst these groups may be attributable to a higher proportion of older women with higher BMI. However, neither BMI or age were cited in our client data as reasons for Caesarean sections.

Planned Caesarean Sections

Our data reveals the following most common reasons cited for planned Caesarean sections:

• Baby’s position
• Previous Caesarean section
• Failed induction
• Various medical factors
• Elective choice

Unplanned Caesarean sections

Our data highlights the following most common reasons cited for unplanned Caesarean sections:

• Lack of progress in labour
• Foetal distress
• Maternal health complications
• Baby's position
• Failed induction or intervention
• Planned Caesarean section moved to earlier date

Recommendations

NHS staff (including those working at all levels in obstetrics and midwifery and in equalities)

Practice Issues & Discrimination 

• Honour the NHS Scotland pledge to reduce health inequalities across the country.
• NHS staff, particularly in obstetrics and midwifery, should commit to being anti-racist. This includes a commitment to learning about equality, diversity, human rights, allyship and intersectionality, and should entail regularly educating oneself and engaging with what it means and how to practice anti-racism in day-to-day life.
• Demonstrate a commitment to improving awareness on the rights and experiences of individuals with varied immigration status (e.g. seeking asylum, no recourse to public funds, destitution).
• Take care to avoid general assumptions about the experiences and health needs of migrants, refugees, or people seeking asylum.
• Embed the principles of the Scottish Government's 'Roadmap for Creating Trauma-Informed and Responsive Change' into care, helping to reduce the risk of re-traumatisation during pregnancy and childbirth amongst those who have experienced gender-based violence (including rape and sexual exploitation).
• Continue to actively engage with local support organisations to signpost and/or make referrals for additional support outside of maternity services. Work collaboratively with other support organisations to respond sensitively and appropriately to each individual's needs (e.g. avoiding unnecessary multiple disclosures).
• Ensure midwives in Glasgow are aware of Amma Birth Companions and how to make a referral for individuals facing pregnancy and birth without support.
• Strive to provide person-centred and equitable care, acknowledging the impact of limited options and poor communication on birth experiences.
• Prioritise minimising psychological distress during childbirth to positively influence maternal mental health, initial interactions with the baby, breastfeeding, and bonding.
• Embrace a model of care that allows for genuine listening to women’s individual experiences.
• Promote patient feedback mechanisms and ensure these are accessible.

Interpreter Provision 

• Demonstrate a commitment to using interpreters whenever needed.
• Ensure all women and those giving birth are informed at their first appointment of their right to an interpreter. Do not assume that someone with conversational English does not need an interpreter.  
• Do not rely on Google Translate or other translation platforms to interpret information about an individual's care or the care of their baby. This is particularly important in situations where consent is required.
• Avoid using partners, family members, friends, or birth companions to interpret.
• Establish clear protocols for what to do if an interpreter is not available (e.g. alternative professional interpreting services).
• Enquire about literacy levels in relevant language prior to sharing written resources.

Rates of Intervention/Lack of Choice

• Ensure that assessment of risk is individualised and evidence-based and social and cultural factors such as race, language, or immigration status are not singled out as reasons for intervention.
• Ensure that all individuals being offered a gestational diabetes screening test understand the reasons why and can provide informed consent to undertake screening. Ensure that every individual being screened for gestational diabetes fully understands the process (e.g. whether to fast), especially when there are language barriers. Provide culturally appropriate and clear dietary advice to help manage gestational diabetes.
• Ensure that NICE guidelines relating to gestational diabetes are embedded in hospital policies.
• When seeking consent, take into consideration that many individuals in the asylum process may feel disempowered to make decisions or ask questions about their care. They may also come from countries where it is not permitted to question healthcare providers. Be aware of power dynamics and how this influences compliance.

NHS Management

Practice Issues & Discrimination 

• Acknowledge that institutionalised racism and discrimination exists and are known to contribute to adverse birth experiences and outcomes.
• Incorporate training for midwifery staff on cultural safety, trauma, gender-based & sexual violence into mandatory annual training programme. This would align with the Scottish Government's National Trauma Transformation Programme and has the potential to benefit all individuals giving birth in Scotland.
• Ensure that staff have dedicated time for regular and meaningful participation in training and continuous professional development, promoting the delivery of the highest quality care for patients.
• Ensure that mechanisms are in place for staff to confidentially and safely speak up about poor practice and discrimination.

Interpreter Provision 

• Explore the most effective ways to access interpreters (e.g. video interpreting) and overcome technical obstacles. Ensure that all clinical areas have the necessary infrastructure and resources to use telephone interpreting services efficiently when required.
• Procure high-quality, ethical interpreting services that prioritise staff wellbeing and offer adequate interpreter provision (e.g. availability of different languages and dialects, genders, medical terminology training).
• Ensure all staff are trained on how to book and work effectively and safely with interpreters. This includes staff in administrative roles.
• Ensure that information leaflets and other resources are available in multiple languages and easy-read formats that staff are aware how to access . Explore the creation of audio resources.

Rates of Intervention/Lack of Choice

• Consider a review of practices related to high rates of induction and Caesarean sections, taking into account race and ethnicity.
• Consider evidence-based practice around the use of ethnicity-based foetal growth charts to determine foetal growth expectations.

Continuous Improvement

• Establish a Maternity Service Liaison Committee for NHSGGC as a mechanism to hear directly from service users about their experiences of maternity care (currently in development). 
• Continue to collaborate with advocacy organisations and participate in ongoing discourse for a more inclusive maternal care system.

Policy Makers and Statutory Bodies: 

Staffing/Resourcing

• Allocate adequate funding and resources to support meaningful and enduring change in maternity services. 
• Recognise the importance of addressing burnout among healthcare staff and invest in measures to improve working conditions. 
• Acknowledge the maternity crisis by placing maternity services at the core of the agenda for the next Scottish Government Programme for Government. 
• Ensure resources are in place to support the emotional and psychological wellbeing off staff who will in turn be better equipped to provide compassionate care.

Addressing Inequalities

• Ensure that any initiatives aimed at tackling racialised health inequalities are adequately funded and resourced. Ensure that participants (especially those with lived experience) in these initiatives are remunerated for their time.   
• Ensure that people with lived experience of the asylum process and relevant third sector support organisations are involved in the development of any strategies to address health disparities. Consider providing free travel, childcare, refreshments, and interpreting services. For those individuals who are unable to accept payment, consider offering a voucher as a thank you for their time.  
• Act on findings from the Scottish Government’s Short Life Working Group on Racialised Inequalities in Maternity Care and other initiatives focused on racialised health inequalities. 
• Dismantle structural barriers to racial equity through national policy changes, making the Race Equality Framework meaningful in practice. 

Data Collection & Monitoring

• Promote and enhance the 'Happy to Ask, Happy to Tell' toolkit to improve data collection practices and address racial health disparities. 
• Collect and analyse feedback around NHS-procured interpreting services to ensure robust monitoring, oversight, and accountability.
• Create a unified and efficient strategy to enhance methods for collecting, organising, and disseminating ethnic data both locally and nationally.

Educators:

• Provide support to expand midwifery education to more universities to address midwife shortages and ensure comprehensive maternity care. 
• Decolonise maternity curriculums and guidance. 
• Integrate the findings of this report into educational curricula to raise awareness among future healthcare professionals about existing inequalities and the importance of culturally sensitive care. 
• Ensure budget is in place to remunerate any third sector organisations who are asked to guest lecture midwifery students. 
• Teach the importance of compassionate, trauma-informed care. Consider engaging with organisations like Make Birth Better and White Ribbon Alliance to educate future midwives about the impact of birth trauma and obstetric violence.  

Amma Birth Companions: 

• Establish formalised feedback mechanisms with the NHS for receiving and acting on feedback, including examples of good practice. 
• Continue to promote self-agency and the ability to make and express choices in one's preferred language within maternity services. 
• Continue to raise awareness about the importance of a trauma-informed, intersectional, and person-centred maternity care framework. 
• Continue to liaise with senior midwifery staff and the NHS Equalities Team to explore solutions and improve conditions for both staff and patients. 
• Establish national network of similar organisations to encourage standardised data collection methods pertaining to migrant women's experiences of maternity care for analysis on a national level.  
• Improve internal data collection methods to understand experiences of labour augmentation.  
• Develop training around interpreter use and cultural safety (co-produced with experts by experience).  
• Continue to participate in initiatives focused on reducing health disparities, e.g. Scottish Government’s Short-Life Working Group on Racialised Inequalities in Maternity Care.