Skin colour checks after birth fail to spot health concerns in Black and Asian babies

Guidelines for the quick assessment given straight after birth (an Apgar score) were designed in the 1950s when the UK’s population was less ethnically diverse than it is today.  

The assessment includes checks for muscle tone, pulse, breathing and reflexes. But healthcare professionals are also still trained to check whether a baby is pink, too pale, or there are signs of blue skin tone.  

For Black and Asian babies, relying on skin tone guidelines only designed for White babies could lead to conditions – such as jaundice - being missed.

The NHS review found that most healthcare professionals adapted the check (they might look for colour changes around the lips, rather than general skin tone) or focused more on other factors rather than skin colour - but there was no consistent, best-practice, approach.

Currently in the UK there is a big difference in health outcomes for babies and mothers of different ethnicities – a shocking disparity that we're working hard to try and reduce.

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.

The NHS Race and Health Observatory review published this week calls for better training for healthcare staff and parents on adapting care for babies of different ethnicities. Among other recommendations it suggests that a ‘national image database’ would be a good step forward in helping healthcare professionals better identify conditions such as jaundice.

Alicia Burnett, Tommy’s Midwife and founder of Black Baby Loss Awareness Week, says:  

“It is extremely positive that calls are being made for APGAR and neonatal jaundice and cyanosis assessments to be immediately updated. Health care professionals need to be able to assess all newborns, including babies from ethnically diverse populations, for signs of deterioration as a matter of public safety.  

“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."    

In an article for The Practicing Midwife journal in 2021, Alicia explored how language and training materials for student midwives which focus on White women and birthing people and White babies, is jeopardising the safety of Black, Asian and minority ethnic individuals.  

Jaundice or cyanosis (an indicator of decreased oxygen which could suggest heart or lung problems) in babies can be missed, she explains. Training which only describes “redness” as an indicator of breast tissue inflammation can also lead to misdiagnosis in women and birthing people. “Midwifery education must be decolonised as a matter of public safety,” Alicia says.

Tackling inequities

Everybody deserves to have good, equitable, care throughout their pregnancy journey, which means ensuring that care is personalised to each woman and birthing person and every baby.  

Checklists which determine a woman or birthing person’s care pathway, or that are used to assess the health of a baby, which are not tailored to individuals contribute toward these inequities continuing.

We’re currently trialling the Tommy's Pathway: Clinical Decision Support Tool across 26 NHS hospitals, supported with £1.8 million from the National Institute for Health and Care Research. The tool enables midwives and doctors to more accurately assess each woman and birthing person’s needs at the start of, and during, pregnancy and to personalise their care.

The aim is to identify women and birthing people most at risk or stillbirth or premature birth. Premature birth is the leading cause of neonatal death: every year nearly 60,000 babies (8%) are born prematurely, with many facing a lifetime of health issues. Babies from Black ethnic groups are most likely to be born early.  

Our recent Saving Babies Lives Progress Report from the Sands & Tommy’s Joint Policy Unit shows that while several reports published in recent years have highlighted the stark disparities which exist for mothers and babies of different ethnicities, we are yet to see a commitment from Government to changing the situation.

In fact, the Government recently declined to set a target for reducing death rates for Black women during and after childbirth.

“When women and birthing people do access care, there are reports of racism or discrimination based on their ethnicity, class, migration status or other factors,” our Sands & Tommy's JPU report explains. This includes “seeing white bodies as the ‘norm’ and failing to recognise symptoms on black or brown skin, such as jaundice and sepsis.”

The problems have been diagnosed – now is the time for meaningful action to address these stark and persistent inequities.