Summary: This document provides a research-informed framework for healthcare executives, educators, and learners to audit maternity and neonatal education modules for racial bias and equity. It offers a structured, evidence-based approach to reforming university-level curricula, ensuring that future clinicians are trained within systems that promote safety, dignity, and fairness for all families.
By identifying and removing racial bias from educational design and delivery, universities and NHS partners can strengthen the pipeline of culturally safe practitioners, improve outcomes for people of colour using and working within maternity and neonatal services, and fulfil national commitments to equity and quality of care.
While this framework focuses on racial bias, it should be applied within a broader equality lens. Executives are encouraged to conduct ongoing Equality Impact Assessments which cover additional characteristics such as disability, socio-economic background, and other determinants of inequity to ensure that educational reform is truly inclusive, representative and future-proofed.
Reducing racial bias in maternity education is both a moral and economic imperative. Each preventable maternal death carries immense personal tragedy but also an enduring cost to the NHS and public expenditure.
The Problem: Significant racial disparities in maternal and neonatal outcomes constitute a public health crisis. In the USA, Black women are two to four times more likely to die from pregnancy-related causes than white women, regardless of socio-economic status (WHO, 2025). Research confirms that these inequities are not explained by genetics, but by systemic racism, implicit bias within healthcare, and the cumulative “weathering” effects of chronic stress (Hoyert, 2023).
In the UK, similar patterns persist. The latest MBRRACE-UK reports show that Black women are almost four times more likely, and Asian women nearly twice as likely, to die during pregnancy or within six weeks of birth compared with white women. Babies born to Black and Asian mothers also experience higher rates of stillbirth and neonatal mortality. A 2025 report by the UK Parliament identified racial bias in healthcare as a key contributing factor (UK Parliament, 2025).
These inequities reflect systemic failures that extend across clinical, educational, and institutional structures. Education therefore represents a critical point of intervention: by embedding anti-racist and bias-aware principles within maternity and neonatal training, we can equip future clinicians to recognise, challenge, and ultimately transform the inequitable systems that sustain these disparities. This approach aligns directly with the NHS Maternity Equity and Equality Delivery Plan and the government’s commitment to tackling health inequalities across England.
Behind each statistic is a human being whose concerns were dismissed, whose pain was minimised, or whose symptoms were misinterpreted. The reforms proposed here aim to ensure those moments of neglect never happen again. The actions proposed here directly operationalise commitments already set out in the NHS Maternity Equity and Equality Delivery Plan and the Women’s Health Strategy.
Core Principles from the Literature
An effective audit should ensure the curriculum is grounded in the following evidence-based principles.
- Explicitly Names and Frames Racism as a Root Cause: The curriculum must move beyond the concept and use of the term ‘health disparities’ to explicitly teach that structural , systemic and interpersonal racism are fundamental drivers of inequitable outcomes (Crear-Perry et al., 2021).
- Centers the Historical Context: Understanding the historical legacy of racism in gynecology and obstetrics (e.g., experiments on enslaved women by J. Marion Sims; general race bias and pain management in UK healthcare BMJ 2022) is crucial for contextualising current patient mistrust and provider-power dynamics (Washington, 2006).
- Integrates, Not Isolates, Equity Content: Content on racial equity should be woven throughout the entire curriculum (physiology, pharmacology, ethics, clinical skills) rather than confined to a single “cultural competency” lecture (McClain et al., 2020).
- Focuses on Systemic Solutions: While individual bias reduction is important, the curriculum must emphasise the redesign of clinical systems, treatment structures and protocols (e.g., standardized risk assessments, escalation procedures) to mitigate the impact of bias (Howell, 2018).
- Equality vectors: Use a tool that covers and repeatedly explains and reminds educators and learners about the vectors of equality.
The Executive Audit Toolkit: Key Elements to Assess
Use the following checklist to evaluate your institution’s education modules.
1. Curriculum Content & Foundational Knowledge
| Element to Audit | Evidence of Bias or Omission | Evidence of an Anti-Bias Approach |
|---|---|---|
| Pathophysiology & Risk | – Attributing disparities primarily to “patient factors” like poverty, education, or “compliance.” – Teaching that Black women are inherently at higher risk for pre-eclampsia without contextualising the role of chronic stress and allostatic load (“weathering”). | – Teaching the “Weathering Hypothesis” (Geronimus, 1992) as a key framework for understanding higher rates of morbidity. – Differentiating between race (a social construct) and genetic ancestry in disease risk. |
| Pain Management | – Perpetuating false biological myths (e.g., “Black people feel less pain” or have “thicker skin”). – Teaching non-evidence-based “cultural” beliefs about pain tolerance. | – Citing studies demonstrating racial bias in pain assessment and treatment (Hoffman et al., 2016). – Teaching patient-centered, validated pain assessment tools and advocating for equitable analgesic administration. |
| Clinical Algorithms & Guidelines | – Uncritically teaching protocols that use race as a proxy for biology (e.g., vaginal birth after cesarean (VBAC) calculators, estimated glomerular filtration rate (eGFR)). | – Critically examining how race-based corrections in clinical algorithms can lead to underestimation of risk and delayed care (Vyas et al., 2020). – Advocating for the validation and adoption of race-neutral tools. |
| Patient Presentation & “Normalcy” | – Using clinical textbooks and images that almost exclusively feature white skin tones, missing common presentations of conditions (e.g., cyanosis, rashes, jaundice) on skin of different tones. | – Integrating diverse medical imagery across all learning materials. – Using pedagogical and tech resources to ensure accurate assessment across skin tones. |
2. Teaching Methods & Pedagogy
| Element to Audit | Evidence of Bias or Omission | Evidence of an Anti-Bias Approach |
|---|---|---|
| Case Studies | – Featuring predominantly white, middle-class patients. – Unconsciously linking people of colour with negative outcomes or social problems (e.g., substance use, non-compliance). – Dated resources that are used without ongoing stakeholder engagement to improve knowledge base. | – Using diverse case studies that portray people of colour as complex individuals across the socioeconomic and cultural spectrum. – Including cases that explicitly involve provider bias and require students to identify and address it. – Audit resources by internationalising case studies for wider examples and evidence. |
| Standardised Patients & Simulation | – Using mannequins and SPs that lack racial diversity. – Running scenarios that reinforce stereotypes. | – Employing high-fidelity mannequins of various skin tones. – Developing simulation scenarios focused on cross-cultural communication, de-escalation, and recognising one’s own implicit bias in a clinical encounter. |
| Classroom Discourse | – Allowing racially biased comments or “race-neutral” language to go unchallenged. – Lack of speaking up support for students who want to challenge predominantly white narratives. – Lack of diverse student base across maternity studies cohorts. | – Establishing ground rules for respectful discussion of equality, race and racism. – Faculty are trained to facilitate difficult conversations and correct misinformation in real-time. – Faculty are guided with ongoing support from race and equality experts for at least 12 to 24 months to ensure learning is embedded and behaviour change is practised. |
3. Assessment and Evaluation
| Element to Audit | Evidence of Bias or Omission | Evidence of an Anti-Bias Approach |
|---|---|---|
| Exam Questions | – Including questions that rely on racially biased clinical algorithms or stereotypes to arrive at the “correct” answer. | – Auditing all exam questions for potential racial bias. – Writing questions that test understanding of structural drivers of health and anti-racist clinical interventions. – Deploy experts to assess questions for bias. |
| Clinical Evaluations | – Using subjective evaluation criteria that are vulnerable to implicit bias (e.g., “professionalism,” “confidence”). | – Implementing structured, objective rubrics for clinical evaluations. – Providing rater training to minimise bias in student assessment. |
4. Faculty and Institutional Readiness
| Element to Audit | Evidence of Bias or Omission | Evidence of an Anti-Bias Approach |
|---|---|---|
| Faculty Expertise & Development | – Expecting faculty members who are people of colour to carry the burden of teaching and championing equity content without compensation or support. – No dedicated faculty training on these topics. – No dedicated equality expert to support faculty in improving equality and anti-bias training, learning and education. | – Investing in ongoing, mandatory faculty development on implicit bias, anti-racist pedagogy, and the science of health inequities. – Compensating equity work formally. – Regular audits of faculty expertise and publications. |
| Student & Patient Voice | – Curriculum is designed without input from diverse stakeholders. | – Establishing a permanent student advisory council with diverse representation. – Incorporating recorded patient narratives and community advisory boards to inform curriculum design. – Deploy equality experts to assess and support student learning about diversity in accessing services. |
Recommended Actions for Executives
- Form a task force: Create a multidisciplinary team including educational deans, faculty, students, equality executives, and community birth workers (e.g., doulas). Ensure representation from staff networks (e.g., Race Equality, Multicultural, LGBTQ+, Disability), public health teams, local NHS maternity voices, and external partners such as Race and Health Observatory, Royal Colleges, Care Quality Commission, and NHS England Maternity Transformation leads.
- Conduct a curriculum map: Systematically review all syllabi, lectures, case studies, assessments, and reading materials against this audit framework. Include a mapping of clinical placements, OSCE scenarios, and technological tools (algorithms, monitors, apps) for race-adjusted content.
- Invest in faculty development: Allocate resources for robust, recurring training on anti-racist pedagogy. This is not a one-time seminar. Embed this training into CPD requirements, induction, and performance reviews. Ensure senior leaders and external examiners attend too.
- Update core resources: Budget for new textbooks, simulation equipment, and image libraries that reflect racial diversity and contemporary, unbiased science. Audit imagery and case studies annually. Collaborate with image banks (e.g., Diverse Skin Tones in Dermatology, Brown Skin Matters) to ensure updates remain current.
- Establish metrics for success: Move beyond satisfaction surveys. Track metrics like student competency in identifying bias, diversity of case studies used, and, ultimately, the career-long outcomes of the clinicians you train. Measure representation in faculty recruitment, attainment gaps in assessments, and complaints data trends. Publish metrics transparently to show progress.
- Ongoing equality impact assessment: Provide evidence of change and use for gap analysis to track progress in embedding equality (including race equality) in teaching design, delivery, learning etc. Ensure EIAs are undertaken at each curriculum review point and shared with the Board of Studies, EDI committees, and relevant NHS Trust partners.
- Toolkit: Develop an online toolkit that can be used and shared by different institutions to debias curriculums and support learners. Invest in sharing resources online to debias training and education across higher education. It is preferable not to work in silos and therefore engaging with professional bodies, international organisations and government departments would also be proficient. Work collaboratively with professional bodies (e.g., RCM, RCOG, NMC), NHSE Maternity Transformation Programme, and the NHS Race and Health Observatory to maintain national consistency and reduce duplication.
- Finance: Set aside sustainable ring-fenced finance for 10 years+. Include accountability for spending and link it to EDI key performance indicators. Use a portion of funds to support student-led innovation and research into bias reduction in clinical education.
- Embed Governance and Accountability: Appoint a senior executive sponsor for anti-racism in education and include racial equity objectives in leadership appraisal frameworks. Require annual board reporting on curriculum equity, EDI progress, and bias incidents.
- Communication and Transparency: Publish an annual Equity in Education Report summarising curriculum updates, staff training, attainment data, and stakeholder feedback. Use accessible channels (intranet, newsletters, open forums) to demonstrate commitment and invite continual dialogue.
Conclusion: Auditing and reforming maternity and neonatal education is a vital upstream intervention in addressing the maternal health inequalities that persist across the UK. Embedding anti-racist and equity-focused principles into clinical training is not simply a matter of fairness, it is a matter of safety, quality, and public accountability. By equipping the next generation of clinicians with the knowledge and confidence to deliver culturally safe, evidence-based care, we strengthen the foundations of healthcare itself and reduce costs. This is how we prevent avoidable harm, rebuild trust with communities, and ensure that every family, regardless of background, receives the respectful, high-quality care they deserve.
By reforming how we teach care, we redefine what it means to deliver it, thus ensuring that every part of the UK, can expect safety, dignity, and respect as their human right.
References
Betancourt, J. R., Green, A. R., Carrillo, J. E., and Owusu Ananeh-Firempong, I. I. (2016) ‘Improving quality and achieving equity: the role of cultural competence in reducing racial and ethnic disparities in health care’,
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Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., and Wallace, M. (2021) ‘Social and structural determinants of health inequities in maternal health’, Journal of Women’s Health, 30(2), 230-235.
Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., and Reid, P. (2019) ‘Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition’, International Journal for Equity in Health, 18(174).
Geronimus, A. T. (1992) ‘The weathering hypothesis and the health of African-American women and infants: evidence and speculations’, Ethnicity & Disease, 2(3), 207-221.
Hoffman, K. M., Trawalter, S., Axt, J. R., and Oliver, M. N. (2016) ‘Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites’, Proceedings of the National Academy of Sciences, 113(16), 4296-4301.
Howell, E. A. (2018) ‘Reducing disparities in severe maternal morbidity and mortality’, Clinical Obstetrics and Gynecology, 61(2), 387.
Hoyert, D. L. (2023) ‘Maternal mortality rates in the United States, 2023’, National Center for Health Statistics Health E-Stats.
Iacobucci G. (2022) ‘Most black people in UK face discrimination from healthcare staff, survey finds’, BMJ 2022; 378.
UK Parliament (2025) ‘Maternal, newborn and infant health: priorities for improved outcomes, UK Parliament, 28 July 2025.
Vyas, D. A., Eisenstein, L. G., and Jones, D. S. (2020) ‘Hidden in plain sight—reconsidering the use of race correction in clinical algorithms’, New England Journal of Medicine, 383(9), pp.874-882.
Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. Doubleday Books.
WHO (2025) “SDG Target 3.1: Reduce the global maternal mortality ratio to less than 70 per 100,000 live births,” World Health Organization, World Health Statistics.
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