Tests that indicate the health of newborns, moments after birth, are limited and not fit-for-purpose for Black, Asian and ethnic minority babies, and need immediate revision according to the NHS Race and Health Observatory.
Neonatal assessments, including the Apgar score, a quick observation test used to assess babies minutes after birth was developed in 1952, and is now considered out of date by many healthcare professionals. Based on a score of 1 to 10, with a high Apgar score indicating good health for babies, minutes following birth, the assessments are used as standard by healthcare professionals regardless of a baby’s skin tone and can give misleading scores.
Whilst newborns are assessed using all categories of the Apgar score with subsequent clinical actions, findings have fundamentally shown the need to review how healthcare professionals reliably and robustly assess the skin colour of non-white babies to ensure that they benefit from timely and appropriate healthcare.
Historically the assessment was developed based on White European babies and implemented regardless of diverse populations and babies with Black and varying skin tones. Some guidance still reference a baby’s skin should be ‘’pink all over’’.
It comes as the independent health body announces the results of a commissioned review undertaken by Sheffield Hallam University which highlights a number of ‘reliability concerns’ around three current neonatal assessments and perinatal practices – the Apgar score and the detection of cyanosis and jaundice.
It calls for immediate update of maternity guidelines that refer to assessments by skin colour and the increased use of screening tool devices, including oximeters and bilirubinometers. Urgent research is also needed which focuses on enhancing the reliability of these tools especially for darker skinned babies.
The report was officially launched at the House of Commons on Tuesday 11 July, at an event hosted by Bell Ribeiro-Addy MP. Co-chair of the Observatory maternal health working group, Professor Jacqueline Dunkley-Bent also joined parents and lead researchers.
Using a mixed methods approach, consisting of data research and in-depth interviews, researchers from Sheffield Hallam University spoke to a total of 33 healthcare professionals including midwives, health visitors, paediatricians, neonatologists, obstetricians, nurses, along with 24 parents.
Systematic reviews were carried out screening around 200 and including over 80 documents on neonatal assessment and practice including but not limited to – the appearance component of Apgar scores, detection of cyanosis and the identification of jaundice. Targeted locations such as around/inside the mouth for Apgar or yellow in the whites of eyes for jaundice may be better indicators than skin colour particularly in Black, Asian, and minority ethnic newborns.
Inconsistencies were also shown with a lack of policy consideration in the formulation of guidelines, understanding and training regarding skin colour in neonatal examinations. Several maternal health policies referred to terms such as “pink” “blue” “pale” or “pallor” in reference to neonatal skin, with no reference to alternative descriptions for Black, Asian and ethnic minority babies. Interviews showed many healthcare professionals were uncertain how to apply the Apgar score in Black, Asian and ethnic minority newborns. This led to many adapting the score in their own way, which did not always align with best practice.
Findings from – Review of neonatal assessment and practice in Black, Asian and minority ethnic newborns: Exploring the Apgar score, the detection of cyanosis, and jaundice – include 56 studies with only six studies related to Apgar scores, three considered the detection of lack of oxygen (cyanosis) and the remainder the detection of jaundice.
Mum, Lauren Clarke, from Nottingham, has described how, within hours of giving birth to her son, Jaxson, it was clear that ‘things were being missed’ and noted incorrectly on paperwork as her son’s eyes were yellow and blood shot.
“We repeatedly questioned Jaxson’s skin tone due to jaundice for the first four days but each time our concerns were ignored. I was readmitted with an infection, and it was only at this point that Jaxson’s jaundice was picked up by a midwife. His levels were so high that he should have immediately had a blood transfusion due to the possible long term affects from jaundice.
“Jaxson was taken away from me mid breastfeeding for immediate treatment and had to have a lumbar puncture and then blood tests every hour to check if his bilirubin levels were coming down but they continued to rise.
“We spent a further five days in hospital for Jaxson to be treated with light therapy and antibiotics. This was obviously not how we were expecting to spend our first few weeks as a new family.”
Evidence supports this, only three previous studies had looked at parents’ experiences of identifying neonatal jaundice in Black, Asian or minority ethnic newborns, but all three reported jaundice to be inadequately identified in their infant by healthcare professionals. A lack of training into clinical assessment of Black, Asian and minority ethnic babies was also highlighted both within the interviews undertaken for this report, as well as in a previous study of midwives and student midwives that particularly focused on the assessment of the Apgar score.
Midwife, Hora Soltani, Professor of Maternal and Infant Health, Sheffield Hallam University, said:
“We are very grateful to the Observatory for supporting this project and for the efforts of our collaborative team who for the first time, have systematically examined the relevance of the most commonly practised neonatal assessments which have been developed decades ago mainly based on White European babies.
“The importance of listening to the parents’ concerns and appropriateness of policies and education of healthcare professionals including access to educational materials which reflect the impact of various skin colour tones on such important areas of neonatal assessment are among the key findings of this work. This was extremely intensive work and although it doesn’t provide all the answers, it certainly highlights research, policy, practice and educational gaps as a first step towards ensuring commonly used neonatal assessments are sensitive to the needs of our super-diverse communities.”
Lack of translation, discrimination and communication were factors for parents impacted by heightened anxiety following a jaundice diagnosis coupled with their lack of understanding of the condition.
Chief Executive of the NHS Race and Health Observatory, Dr Habib Naqvi, said:
“We need to address the limitations in visual examinations of newborns, such as Apgar scores, where the assessment of skin colour can potentially disadvantage Black, Asian and ethnic minority babies with darker skin. The results from this initial review highlight the bias that can be inherent in healthcare interventions and assessments and lead to inaccurate assessments, late diagnosis and poorer outcomes for diverse communities. The Observatory is committed to providing practical solutions to patient safety challenges.”
Racism and bias was also an issue with some women feeling silenced within the healthcare system, whilst some felt dismissed, ignored, or belittled, others feared raising concerns due to worries over being labelled as “difficult” or “too much trouble”. The review also reports on an infant developing cerebral palsy due to failures in listening to the mother’s concerns over jaundice.
Lauren added: “If the various health professionals we saw had listened to our concerns or been trained correctly to include every ethnicity, it is a trauma that could have been avoided for ourselves and many other families. We lost trust and faith in the system that should have been supporting us to keep our baby safe and well. We repeatedly felt judged and ignored when we questioned the ability to understand our child’s needs.”
Co-chair of the Observatory’s maternal working group, Professor Jacqueline Dunkley-Bent, said:
“The findings of this study show that we have much to do to ensure that women, babies and diverse people of colour receive the same healthcare, and have the same childbirth outcomes and experiences as those who receive the best. We are keen to work with health commissioners and maternity service providers to ensure the best outcomes for parents and newborns.”
Several recommendations have been made for healthcare policy, providers and researchers, including:
- Immediate update of guidelines that refer to neonatal assessment by skin colour
- Medical devices should be used to detect jaundice and cyanosis
- Better education for parents and families to be able to spot the signs of jaundice
- A data bank of open access images of Black, Asian and ethnic minority neonates to be included in health care education and training
- Urgent need for education and training for healthcare professionals on clinical assessment on neonates from Black, Asia and minority ethnic backgrounds.
- Further studies into reliability of using Apgar score and how healthcare professionals use this when assessing babies from Black, Asian or minority ethnic backgrounds
In the UK, Black women are four times more likely to die during pregnancy or childbirth compared to White women with women from Asian backgrounds facing twice the risk of maternal mortality. Similarly, there is also a higher rate of stillbirth and neonatal death for babies from Black and Asian ethnic minority groups.
Details of a forthcoming new research commission by the NHS Race and Health Observatory will seek to establish the existing evidence on screening for jaundice in Black, Asian and ethnic minority babies and determine clear implications and recommendations for clinical practice, healthcare users and their families.