Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol

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Maher" }, { "@type": "Person", "name": "Joye McKernan" }, { "@type": "Person", "name": "Paul Corcoran" }, { "@type": "Person", "name": "John R. Higgins" }, { "@type": "Person", "name": "John P. Browne" } ], "publisher": { "@type": "Organization", "name": "HRB Open Research", "logo": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 566, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 1200, "width": 127 }, "description": " Introduction European research consistently highlights that women from migrant and ethnic minority backgrounds are at higher risk of negative clinical outcomes and patient experience. However, problems with ethnicity data collection, coding, and use limit the capacity of healthcare systems to assess and respond accordingly. Objective This scoping review aims to map the current coding practices and describe the evidence base on 1) how ethnicity is defined and recorded in maternity care and clinical research in Europe, and 2) how ethnicity is analysed in studies involving maternity populations evaluating disparities in clinical outcomes. Inclusion criteria The Joanna Briggs Institute’ (JBI) population, concept and context (PCC) framework will structure this scoping review. Research studies eligible for inclusion will focus on maternity populations in European healthcare settings. Studies published from 2015 onwards, and in any language will be eligible for inclusion, encompassing a range of qualitative, quantitative, and mixed methods designs, as well as relevant grey literature. Methods A systematic search will be conducted using the following electronic databases: MEDLINE (OVID), CINAHL, PubMed, and Scopus. The search strategy will be developed and pretested by the review team, following consultation with a research librarian to refine search syntax and terms. All identified records will be imported to a reference management tool and duplicates will be removed. Two reviewers will independently screen titles and abstracts, and relevant literature will be selected based on predetermined inclusion and exclusion criteria. Data will be extracted using a structured form and synthesised to describe the size, focus and quality of the evidence base and identify the common practices. Findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist (PRISMA-ScR). 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HRB Open Res 2025, 8 :111 ( https://doi.org/10.12688/hrbopenres.14266.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] Daire Buckley https://orcid.org/0000-0002-8927-8791 1 , Laura Cronin https://orcid.org/0000-0002-9273-6263 1 , Gillian M. Maher https://orcid.org/0000-0002-6722-0484 2 , [...] Joye McKernan 3 , Paul Corcoran https://orcid.org/0000-0003-1201-7136 3 , John R. Higgins 1 , John P. Browne https://orcid.org/0000-0003-3494-4336 4 Daire Buckley https://orcid.org/0000-0002-8927-8791 1 , Laura Cronin https://orcid.org/0000-0002-9273-6263 1 , [...] Gillian M. Maher https://orcid.org/0000-0002-6722-0484 2 , Joye McKernan 3 , Paul Corcoran https://orcid.org/0000-0003-1201-7136 3 , John R. Higgins 1 , John P. Browne https://orcid.org/0000-0003-3494-4336 4 PUBLISHED 22 Oct 2025 Author details Author details 1 Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland 2 INFANT Research Centre, University College Cork, Cork, County Cork, Ireland 3 National Perinatal Epidemiology Centre, University College Cork, Cork, County Cork, Ireland 4 School of Public Health, University College Cork, Cork, County Cork, Ireland Daire Buckley Roles: Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Laura Cronin Roles: Investigation Gillian M. Maher Roles: Supervision, Writing – Review & Editing Joye McKernan Roles: Supervision Paul Corcoran Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing John R. Higgins Roles: Conceptualization, Project Administration, Supervision John P. Browne Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Maternal and Child Health collection. Abstract Introduction European research consistently highlights that women from migrant and ethnic minority backgrounds are at higher risk of negative clinical outcomes and patient experience. However, problems with ethnicity data collection, coding, and use limit the capacity of healthcare systems to assess and respond accordingly. Objective This scoping review aims to map the current coding practices and describe the evidence base on 1) how ethnicity is defined and recorded in maternity care and clinical research in Europe, and 2) how ethnicity is analysed in studies involving maternity populations evaluating disparities in clinical outcomes. Inclusion criteria The Joanna Briggs Institute’ (JBI) population, concept and context (PCC) framework will structure this scoping review. Research studies eligible for inclusion will focus on maternity populations in European healthcare settings. Studies published from 2015 onwards, and in any language will be eligible for inclusion, encompassing a range of qualitative, quantitative, and mixed methods designs, as well as relevant grey literature. Methods A systematic search will be conducted using the following electronic databases: MEDLINE (OVID), CINAHL, PubMed, and Scopus. The search strategy will be developed and pretested by the review team, following consultation with a research librarian to refine search syntax and terms. All identified records will be imported to a reference management tool and duplicates will be removed. Two reviewers will independently screen titles and abstracts, and relevant literature will be selected based on predetermined inclusion and exclusion criteria. Data will be extracted using a structured form and synthesised to describe the size, focus and quality of the evidence base and identify the common practices. Findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist (PRISMA-ScR). READ ALL READ LESS Keywords ethnicity data; coding; collection; disparity analysis; European maternity settings Corresponding Author(s) Daire Buckley ( [email protected] ) Close Corresponding author: Daire Buckley Competing interests: No competing interests were disclosed. Grant information: The author(s) declare that this work was supported by financial funding from the HSE Office of National Quality and Patient Safety. Copyright: © 2025 Buckley D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Buckley D, Cronin L, Maher GM et al. Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.12688/hrbopenres.14266.1 ) First published: 22 Oct 2025, 8 :111 ( https://doi.org/10.12688/hrbopenres.14266.1 ) Latest published: 22 Oct 2025, 8 :111 ( https://doi.org/10.12688/hrbopenres.14266.1 ) Introduction European research consistently highlights that women from migrant and ethnic minority backgrounds using maternity services have poorer than expected clinical outcomes and negative patient experiences 1 , 2 . Specifically, studies have documented higher rates of obstetric complications among these groups, including increased risk of maternal morbidity and mortality 3 , 4 . Adverse neonatal outcomes such as preterm births, stillbirths, and low birth weight infants are also more prevalent 1 – 5 . In terms of negative patient experience, women from migrant and ethnic minority backgrounds often encounter multiple barriers to appropriate maternity care, including limited or lack of access to maternal health services, language and cultural differences, lack of familiarity with the healthcare system, and legal or socio-economic constraints 2 , 5 , 6 . These challenges contribute to lower levels of service uptake and delayed engagement with antenatal services, which in turn can increase the risk of poor outcomes for both mother and baby 2 . Furthermore, many women report experiences of poor communication with healthcare professionals, a lack of culturally sensitive care, and feelings of being dismissed or not listened to 2 , 3 , 6 , 7 . Concerns around respect, dignity, and autonomy are frequently raised, with some women describing discriminatory attitudes and behaviours from staff that undermine trust in the healthcare system, further contributing to negative care experiences 2 – 10 . Most European countries offer publicly funded maternity care and express commitment to equity in maternal health 11 . Shared policy frameworks and similar migration patterns—including a recent increase in refugees, asylum seekers, and other non-EU migrants—make Europe a reasonably coherent context for examining systemic drivers of inequality in maternal outcomes 11 – 13 . One important factor shaping these inequalities is ethnicity. Ethnicity is a complex, multi-dimensional, socially constructed concept which refers to a group identity based on shared characteristics such as language, ancestry, cultural heritage, and traditions. However, identities are fluid and can evolve over time, which presents challenges for collecting ethnicity data 14 . Across Europe, ethnicity is not routinely recorded, and operational definitions and coding practices for ethnicity vary widely, particularly in maternity care, which often functions as a distinct sub-system within national healthcare structures 14 – 16 . In 2016, the European Court of Auditors urged the European Commission to develop a unified approach to ethnicity data collection across EU Member States 17 . While not healthcare specific, it does have implications for health systems, including maternity care. Ethnicity data is crucial for monitoring disparities, informing service design, and developing policies that promote equitable access and outcomes. Despite this, wide variation remains in legal and policy approaches to ethnicity data collection across European healthcare systems. Outside the EU, the United Kingdom has established systematic approaches to capturing ethnicity in healthcare data within its National Health Service (NHS). Ethnicity data is routinely collected and integrated into patient records. This routine data collection extends to maternity care. For example, MBRRACE-UK conducts national surveillance and confidential enquiries into maternal and perinatal outcomes 18 . Such data enables the evaluation of disparities and identifies patterns of inequality or discrimination. The findings are published using standard 16 ONS NHS ethnicity categories – matched with the UK Census - and inform policy development and service reform 16 , 19 . Conversely, countries such as France, Denmark, Germany, and Sweden, adopt ‘colour-blind’ policies that prohibit the collection of ethnicity data entirely across all healthcare services 20 . While this approach is intended to promote equality by emphasizing a “sameness” among citizens, it often masks the lived realities of marginalised groups. The absence of such data in these contexts undermines efforts to detect and address inequities resulting in unmeasured disparities of maternal health outcomes 20 . In Ireland, the legal obligation for publicly funded bodies to promote equality and human rights is grounded in the 2014 Irish Human Rights and Equality Commission's Public Sector Duty. In alignment with this legislation, both the Health Service Executive’s (HSE) National Intercultural Health Strategy and Ireland’s Migrant Integration Strategy have advocated for improved ethnicity data collection in healthcare settings 15 . However, ethnicity is recorded in only 14 of 97 national health and social care datasets 19 . Despite the legal requirement to record ethnicity data in health services, it is not routinely collected—including in maternity care, where data collection remains inconsistent across care settings. The inclusion of an ethnic identifier within existing health information systems was proposed to address these issues 21 . The approach is grounded in self-identification and uses the ethnic and cultural categories from the Irish Census, to enable consistency and comparability across datasets. Nonetheless, implementation has been inconsistent across most services, including maternity care, hindering the capacity to monitor and address ethnic disparities in maternal outcomes 15 , 19 . Across Europe, the evidence suggests that where ethnicity data is recorded, variations persist in coding standards, classification systems (e.g., self-identification versus proxy indicators), and the analytical use of this information in disparities research. Such inconsistencies limit the effectiveness of data-driven efforts to identify, monitor, and address ethnic inequalities in healthcare outcomes. Without robust evidence on ethnic disparities – and on the strategies to address them - maternity care systems risk perpetuating inequities that undermine women’s health, trust in services, and broader public health goals. Preliminary searches revealed no existing systematic or scoping reviews that synthesise coding practices and analytical approaches used across Europe to examine disparities in maternity care. While several studies have investigated maternal health experiences by ethnicity, few have explicitly addressed the coding practices underlying these analyses or examined how ethnicity data is treated methodologically in both epidemiological research and quality improvement efforts. This points to a critical gap in the literature. Given these complexities, a scoping review is the most suitable approach to map the breadth and diversity of existing evidence, identify knowledge gaps, and inform future research and policy development. Research question We used the Joanna Briggs Institute’ (JBI) population, concept and context (PCC) framework to structure this scoping review 22 . Studies eligible for inclusion will focus on maternity populations within European countries, and address practices related to the collection of ethnicity data and the analytical approaches to evaluate disparities. The scoping review will address the following research question: “In maternity care settings across Europe, how is ethnicity recorded in research studies, and how are ethnicity-related disparities analysed?” Sub-questions: i) How is ethnicity recorded, defined, categorised, and collapsed in European maternity care studies? ii) What analytical strategies, i.e. statistical and methodological approaches, are used to analyse ethnicity-related disparities in maternity care? Inclusion criteria Population This review will include: Studies involving women receiving maternity care (antenatal, intrapartum and postnatal care) in Europe. Studies involving healthcare providers of maternity care (e.g. midwives, obstetricians, reception staff, data managers, and informatics teams) if the analysis relates to ethnicity. Concept The central concept is the collection and analysis of ethnicity data in maternity care, encompassing: Recording of ethnicity (e.g., coding systems, categories, definitions, data sources) Epidemiological and quality improvement methods to evaluate ethnicity-related disparities in clinical outcomes. (e.g., statistical and methodological approaches such as statistical tests, regression models, etc.). Context The context is European maternity care , including hospital-based care, community-based care, and integrated care. The search will be restricted to peer-reviewed studies published between 2015 to 2025. This date range reflects increasing awareness and policy development around ethnicity data and health equity in the aftermath of key EU directives and global initiatives on health data standardisation, as well as heightened attention to health inequalities during the COVID-19 pandemic and the global Black Lives Matter movement. Studies published in any language will be eligible for inclusion, with translation support provided for non-English full texts if necessary. An overview of the inclusion and exclusion criteria is presented in Table 1 . Table 1. Inclusion and Exclusion criteria. Inclusion Exclusion Population -Women receiving maternity care (antenatal, intrapartum, postnatal) in Europe. -Healthcare providers of maternity care (midwives, obstetricians, reception staff, data managers, informatics teams) if analysis relates to ethnicity. -Studies not involving maternity care. - Studies involving populations outside Europe. - Studies where healthcare providers are included but ethnicity is not addressed. Concept - Recording of ethnicity (coding systems, categories, definitions, data sources). - Analysis of ethnicity data (epidemiological or quality improvement methods, e.g., statistical tests, regression models). - Studies addressing ethnicity-related disparities in clinical outcomes. - Studies not addressing ethnicity data. - Studies not analysing collection, categorization, or use of ethnicity in maternity care. - Non-empirical papers unless providing methodological frameworks directly relevant to ethnicity data in maternity care. Context European maternity care settings: hospital-based, community-based, or integrated care. - Non-European contexts. - Healthcare settings unrelated to maternity Study types Qualitative, quantitative, mixed methods Commentaries, editorials Types of sources This review will consider: Quantitative studies (analytical and descriptive observational designs, including cohort, cross-sectional, and case-control studies) Qualitative studies Mixed methods studies Audit and feedback interventions including ethnicity-related analysis. Systematic reviews and scoping reviews that meet the inclusion criteria. Grey literature including policy documents, and technical reports. Methods The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews 22 . The review is registered with Open Science Framework (OSF) https://doi.org/10.17605/OSF.IO/XP3MV . Search strategy A systematic search will be conducted. The search strategy will be developed and pretested by the review team, following consultation with a research librarian to refine search syntax and terms. A three-step search strategy will be used: 1. Initial search: A preliminary limited search of MEDLINE and PubMed to identify keywords and indexing terms relevant to ethnicity coding in maternity care. 2. Full search: A comprehensive search across databases: MEDLINE, CINAHL, PubMed, and Scopus will be executed according to the principles of Boolean logic (AND, OR, NOT) and using Medical Subject Headings (MeSH). 3. Reference checking: Review of bibliographies of included articles for additional relevant studies. The search strategy, including all identified keywords and index terms, will be adapted for each included database. An illustrative example of the search strategy developed for MEDLINE is provided in Table 2 . Table 2. Search Strategy. Ovid MEDLINE ® #1 (pregnan* OR prenatal* OR antenatal* OR intrapartum OR perinatal* OR postnatal* OR postpartum OR maternal OR maternit* OR gestational)ti,ab. 992,023 #2 exp "maternal health services"/ OR "maternal health"/ OR "maternal ethnicity"/ 64,301 #3 #1 OR #2 1,004,467 #4 ("ethnicity classification" OR "ethnicity recording" OR "ethnicity categorisation" OR "ethnicity coding" OR "ethnic differences" OR "racial differences" OR "ethnic origin" OR "health record" OR "health data").ti,ab. 48,729 #5 (Austria OR Belgium OR Bulgaria OR Croatia OR Cyprus OR Czechia OR Denmark OR Estonia OR Finland OR France OR Germany OR Greece OR Hungary OR Ireland OR Italy OR Latvia OR Lithuania OR Luxembourg OR Malta OR Netherlands OR Poland OR Portugal OR Romania OR Slovakia OR Slovenia OR Spain OR Sweden OR England OR "United Kingdom" OR UK OR "Great Britain").ti,ab 758,447 #6 #3 AND #4 AND #5 314 Information sources Databases to be searched: Ovid MEDLINE ® CINAHL Plus with Full Text ® NCBI PubMed Scopus Sources of grey literature: Organisation for Economic Co-operation and Development: OECD The World Health Organisation (WHO) European Region databases Reference lists of relevant studies Study/Source of evidence selection All identified citations will be collated and imported to Zotero Reference Manager. Duplicates will be removed before being uploaded to Rayyan Software for screening and further cross-checked within Rayyan. Following a pilot screening, two independent reviewers (DB and LC) will screen titles and abstracts. Full texts of potentially relevant sources will be assessed against inclusion criteria. Reasons for excluding sources at the full-text stage will be documented using predefined labels in Rayyan and reported in the scoping review. Any discrepancies will be resolved through consensus or, if necessary, consultation with a third reviewer (JB). Data extraction As part of this process reviewers will independently extract the data from the retrieved articles using the proposed preliminary data extraction table developed for this review ( Table 3 ). The tool will be adjusted and refined during the data extraction phase if necessary to ensure relevance and completeness. Any changes made will be documented and reported in the final review. Discrepancies will be resolved through consensus or, consultation with a third reviewer (JB). Where essential data is missing or unclear, efforts to contact the study authors will be made for clarification purposes. Table 3. Data extraction. Study details and characteristics Citation details (author(s), date, title, journal, volume, issue, pages) Country Study aims Study design Methodology (interviews, surveys, routine data analysis) Setting (hospital, community maternity services) Population (pregnant, postpartum women, healthcare professionals) Sample size Ethnicity data practices How is ethnicity data collected? (e.g., self-report, observation, proxy indicators) How is ethnicity recorded/coded/classified? (e.g., national codes/ census/ hospital codes) How is ethnicity data analysed or used? (e.g., descriptive analysis, regression) Is the classification system described or referenced? (e.g., limitations, missing data handling) Analytical strategies to monitor ethnicity-related disparities Statistical approaches (e.g., cohort analysis, longitudinal, qualitative thematic analysis) Methodological approaches (e.g., confounder adjustment, stratification, sensitivity analysis Adjustment/covariates (e.g., age, parity, socioeconomic status) Outcome measures (e.g., maternal morbidity/ mortality, neonatal outcomes, patient experience) Data analysis and presentation Findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist (PRISMA-ScR) 23 . The results of the search and the study inclusion will be reported in full in the final scoping review and presented in a PRISMA flow diagram. The extracted data will be mapped in relation to each research question. Findings will be reported through tabulation and narrative formats and organised by the following themes: Ethnicity coding practices (methods of data collection, recording, coding, categorisation) Analytical strategies for examining disparities (statistical methods, adjustment models (e.g., confounders, mediators, time frames of analysis) Discussion To our knowledge, this will be the first review to systematically map how ethnicity is recorded, coded, and analysed in maternity care research across Europe. By synthesising current practices, the review will provide an overview of the extent to which existing research supports the identification and monitoring of ethnic disparities in maternal outcomes. The findings will identify methodological gaps, highlight areas of good practice in ethnicity data collection and analysis, and be disseminated through academic conferences, peer-reviewed publication, and engagement with service providers. The review will also inform future clinical practice and health service planning. In particular, the results will support the development of a pilot audit and feedback intervention for maternity services at Cork University Maternity Hospital, enabling systematic monitoring of disparities in maternal outcomes and serving as a reference point for evaluating progress in implementing equity commitments within maternity care, with the goal of eventual national rollout. Furthermore, the methodological approach adopted here may be applicable to other areas of healthcare where consistent ethnicity data collection and analysis is essential for monitoring and addressing inequalities. Potential strengths and limitations There are some potential strengths and limitations that may be associated with this scoping review. Firstly, it will address a clear gap in the literature by mapping how ethnicity is recorded and analysed in maternity care settings across Europe. As previously stated, no existing review has synthesised coding practices and methodological approaches in this vein, despite its centrality to addressing inequities. The review will have a broad scope, covering both service users and providers across diverse national contexts, which will enhance its relevance for policy and practice. Leading journals such as The Lancet now emphasise that robust reporting of ethnicity data is essential to uncover and address health inequities 24 . Yet across Europe, maternity research continues to face inconsistent or absent ethnicity coding, masking disparities and limiting accountability. This review will provide timely evidence to inform policies and data practices that support equity in maternal health. Nevertheless, some limitations must also be acknowledged. Considerable heterogeneity in definitions, coding standards, and data practices across countries is anticipated, which may limit comparability of findings. Sourcing of eligible studies is likely to challenging, particularly in certain European countries where ethnicity data are not routinely collected due to legal, cultural, or historical sensitivities. Restricting studies published between 2015 and 2025, may exclude earlier work that helped shape current practices, however, this timeframe is justified given the policy and research attention to ethnicity in healthcare, as well as heightened attention to inequalities in health following key events such as the COVID-19 pandemic and the Black Lives Matter movement. Both of which highlighted the urgency to document and address ethnic inequalities. Data availability 25 Zenodo: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol PRISMA ScR Checklist https://doi.org/10.5281/zenodo.17358024 This project contains the following extended data: PRISMA-ScR checklist Data are available under the terms of the License: Creative Commons Attribution 4.0 International license (CC-BY 4.0). Faculty Opinions recommended References 1. Vousden N, Bunch K: Impact of maternal risk factors on ethnic disparities in maternal mortality: a national population-based cohort study. Lancet Reg Health Eur. 2024; 40 : 100893. PubMed Abstract | Publisher Full Text | Free Full Text 2. Grand-Guillaume-Perrenoud JA, Origlia P, Cignacco E: Barriers and facilitators of maternal healthcare utilisation in the perinatal period among women with social disadvantage: a theory-guided systematic review. Midwifery. 2022; 105 : 103237. PubMed Abstract | Publisher Full Text 3. Arcilla JT, Nanou A, Hamed S, et al. : Racialized migrant women’s discrimination in maternal care: a scoping review. Int J Equity Health. 2025; 24 (1): 16. PubMed Abstract | Publisher Full Text | Free Full Text 4. Gieles NC, Tankink JB, van Midde M, et al. : Maternal and perinatal outcomes of asylum seekers and undocumented migrants in Europe: a systematic review. Eur J Public Health. 2019; 29 (4): 714–23. PubMed Abstract | Publisher Full Text | Free Full Text 5. Pařízková A, Clausen JA, Balaam MC, et al. : Inclusiveness of access policies to maternity care for migrant women across Europe: a policy review. Matern Child Health J. 2024; 28 (3): 470–80. PubMed Abstract | Publisher Full Text | Free Full Text 6. Lien IL: Health workers and Sub Saharan African women’s understanding of equal access to healthcare in Norway. PLoS One. 2021; 16 (9): e0255934. PubMed Abstract | Publisher Full Text | Free Full Text 7. Higginbottom GMA, Evans C, Morgan M, et al. : Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review. BMJ Open. 2019; 9 (12): e029478. PubMed Abstract | Publisher Full Text | Free Full Text 8. Liu C, Ahlberg M, Hjern A, et al. : Perinatal health of refugee and asylum-seeking women in Sweden 2014–17: a register-based cohort study. Eur J Public Health. 2019; 29 (6): 1048–55. PubMed Abstract | Publisher Full Text | Free Full Text 9. Lyons SM, O’Keeffe FM, Clarke AT, et al. : Cultural diversity in the Dublin maternity services: the experiences of maternity service providers when caring for ethnic minority women. Ethn Health. 2008; 13 (3): 261–76. PubMed Abstract | Publisher Full Text 10. Gkiouleka A, Huijts T: Intersectional migration-related health inequalities in Europe: exploring the role of migrant generation, occupational status & gender. Soc Sci Med. 1982, 2020; 267 : 113218. PubMed Abstract | Publisher Full Text 11. Topcu G, Savona-Ventura C, Ayres-de-Campos D, et al. : Provision of antenatal care in Europe-a scientific study commissioned by European Board and College of Obstetrics and Gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol. 2022; 272 : 30–6. PubMed Abstract | Publisher Full Text 12. Ledoux C, Pilot E, Diaz E, et al. : Migrants’ access to healthcare services within the European Union: a content analysis of policy documents in Ireland, Portugal and Spain. Glob Health. 2018; 14 (1): 57. PubMed Abstract | Publisher Full Text | Free Full Text 13. Rechel B, Mladovsky P, Devillé W, et al. : Migration and health in the European Union: an introduction. Open University Press; (European Observatory on Health Systems and Policies), 2011; 3–13. Reference Source 14. Lam J, Aldridge R, Blackburn R: How is ethnicity reported, described, and analysed in health research in the UK? A bibliographical review and focus group discussions with young refugees. BMC Public Health. 2023; 23 (1): 2025. PubMed Abstract | Publisher Full Text | Free Full Text 15. Roura M, LeMaster JW, Hannigan A, et al. : ‘If relevant, yes; if not, no’: General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: a qualitative analysis using Normalization Process Theory. PLoS One. 2021; 16 (5): e0251192. PubMed Abstract | Publisher Full Text | Free Full Text 16. Jardine JE, Frémeaux A, Coe M, et al. : Validation of ethnicity in administrative hospital data in women giving birth in England: cohort study. BMJ Open. 2021; 11 (8): e051977. PubMed Abstract | Publisher Full Text | Free Full Text 17. Farkas L: Analysis and comparative review of equality data collection practices in the European Union: Data collection in the field of ethnicity. Luxembourg: Publications Office of the European Union, 2017. Publisher Full Text 18. Felker A, Patel R, Kotnis R, et al. : Saving Lives, Improving Mothers’ Care Compiled Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2024. Reference Source 19. Hannigan A, Villarroel N, Roura M: Ethnicity recording in health and social care data collections in Ireland: where and how is it measured and what is it used for? Int J Equity Health. 2020; 19 (1): 2. PubMed Abstract | Publisher Full Text | Free Full Text 20. Balestra C, Fleischer L: Diversity statistics in the OECD: How do OECD countries collect data on ethnic, racial and indigenous identity? OECD Statistics Working Papers. OECD Statistics, 2018. Publisher Full Text 21. Second National Intercultural Health Strategy 2018-2023. Health Service Executive, 2018. Reference Source 22. Peters M, Godfrey C, McInerney P, et al. : Scoping Reviews. JBI Manual for Evidence Synthesis. 2020; 2024 . Reference Source 23. Tricco A, Lillie E, Zarin W, et al. : PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018; 169 (7): 467–73. PubMed Abstract | Publisher Full Text 24. Chew M, Samuel D, Mullan Z, et al. : The Lancet Group’s new guidance to authors on reporting race and ethnicity. Lancet. 2024; 403 (10442): 2360–1. PubMed Abstract | Publisher Full Text 25. Buckley D, Cronin L, Maher GM, et al. : Ethnicity coding in European Maternity care services - practices and analytical approaches to evaluate disparities: a scoping review protocol PRISMA ScR Checklist. Zenodo. 2025. Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 22 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland 2 INFANT Research Centre, University College Cork, Cork, County Cork, Ireland 3 National Perinatal Epidemiology Centre, University College Cork, Cork, County Cork, Ireland 4 School of Public Health, University College Cork, Cork, County Cork, Ireland Daire Buckley Roles: Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Laura Cronin Roles: Investigation Gillian M. Maher Roles: Supervision, Writing – Review & Editing Joye McKernan Roles: Supervision Paul Corcoran Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing John R. Higgins Roles: Conceptualization, Project Administration, Supervision John P. Browne Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declare that this work was supported by financial funding from the HSE Office of National Quality and Patient Safety. Article Versions (1) version 1 Published: 22 Oct 2025, 8:111 https://doi.org/10.12688/hrbopenres.14266.1 Copyright © 2025 Buckley D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Buckley D, Cronin L, Maher GM et al. Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.12688/hrbopenres.14266.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 22 Oct 2025 Views 0 Cite How to cite this report: Vousden N. Reviewer Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r52549 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-111/v1#referee-response-52549 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Jan 2026 Nicola Vousden , University of Oxford, Oxford, England, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15690.r52549 This is a well written paper that has identified a novel and important gap in the current literature. This study aims to clarify the current coding practices of ethnicity in maternity care and maternity clinical research ... Continue reading READ ALL This is a well written paper that has identified a novel and important gap in the current literature. This study aims to clarify the current coding practices of ethnicity in maternity care and maternity clinical research in Europe. The methods of the review and reporting seem relevant and robust. I suggest a number of changes to the text and methods as below to improve the paper: Introduction: It may be helpful to cite the recent NHS guidance about improving the quality of ethnicity data recording. (1) The implications of differences in recording ethnicity data across European countries also limits our comparison of policy impacts. For example, in this European analysis of the impact of COVID-19 to understand the policy impact amongst different ethnic groups we had to combine migrant status with a binary measure of ethnicity as there was no other way to reconcile the differences in data collection between countries (2). How will papers that include both European and UK countries be handled? Is there any mechanism to describe what is used instead as proxy for ethnicity where it is not reported directly? It would increase the policy and practice implictions of the paper if the authors could also make practical suggestions on how these differences can be reconciled when changes to ethnicity data collection are unlikely to be seen in the short term. Objectives: The second objective – to describe the methodological and analytical methods to describe disparities needs better justification within the introduction. I’m also concerned this may generate a long list of different approaches with limited ability to understand the merits and limitations between them. Is there any gold standard guidance or methods against which the methods can be compared? Methods: If I understand correctly from the PICO and extraction tool then the aim is to include of any published study in maternity settings across Europe in the 10 year period that includes ethnicity as a variable will retrieve a huge number of eligible papers. For example, all the literature on mental health, gestational diabetes or preeclampsia as an outcome may have reported ethnicity in demographic tables and stratified or analysed results by ethnic group would be included. I am concerned that if the search strategy truly captures all these papers (which I don’t think it will in its current format) it will result in an unfeasibly large number of papers to include. I don’t think it would reduce the robustness of the study to make the inclusion criteria stricter, for example restricting to quantitative papers only. I appreciate the search strategy is to be refined with a librarian. I would suggest that the search term inequalities should be included. https://www.england.nhs.uk/long-read/ethnicity-recording-improvement-plan/ https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.14643 Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public health, inequalities, obstetrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vousden N. Reviewer Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r52549 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-111/v1#referee-response-52549 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: O'Carroll J. Reviewer Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r51211 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-111/v1#referee-response-51211 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 02 Dec 2025 James O'Carroll , University College London Hospitals NHS Foundation Trust, London, England, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15690.r51211 Dear editor, We would like to commend the authors on this well designed and novel scoping review protocol regarding ethnicity coding in European maternity care services. This study aims to clarify the current coding practices of ... Continue reading READ ALL Dear editor, We would like to commend the authors on this well designed and novel scoping review protocol regarding ethnicity coding in European maternity care services. This study aims to clarify the current coding practices of ethnicity in maternity care and maternity clinical research in Europe. The objectives of the study, and proposed methodology are eloquently and succinctly described. Appropriate use of both the JBI framework and the PRISMA ScR for the reporting of the review. Please add a section regarding the difference between ethnicity and racial groups. JAMA have published regarding this recently in the US population and it is as important in the European populations. Remembering that race and ethnicity are both social constructs. I would consider looking at further metrics of inequity coding in the analytical strategies, is it just ethnicity/ racial groups or other potential bias/ confounders are measured or importantly excluded including language, educational attainment, social groups etc. A further concern pertains to the search strategy. All 27 European Union countries are included in the search strategy. Countries which are in Europe, but not part of the EU are not included (with the exception of the United Kingdom). Although I understand there is no single universally accepted legal or political definition of a “European country,” the inclusion criteria of this study specifies “maternity populations in European healthcare settings”. Therefore, I recommend the search strategy should either include the MeSH term Europe or list the additional countries of Europe to ensure inclusion of data from non-EU member states of Europe. I would also consider at which part of the maternity journey the coding occurs. ( preconception, gestational age, intrapartum, postpartum) Please also comment on the potential of publication bias with this review's included articles and how you will account for this if applicable. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Inequity, quality of care, obstetrics, pain I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT O'Carroll J. Reviewer Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r51211 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-111/v1#referee-response-51211 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 22 Oct 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 22 Oct 25 read read James O'Carroll , University College London Hospitals NHS Foundation Trust, London, UK Nicola Vousden , University of Oxford, Oxford, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Vousden N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Jan 2026 | for Version 1 Nicola Vousden , University of Oxford, Oxford, England, UK 0 Views copyright © 2026 Vousden N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a well written paper that has identified a novel and important gap in the current literature. This study aims to clarify the current coding practices of ethnicity in maternity care and maternity clinical research in Europe. The methods of the review and reporting seem relevant and robust. I suggest a number of changes to the text and methods as below to improve the paper: Introduction: It may be helpful to cite the recent NHS guidance about improving the quality of ethnicity data recording. (1) The implications of differences in recording ethnicity data across European countries also limits our comparison of policy impacts. For example, in this European analysis of the impact of COVID-19 to understand the policy impact amongst different ethnic groups we had to combine migrant status with a binary measure of ethnicity as there was no other way to reconcile the differences in data collection between countries (2). How will papers that include both European and UK countries be handled? Is there any mechanism to describe what is used instead as proxy for ethnicity where it is not reported directly? It would increase the policy and practice implictions of the paper if the authors could also make practical suggestions on how these differences can be reconciled when changes to ethnicity data collection are unlikely to be seen in the short term. Objectives: The second objective – to describe the methodological and analytical methods to describe disparities needs better justification within the introduction. I’m also concerned this may generate a long list of different approaches with limited ability to understand the merits and limitations between them. Is there any gold standard guidance or methods against which the methods can be compared? Methods: If I understand correctly from the PICO and extraction tool then the aim is to include of any published study in maternity settings across Europe in the 10 year period that includes ethnicity as a variable will retrieve a huge number of eligible papers. For example, all the literature on mental health, gestational diabetes or preeclampsia as an outcome may have reported ethnicity in demographic tables and stratified or analysed results by ethnic group would be included. I am concerned that if the search strategy truly captures all these papers (which I don’t think it will in its current format) it will result in an unfeasibly large number of papers to include. I don’t think it would reduce the robustness of the study to make the inclusion criteria stricter, for example restricting to quantitative papers only. I appreciate the search strategy is to be refined with a librarian. I would suggest that the search term inequalities should be included. https://www.england.nhs.uk/long-read/ethnicity-recording-improvement-plan/ https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.14643 Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Public health, inequalities, obstetrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Vousden N. Peer Review Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r52549) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-111/v1#referee-response-52549 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 O'Carroll J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 02 Dec 2025 | for Version 1 James O'Carroll , University College London Hospitals NHS Foundation Trust, London, England, UK 0 Views copyright © 2025 O'Carroll J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear editor, We would like to commend the authors on this well designed and novel scoping review protocol regarding ethnicity coding in European maternity care services. This study aims to clarify the current coding practices of ethnicity in maternity care and maternity clinical research in Europe. The objectives of the study, and proposed methodology are eloquently and succinctly described. Appropriate use of both the JBI framework and the PRISMA ScR for the reporting of the review. Please add a section regarding the difference between ethnicity and racial groups. JAMA have published regarding this recently in the US population and it is as important in the European populations. Remembering that race and ethnicity are both social constructs. I would consider looking at further metrics of inequity coding in the analytical strategies, is it just ethnicity/ racial groups or other potential bias/ confounders are measured or importantly excluded including language, educational attainment, social groups etc. A further concern pertains to the search strategy. All 27 European Union countries are included in the search strategy. Countries which are in Europe, but not part of the EU are not included (with the exception of the United Kingdom). Although I understand there is no single universally accepted legal or political definition of a “European country,” the inclusion criteria of this study specifies “maternity populations in European healthcare settings”. Therefore, I recommend the search strategy should either include the MeSH term Europe or list the additional countries of Europe to ensure inclusion of data from non-EU member states of Europe. I would also consider at which part of the maternity journey the coding occurs. ( preconception, gestational age, intrapartum, postpartum) Please also comment on the potential of publication bias with this review's included articles and how you will account for this if applicable. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Inequity, quality of care, obstetrics, pain I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) O'Carroll J. Peer Review Report For: Ethnicity Coding in European Maternity Care Services – Practices and Analytical Approaches to Evaluate Disparities: A Scoping Review Protocol [version 1; peer review: 2 approved with reservations] . HRB Open Res 2025, 8 :111 ( https://doi.org/10.21956/hrbopenres.15690.r51211) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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