“You think, like, you’re neutral but you’re not”: A mixed- methods study of racial/ethnic bias in pain assessment, management and treatment in maternal and newborn care in the Netherlands

“You think, like, you’re neutral but you’re not”: A mixed- methods study of racial/ethnic bias in pain assessment, management and treatment in maternal and newborn care in the Netherlands | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “You think, like, you’re neutral but you’re not”: A mixed- methods study of racial/ethnic bias in pain assessment, management and treatment in maternal and newborn care in the Netherlands Evelien Overtoom, Bahareh Goodarzi, Syllona Kanu, Alana Helberg-Proctor, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6600363/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2025 Read the published version in International Journal for Equity in Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Studies indicate racial and ethnic inequities in pain assessment, management and treatment in maternal and newborn care. Namely, racially and ethnically marginalised womxn are less likely to receive pain relief in labour and the post-partum period, and are more likely to experience severe perinatal outcomes such as uterine rupture. This inequity may be explained by racial/ethnic bias in maternal and newborn care professionals’ pain assessment, management and treatment. The aim of this study was to investigate the role of racial/ethnic bias in the assessment, management and treatment of pain during labour in the Netherlands. Methods This mixed methods study consisted of two parts: a quantitative and a qualitative study. The quantitative part was a prospective nationwide population-based cohort study where cases of uterine rupture were collected through the Netherlands Obstetric Surveillance System (NethOSS) in which we retrospectively investigated the association between categories of race/ethnicity, language barrier, the difference in the response time to pain, and maternal and perinatal outcomes up to 28 days post-partum. The qualitative part was an explorative study to investigate racial and ethnic bias in pain assessment, management and treatment among maternal and newborn care professionals using semi-structured interviews and thematic analysis. Results The quantitative results indicated that caesarean section was significantly more frequently performed in more than 180 minutes after the first complaint of pain in the non-Western category compared to the Western category. The qualitative analysis showed the simultaneous presence and unawareness of stereotypes and assumptions about how womxn of different racial/ethnic groups experience and express pain among maternal newborn care professionals. The findings provide insight in how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment. Conclusions The results of this study provide a starting point to investigate racial and ethnic inequity in maternal and newborn care in the Netherlands, and to address the ways that these differences can be mitigated. Our findings underscore the disavowal of the role of racial thinking and notions of ethnic differences in pain assessment, management, and treatment, and highlights the need for critical reflection on the role of maternal and newborn care in shaping, causing, maintaining, sustaining, and (re)producing racial/ethnic inequity. race ethnicity pain birth racism bias stereotypes maternal newborn care obstetrics Figures Figure 1 Introduction Studies indicate racial and ethnic inequities in pain assessment, management and treatment in maternal and newborn care (MNC). Womxn 1 categorized as Black, Indigenous, of Colour or non-Western 2 are less likely to receive pain relief in labour and the post-partum period.( 1 – 6 ) Pain is one of the first indicators of medical conditions such as uterine rupture, which is a serious but rare obstetrical complication with risk of severe maternal, foetal and neonatal morbidity and mortality. Timely assessment of pain is imperative as the severity of maternal, foetal and neonatal morbidity and mortality in the case of uterine rupture relies on the time between rupture and the required intervention, i.e. caesarean section (CS).( 7 ) Studies in the United States (U.S.) and United Kingdom show higher prevalence of uterine rupture amongst womxn categorised as Black and Asian, and Bangladeshi, Pakistani and Black African respectively.( 8 – 10 ) Similarly, a nationwide population based cohort study in the Netherlands showed that uterine rupture was significantly more prevalent amongst womxn categorised as non-Western, in particular the sub-Saharan African category, compared to the Western category.( 11 , 12 ) The reason for the racial and ethnic difference in the administration of pain relief during labour and the prevalence of uterine rupture remains unknown.( 8 , 9 , 11 , 12 ) Both race and ethnicity can be considered to be multiple socio-scientific objects, methods, and theories used to categorise populations.( 13 , 14 ) In health education, research, and care, race and ethnicity are often used interchangeably and with unfixed definitions, leading to diverse definitions and varying interpretations of their sub-categories in different contexts.( 14 – 18 ) The nature of present-day categorisation in racial groups in healthcare is often biological and hierarchical in nature, based on superficial physical characteristics such as skin colour, stature, and facial features. Due to the centrality of race and race-science in genocidal eugenics movements, particularly in the Holocaust, and the discriminatory nature of race after World War II, the term ‘race’ was considered highly problematic in many countries. In health research the term ‘ethnicity’ was proposed in the mid-20th century as a substitute for the term ‘race’, encompassing a wider range of shared characteristics within populations, including both physical attributes and common cultural characteristics such as language, religion, dietary practices, and nationality.( 19 – 24 ). Although ethnicity was introduced to move away from the biological conception of differences between populations, and to acknowledge the complex nature of their shared characteristics, it is commonly used as an equivalent to biological race in health research. This is evident in that racial and ethnic categories are used simultaneously and interchangeably, and that care differences found between ethnic categories are often attributed to biological causes.( 25 ) 3 Racial and ethnic discrimination in healthcare is known to be a determinant of health inequities.( 26 – 30 ) This phenomenon is referred to as ‘medical racism’,( 31 ) where differential treatment is provided that is unfavourable to a group or individual based on their perceived race/ethnicity.( 26 , 31 ) Clear examples are skin colour bias in SpO2 estimation and racial bias in kidney function.( 32 ) Davis (2019) describes this medical racism in MNC as ‘obstetric racism’, identifying seven dimensions including diagnostic lapse, and neglect, dismissiveness or disrespect.( 33 ) Ideas about biological differences between populations have resulted in the belief that certain groups have a higher pain tolerance during childbirth than others, coined by Davis (2019) as ‘obstetric hardiness’.( 33 ) Historically we see the development of the notion that Black racialized womxn are the most obstetrically hardy, resulting in the stereotype that they feel less pain than other womxn.( 33 – 37 ) This racial thinking informed shockingly unethical practices such as the infamous obstetric and CS surgeries by Marion Sims and Francois Marie Provost, who experimented on non-consenting enslaved Black racialised womxn without the use of anaesthesia.( 34 , 37 ) As a result, womxn racialised as Black today are still perceived to be ‘uncannily durable’, and physicians often overlook their pain based on the belief that there is less urgency for medical intervention.( 34 ) Even today, the racialised misconceptions about pain tolerance bias the maternal and newborn care professionals’ (MNCP) pain assessment, management and treatment.( 24 , 35 , 38 – 41 ) A frequently cited study by Hoffman et al. (2016) amongst medical students and residents in the U.S. showed that healthcare professionals hold false beliefs about biological differences between Black and White identified people, and demonstrates that these beliefs predict racial bias in pain perception, management and treatment recommendation accuracy. Racial and ethnic bias in MNCPs’ pain assessment, management and treatment may explain the inequity in pain relief in labour and uterine rupture due to misinterpretation of the womxn’s pain.( 11 , 33 ) A better understanding of the role of racial thinking and notions of ethnic differences in pain assessment, management and treatment in MNC is required to develop interventions to foster equitable care. In this exploratory study, we aimed to investigate 1) the association between race/ethnicity and language barrier and the difference in the response time of MNCP to pain, and maternal and perinatal outcomes, and 2) explore racial/ethnic bias in pain assessment, management and treatment among MNCP in the Netherlands. Methods To further understand the role of racial thinking and notions of ethnic difference in pain assessment, management and treatment in MNC, we employed an exploratory mixed-methods design consisting of two parts: a quantitative and a qualitative study. The quantitative part is a prospective nationwide population based cohort study where cases of uterine rupture were collected through the Netherlands Obstetric Surveillance System (NethOSS) in which we retrospectively investigated the association between race/ethnicity categories and language barrier and difference in the response time to pain and maternal and perinatal outcomes up to 28 days post-partum.( 12 ) The qualitative part is based on semi-structured interviews with MNCPs to investigate racial and ethnic bias in pain assessment, management and treatment. Quantitative study For the quantitative study, we performed an analysis of data identified in a multi-centre nationwide study on uterine rupture in the Netherlands conducted by NethOSS, a registration system for maternal morbidity and mortality in the Netherlands between April 1st 2016 to March 31st 2018.( 12 ) Data were collected via monthly e-mail to an assigned reporting MNCP (physician or research midwife) at every hospital with an obstetrician-led maternity unit in the Netherlands (2016–2018, n = 86). The MNCPs were asked to report the number of cases of uterine rupture that had occurred in the previous month. Upon notification of a uterine rupture case, anonymised copies of the medical files were requested. These files were specifically asked to include information on general history, obstetric history, current pregnancy, labour management, and maternal and perinatal outcomes. Only cases in which a race/ethnicity category was registered were included in the analyses. The determinants examined were maternal race/ethnicity categorisation and language barrier. In the NethOSS database race/ethnicity was registered according to the following predetermined categories related to race, region and country: ‘Caucasian’, ‘North African’, ‘African other’, ‘Asian’, ‘Asian other’, ‘Latin American’, ‘Hindustani’, ‘Turkish’, ‘Mixed’ and ‘Unknown’. For this registry, it is unknown how patients are categorised by MNCPs, and what these terms mean to them.( 42 ) Therefore, we use these categories as information about how womxn were perceived and categorised by MNCPs or as how these patients self-identified when asked by the MNCPs. Most of these predetermined categories were too small to conduct statistical analysis. Therefore, for analysis of racial and ethnic bias, we re-grouped them into two broad categories: ‘Western’ and non-Western’, categorising ‘Caucasian’ as ‘Western’ and all other categories as ‘non-Western’. In the Dutch context, the Western and non-Western categories reflect notions of belonging, who is same and who is other .( 25 , 43 ) In the NethOSS database language barrier was registered as ‘yes’ or ‘no, based on the perceived barrier in verbal communication. Language barrier was included it is known to influence the MNCPs’ pain assessment.( 38 ) The following outcomes were examined: care processes, time to CS, adverse maternal outcomes, and adverse perinatal outcomes. Care processes were augmentation of labour, induction of labour, and administration of pain relief. Adverse maternal outcomes were total blood loss, hospital and/or intensive care unit (ICU) admission, medical and/or surgical therapies, and complete or incomplete uterine rupture. Complete uterine rupture was defined as uterine rupture of both the myometrium and the peritoneum and incomplete uterine rupture as uterine rupture of only the myometrium with an intact peritoneum. Adverse perinatal outcomes were neonatal asphyxia, admission to a neonatal intensive care unit (NICU) or neonatology ward due to convulsions, hypotonia, ischemia with ultrasonic abnormalities, hypoxic ischemic encephalopathy and/or multiple organ failure, and perinatal mortality up to 28 days post-partum. Neonatal asphyxia was defined as arterial umbilical cord pH 16mmol/l, Apgar scores (AS) ≤ 5 at 5 min, resuscitation, or artificial ventilation for > 10 min afterbirth, Thompson score > 7 or Sarnat score > 1. Maternal symptoms of pain were abdominal pain or pain in the area of the CS scar, in which abdominal pain was distinguished from uterine contractions by the presence of abdominal pain between contractions. The time of first complaint of pain was based on the first time abdominal pain was registered in the notes of the MNCP present during labour. Statistical analysis was conducted using the IBM SPSS Statistics (Version 29). Descriptive statistics were used to describe the demographic characteristics of the dataset and are presented as the number of observations ( n ) and prevalence (%). For categorical data, differences are presented as odds ratio (OR) with 95% confidence intervals (95% CI). Qualitative study The qualitative study consisted of thematic analysis of open-ended, semi-structured interviews conducted with MNCPs in the Netherlands. We used the consolidated criteria for reporting qualitative research to report our data collection and analysis processes.( 44 ) The study population included obstetricians, midwives, obstetric nurses, and obstetric residents practicing in a hospital in the Amsterdam region. Thirteen interviews were conducted in person or online at the participants’ request in May 2023, and lasted from 38 to 124 minutes. Participants were recruited using e-mail invitations to hospitals’ head of obstetric departments and NethOSS representatives, as well as posters distributed via social media and in hospital newsletters. All interviews were conducted by SK. The interviews were conducted in English, therefore only participants were included that were comfortable communicating in English. The interviews were guided by the study of Hoffman et al (2016) into beliefs about racialised biological differences amongst medical students and residents in the U.S. With this approach we intended to lower the chance of socially desirable answers by first reflecting with the participants on these beliefs. The participants were presented with a summary of the results of the study by Hoffman et al. ( 35 ), and were asked what results such a study might yield in the Netherlands and in their hospital, and were then asked questions about their own understanding of ethnicity (Fig. 1 ). The interviews were transcribed verbatim. All interview transcripts were read and discussed by SK, BG and EO. The transcripts were thematically coded using a deductive approach following two dimensions of Davis’ conceptualisation of obstetric racism (2019) — diagnostic lapse, and neglect, dismissiveness or disrespect; and an inductive approach following topics that emerged from the interviews. The first transcript was coded by SK and BG independently using Atlas.ti Mac (Version 23.1.1). They discussed the difference in coding. The remaining interviews were coded by SK. The codes were then organised into themes by SK, BG and EO. In the last step, the interrelations between the themes were analysed and the overarching theme was formulated. The themes were discussed with the whole research group.( 45 ) Results Results of the quantitative study Of the 98 cases of uterine rupture in the quantitative study, race/ethnicity categories were registered in 54 cases, only these cases were included in the analysis. The characteristics of the study population are presented in Table 1. Table 2 presents the descriptive analysis of the care processes, time to CS, maternal outcomes and perinatal outcomes. Care processes Rates of augmentation of labour and induction of labour were not significantly different in the race/ethnicity or in the language barrier categories. Pain relief by epidural was significantly less often administered in the language barrier category compared to the non-language barrier category (1/10 (10%) vs 25/42 (54.8%) respectively) (OR 0.08, 95% CI 0.01-0.65). On the other hand, pain relief by remifentanil was significantly more often administered in the language barrier category compared to the non- language barrier category (4/10 (40%) vs 1/42 (2.4%) respectively) (OR 27.33, 95% CI 2.60-287.41). This difference was not significant between the non-Western or Western category. Time to caesarean section In total, 25 womxn complained of pain before birth. Although the results were not significant, a trend was seen towards more time between first complaint of pain and the call for CS between the non-Western and Western category. In the non-Western category, the call for a CS was made less frequently under 30 minutes after the first complaint of pain compared to the Western category (3/11 (27.3%) vs 7/11 (63.6%) respectively), and more frequently after 180 minutes following the first complaint of pain (5/11 (45.4%) vs 2/11 (18.2%) respectively). CS was significantly more frequently performed after 180 minutes following the first complaint of pain in the non-Western category (8/15 (53.3%)) compared to the Western category (1/12 (8.3%)) (OR 12.57, 95%CI 1.28-123.48). No significant differences were found in the association between time between first complaint of pain and decision for CS and language barrier. Adverse maternal outcomes The prevalence of major obstetric haemorrhage was similar among both the non-Western and Western category. The prevalence of complete uterine rupture was higher in the non-Western category compared to the Western category (11/28 (39.3%) vs 7/26 (26.9%) respectively). However, this difference was not significant. A similar trend was seen for the prevalence of complete uterine rupture in the language barrier category compared to the non-language barrier category (5/10 (50%) vs 12/42 (28.6%)) respectively. Adverse perinatal outcomes More babies suffered from neonatal asphyxia born in the non-Western compared the Western category (9/28 (32.1%) vs 5/26 (19.2%) respectively), though this difference was not significant. Perinatal admission to a neonatology ward or NICU, and mortality were also not significantly different between the race/ethnicity categories and the language barrier categories. Results of the qualitative study For the qualitative study, thirteen semi-structured interviews were conducted and analysed. The study population consisted of three obstetricians, four obstetric residents, four clinical midwives and two obstetric nurses. Of the thirteen participants, during the interviews, two self-identified as male and three as having a non-Western migration background. Their years of experience varied between a year and a half and nineteen years. Thematic analysis resulted in four themes: racial and ethnic stereotypes; contradictory ideas about racial and ethnic bias in pain assessment, management and treatment; effects of racial and ethnic bias explained away; and assumed protection and threats. Racial and ethnic stereotypes Stereotypes regarding how womxn of different racial and ethnic groups experience and express pain arose in eleven out of thirteen interviews, these are summarised in table 3. Three observations can be made from these stereotypes. First, the participants used racial and ethnic language interchangeably. Second, the participants talked about White identified womxn as the norm, to whom the pain experience and expression of other racial and ethnic groups was compared. “[…] So to the way we perceive pain in usually black women is different than we perceive in or how we assess pain in, in, in white women, because that's a reaction we know.” (P4) Third, the participants reported being familiar with various stereotypes about specific racial and ethnic groups and their experience and expression of pain circulating in their professional settings. One common idea that was spoken about was that South Asian, Hindustani and Indian identified womxn were believed to have a lower tolerance for pain and that they were theatrical and dramatic in their pain presentation during labour. “[…] I t's a joke among midwives. . . that Indian women have a lower... they can't cope as well with pain as not Indian people.” (P5) Womxn identified as Mediterranean and Arabic were described in a similar manner. Participant 6, for example, spoke about “mediterranean fever” or “mediterranean presentation” which they described as: “ They really exaggerate or over present their pain in order to get attention from doctors.” Chinese identified womxn, on the other hand, were believed to be very insular in their presentation of pain. Black and (West) African identified womxn were believed to have a higher tolerance for pain, and that they often expressed pain less than womxn from other racial and ethnic groups. “ I have heard that black women can for example, handle pain better […]. Black women are strong, for example .” (P3) Two participants expressed a feeling of shame when talking about racial and ethnic stereotypes that circulated amongst MNCPs. Participant 8, for example, explained: “I hear my colleagues saying these things, or and maybe I've said that them as well, and I'm not proud of that. But about originally African women sometimes, healthcare professionals we say like ‘she’s like this strong African woman, she can take it, she can handle it’” (P8) Contradictory ideas about racial and ethnic bias in pain assessment, management and treatment Although racial and ethnic stereotypes were mentioned in almost all interviews, most participants stated that they treated every womxn equally, regardless of race or ethnicity, and would always administer pain relief upon request. This apparent paradox highlights that, while participants acknowledge the existence of bias and stereotypes, they do not believe these factors impact the care that womxn receive. “[…] We have 24/7 access to pain medication. We counsel everybody with the same text and same tools.” (P1) “I think I do have biases. And I am sure I'm not always aware of them, at the moment […]. I think everybody will say it, but I think that it does not influence my care. […] Like I think “Ohh well, maybe you are being more theatrical about your pain, but ohh well, if you want pain medication, of course you can have it.[…] Yeah, I think in those instances, that I think they have less pain than they are making to believe, but that will only mean that they will get pain medication sooner […].” (P3) “Am I influenced by the ethnic background of people when I see them about their pain? I don't have that idea.[…] And there's when people tell me that they are in pain, we talk about it and we come to a solution […].Maybe I do but I don't have the idea that it influences [me].” (P9) […] If someone is in pain, we take it seriously. So you're not looking at the colour[…]. (P13) A few participants acknowledged that their unconscious bias regarding race and ethnicity and pain might influence their practice. P11, for example, explained: “I don't think I treat people differently. I always tell the patients, like I cannot decide for you. Where is your pain threshold? If you need something, tell me but I will try to guide you through it, and but I can imagine that somewhere in the back of your head it might be. […] ‪ At least that's what I hope and I and I believe that I do that, but it might be that I'm not aware of that I treat people differently.” (P11) Some participants explained that under certain circumstances pain medication would be actively offered to the womxn. “ ‪ No, we only give pain medication when women actively ask it, and sometimes you see that women are struggling a lot during birth and then we offer it.” (P5) Participant 4 explained that, due to the individualised approach, they did not believe that racial and ethnic differences in the administration of pain relief was due to racial or ethnic bias. While the participants explained that their assessment, management and treatment of pain was not affected by racial and ethnic stereotypes, and that their administration of pain relief was always guided by individual requests, they also talked about how they perceived differences in pain expression between racial and ethnic groups, and that this sometimes impeded their assessment of pain. “[…] A reason I talked about Chinese people because I think they are the most difficult to assess. So I do think that I might have missed some signals from them, for example, but I also might have underrated pain experience, for example, by Indian people because they feel the pain very heavily. […]” (P7) Participant 2 talked about sometimes using alternative methods of enquiry to assess the pain of womxn of certain racial and ethnic groups of whom they believed that they expressed pain differently. “I think with South Asians [. . .], I try to get more clarification or specification to is it really pain or is it something different? I don't want to over-treat them, and I do that more with South Asians than with other people from other backgrounds.” (P2) About half of the participants also talked about how race and ethnicity was used for fast decision making in high-stress and time-constrained circumstances. As participant 6 explained: “We are constantly [...] facing decisions which are very often […]black and white, then we may need to have some sort of internal shortcut to make these decisions based on prejudices or based on experience” (P6) Similarly, participant 8 explained that MNCPs include race and ethnicity as part of data collection in their decision-making process, “It's part of our data collection, so our whole profession is about collecting as much data as accurately as you can in a very short time to make sure you can help the patients or treat the patient as best as you can and so therefore we have developed a way of collecting the data by different signs, and those signs evidently make up a puzzle or an assumption in our head, and that is constructed also of our own context of people who we talk to, what we learn, what we know.” (P8) Participant 11 highlighted how these shortcuts in the decision-making process gives room for racial and ethnic bias. “ If he or she had already looked after some people from India, or some other ethnicities, and they [would always] ask for pain relief [the professional] would maybe easily say like ‘OK, just go for it’ or actively promote pain relief because maybe in the back of their heads, they believe that this will be the outcome anyway.” (P11) The participants talked about how, even though the administration of pain relief was guided by individual requests, racial and ethnic bias might impact both the type of pain relief that is administered, and whether pain relief is administered at all. For example, participant 7 explained: “[…] Chinese people almost never ask for pain medication, so in that way I can understand that they get treated less for pain because they don't show that they are in pain, and they don't ask for pain medication. So, it's more difficult to see if they are in pain. […] I do think I might have underestimated their pain. But I also think that sometimes people say they are in more pain than they actually are. Yeah. And it's also the question - Do you give them the pain relief or not? Do you still wait? […] I think it's always difficult. But I have learned that because pain is so very personal that it's not up to me to judge if they are in pain, it is up to them if they want pain medication and if they want pain medication if and if they are not very in very much pain, well then for the whole labour experience it could be better to just give them the pain medication. […] But I do think, yeah, especially in the, yeah, in the first years after, after my graduation I have misjudged the pain and maybe sometimes even now I have misjudged it, yeah.” (P7) Some participants expressed biological beliefs regarding the course of labour and talked about how these beliefs affected their pain assessment, management and treatment. For instance, assumptions about how quick womxn from certain racial and ethnic groups give birth influence decisions about pain relief. Specifically, if womxn are believed to biologically give birth quickly, the MNCP will administer remifentanil instead of an epidural. “ Many of my colleagues think that women from West Africa have a bit more of a curved spine. […] So, it takes a while but when [the baby is at the curve], the delivery is fast. […]. It might impact of course when you think ‘OK, once she's there then delivery goes fast so pain medication is not needed’. Yeah it can impact of course. […] I personally do not think that it's about biological differences. […]But I do think in the Netherlands people think biological differences are also important.” (P4) Participants stated that although MNCPs believe they treat everyone the same, beliefs about race and ethnicity, and pain experience and expression can influence their treatment of womxn. Participant 4 explained: “Y ou think like, you're neutral, but you're not. […] We think that we're treating everyone the same, but we're not. And we don't want to express that we think there are differences […] but I think they're more unconscious than we think […] [It is] socially more acceptable to say everyone is the same, so we're trying to express that as well, but there are many unconscious biases and beliefs that influence the way we assess pain and advise pain killers or not during labour.” (P4) Effects of racial and ethnic bias explained away Participants attributed differences in the assessment, management and treatment of pain between racial and ethnic groups to reasons other than the presence of stereotypes and assumptions associated with race/ethnicity, and in doing so, insinuated that racial and ethnic discrimination does not exist in Dutch MNC. The most commonly cited reasons were womxn' individual profile, culture, language barrier and socio-economic position (SEP). Individual profile Individual profile was used to describe differences that exist between individuals, regardless of race and ethnicity. Participants 8 and 12, for example, explained how individual profile influenced their assessment, management and treatment of pain. “[…] It's not always the pain disparities between different ethnic groups, but rather between people. […] People’s pain, acceptance or pain levels or the way they deal with pain. […] We also use assumptions about people about also, whether they, what kind of life they have, what is their background, have they been to the hospital very often with this kind of pain? Do they, what is my personal relation to them? So do I feel like I should take the pain very seriously, or do I think it's more of a show, a dramatic show.” (P8) “Yeah, if someone has intellectual disabilities and if someone is sometimes, like maybe more anxious or more afraid of labour, sometimes we do, for instance, ourselves suggest that they take pain relief early, earlier, for instance, that maybe that will help them, for instance to be more relaxed and be more trusting of the process.” (P12) P5 described that, for instance, some people do not express their needs during labour, using the example of undocumented womxn in the Netherlands, and their fear of being deported. “[…]When they are saying things that they don't like or if they don't express themselves in the way that they should be that they are scared that you will go to the IND to tell that they are here illegal or something like that and those kind of things that you are maybe going to the police or something like that to say that they are here and they are not with the good papers..” (P5) Culture Many participants associated pain experience and expression to culture rather than race and ethnicity. They stated that, in their opinion, cultural differences influence how womxn respond to pain. “[…] There are cultures where it's very common to scream a lot when you're having pain or to express yourself a lot when you're having pain. And there are cultures where it's much more common to withhold it in yourself and to keep it small, to not overgo or not letting it [show] too much.” (P5) “No, I don't think it really is the ethnicity. I do think it's more the way how she responds to pain, which can be different in different cultures. I don't think it's ethnicity at itself.” (P7) “[…] A woman coming from Africa just here knows the culture that how women birth, give birth in Africa. It's like you never hear them complain. They just give birth. It's part of life. They go for it and that's OK […]. And then when you see women who have been here for their whole life or a longer period, that they know what the options are, and I think they're… How do you say it… their perception or their… they know there are different options for pain relief that they are more willing to ask for it or want help or things like.” (P10) Participants 2, 7 and 8 further explained how culture might influence MNCPs pain assessment, management and treatment by suggesting that within certain cultures, the expression of pain is either understated (P7), exaggerated (P8) or a call for attention or help (P2). In their references to culture, these participants used racial/ethnic labels. “[…] I think different cultures also respond differently on pain, but maybe . . . “response” is [not] the right word but how they show that they are in pain, there are very big differences. But I am a bit shocked that the treatment is different because I do think that if somebody wants pain medication and they ask for it, well, that's very personal. If you feel pain or if you don't feel pain, which doesn't really depend on your ethnicity. […] Chinese people who don't show their pain and who don't ask for pain [medication], I think sometimes they will be entitled to have more pain medication than they get now. And for example the Indian people, they have overall, they feel a lot of pain very quickly. So I can imagine that they sometimes will get pain relief very early in their delivery. But also sometimes . . . healthcare workers think well, we can probably wait a little bit longer because of the culture where, well it's not very nice to say, I don't know how to say it in good English, but with this construction they sometimes think that they are going to die because of the pain and they are very shocked by the pain. But I do think that sometimes they get their pain relief a little bit later because it's a really cultural thing, which all Indian people have that they experience a lot of pain.” (P7) “So often heard things are ‘ohh yeah, Arabic woman women are usually very dramatic in their presentation of pain’, and this affects how healthcare providers are assessing pain for sure, 100% in every other situation.” (P8) “What I think is that people from India or Pakistan that they use pain, or they express pain with a different purpose […]. I think it's also a way to communicate to their community that they need attention or help. So that it's not only that they feel that they need to have different pain treatment or medication, but that they need, yeah, also attention or help or a cry for help.” (P2) Differences in the administration of pain relief was also cited to be related to the birthing womxn’s unfamiliarity with Dutch cultural practices of pain relief during labour (P4), and the healthcare system (P1). “Of course in the Netherlands more than 50% of the women deliver with epidural so, and depending on where the woman is from, it's not even possible, or way less, so if it's the woman's choice, of course, that's the most important thing. So [...] yes, [black immigrants] want it less than white women.” (P4) “[…] They don't really know what the options are. And they do know that maybe in their home country that pain relief is more difficult to get or everything, so they won't ask as quickly as people maybe from here or like people are super well informed. So I think that might be, that might be something that they will as. […].” (P1) The participants described scenarios whereby womxn of non-Dutch origin perceive a power imbalance when interacting with Dutch MNCP. For example, participant 4 talked about their observation of African identified womxn, who view Dutch MNCPs as officials, and so are hesitant to ask for assistance during labour: “[Women from Nigeria and Ghana] just go through labour a little bit more like isolated, so not very talkative […] or asking much, [they] even don't ask the nurse for anything and so they're a bit more like, we call it in Dutch, we say ‘onderaan’… . They see the healthcare workers as . . . very official and they don't want to ask them for anything extra. So, they just undergo labour instead of actually receiv[ing] coaching from us.” (P4) Participant 1 discussed the pitfalls of attributing pain experience and expression solely to culture, as it may overlook many other factors that might influence someone’s health and the care they receive, such as accessibility of MNC and the quality of care provided: “[…] “It's just their culture” is such a way how you can stereotype people and not be curious to what is really going on, what care do we provide? How is the quality of care? How's our health system working? It's such it can be such a lame excuse to not talk about all those more complex issues that you cannot solve tomorrow that are very difficult to tackle, but we need to look into and be uncomfortable.” (P1) Language barrier Language barrier was stated by nine out of thirteen participants as a barrier that could result in under administration of pain relief, for example leading to a scenario where the anaesthesiologist may be unwilling to administer pain relief if the MNCP cannot effectively communicate the risks to the birthing womxn. “[…] If we can't communicate well enough with them, our anaesthesiologist is sometimes having issues or doesn't want to give them an epidural because they say, ‘well then I can't counsel them good enough about possible risks, or they can't tell, the patients can't tell the professionals well enough when something is the matter’, so when they start to feel short of breath that maybe their peripherals too high or they have a spinal block or whatever, and they're and the patients are not well enough to give those signals to the to the healthcare professionals because of language issues. […] Yeah, I think that really affects our pain assessments and treatment.[…]” (P2) Participants mentioned that the primary tool to overcome the language barrier was to use a translator available by phone, although the infeasibility of this was also highlighted due to time constraints. “If a Polish lady comes and who doesn't speak a word of Dutch, it's also very difficult to see if she needs pain medication, but also to explain what kind of pain medication do we have which is good for her. How do you do an informed consent if you don't talk the language? You can call the ‘Tolk’ telephone, the translator. But it also takes time.” (P7) Socioeconomic Position SEP was mentioned by seven out of thirteen participants as a determinant of differential experience and expression of pain, and MNCP’ pain assessment, management and treatment of pain. Two participants posited that the occurrence of differences in pain relief administration has more to do with SEP than with race and ethnicity. In response to a question concerning the reasons for differences in pain assessment, management and treatment in the U.S, participant 5 stated: “I don't think that it's only racial, it also has to do with the [economic] status. But that's the same as here I think, because it doesn't matter where you're from.” (P5) Participant 5 further posited that those identified as having a lower SEP have more experiences of overcoming difficult things in life and therefore may cope more easily with pain in childbirth, while conversely those whose first time it might be to experience such pain during labour and birth, may more quickly choose to use pain relief during labour. The participants additionally spoke about their observations of womxn with more wealth access having more access to social support such as a doula (P5). Again, reflecting on the impact that social support has on how a womxn experiences labour, participant 7 posited that in their experience the “social environment” matters a lot, as womxn who “have a lot of support, then they might need less pain medication because they have the support system, but if they are all alone, then they might need some pain medication earlier.” (P7) Participant 6 spoke about their experiences providing care to people identified as having a higher SEP who, in contrast to those identified as having of a lower SEP, display entitlement to timely care. Similarly to participant 5, they posited that this may also coincide with a higher use of pain medication. Although they mentioned that this phenomenon can occur in womxn of any race and ethnicity, in their experience “it’s primarily white, younger professionals […] [who] think they earn something and that they get something now, even though they're not as much in pain and that doesn't matter.” (P6) Assumed protection and threat The participants described different factors that they believed prevented or (re)produced bias in pain assessment, management and treatment. Protective factors included representation in the MNC workforce and diversity in the patient population, while perceived threats included medical education, hierarchy and MNCPs working in isolation. Representation Almost all participants cited diverse perspectives in the workplace as being pivotal to developing a less biased worldview and providing better care to womxn of all racial and ethnic backgrounds. “[…] I think if you treat people differently that it's a part of racism and I, but I don't think that they are, that it's intended racism. But if you don't see that anything but your own normal is normal, then you might mistreat others, or at least don't give them the same treatment.” (P3) “I think it's so important that you have this diversity […] if it's cultural background or ethnicity or gender or whatever so you can just talk and be uncomfortable with each other about things to make sure you talk about things so you can learn more. And I think that will make us all better humans and provide better care as well, because then there are things that I don't see as well […] then I need a colleague who sees from another perspective.” (P1) The MNCPs’ own race and ethnicity were noted by the participants as important determinants of pain assessment, management and treatment. The participants described differential treatment of womxn whose race/ethnicity differed from their own, due to a lack of understanding outside of “ your own normal” (P3) and decreased empathy, stating that you will feel frustrated sooner with womxn you cannot relate to. According to one participant, professionals tend to “care better for people who look like [them].” (P1).One participant, who self-identified as Black, explained that they felt more responsible for the outcome when they identified with the womxn they care for: “[…]I don't know if the ethnicity plays a role, but I feel an extra importance to take extra good care of my sisters […] So, if that's not the case, I will be extra disappointed.” (P3) Some participants stated that the diversity in cities like Amsterdam is not represented in the care that is delivered or the health research that is being carried out. Participant 8, for example, explained: “Because our care in the past decades has been mainly focused, also the research that has been formed, mainly focused on one ethnic group and now there's a lot of more diversity coming in, but [it’s] still not a good representation of our population” (P8). A lack of diversity in the workplace was further talked about in relation to the lack of diversity among medical students, and especially about the fact that students with a migration background are underrepresented in training for medical specialisation. Participant 3, for example, explained: “[…] 25% of the students are of also migration background, but when you go and look at the specialties, I think it's also specialties in the hospital and the one[s] who become gynaecologists, who become surgeons, who become, well, a medical specialist in the hospital, they are, that is 4% that have a migration background. And so, they call it a bit of a ‘leaky pipeline’ and we [haven’t] fully grasped why that is.” (P3) Participant 4 believed that due to the lack of diversity in the Dutch medical education system, healthcare professionals will eventually conform to the norm. “[…] You're forced into this path of 12 years indoctrination, so we all end up like the same sausage about how to, yeah, how to do your work. […] If you are Black, but you've been trained six years by white doctors, then at the end of the road you think like a white doctor. (P4) Diverse population Many participants described that working with the diverse population of Amsterdam had accustomed them to the different needs of people with different racial and ethnic background, preventing racial and ethnic bias in pain assessment, management and treatment. They used this narrative as an argument to deny systemic racial and ethnic discrimination in the Netherlands. “[…] Because we have such a large amount of people from all over the world, I think we're more used to that. […] So I think my opinion is different and maybe milder, more outgoing or more welcoming to other ethnicities, where my family, they are, work wise, not seeing that many people from a different background.” (P2) “[…] The population is almost only people with different ethnicities. And so that's a norm there. So that's why I don't think that there will be a lot of bias. (P3) Medical education The participants spoke about medical education as an issue that reinforced racial/ethnic bias. Both participants 4 and 6 referred to the learned beliefs that healthcare professionals acquire throughout their education. In recalling a lecture where the idea of “ mediterranean fever ” was presented, participant 6 suggested that internal biases within the profession can be learned through education. “[…] That we sort of have internal biases that we apparently learn. Sort of, because I think our profession is something that we learn, it's not something that we're born with […].” (P6) Two participants also spoke about the influence that your peers can have on how you carry out your work. Participant 1 suggested that inexperienced medical professionals may be influenced by the biased beliefs of more senior colleagues. Similarly, participant 6 explained that during collaboration in decision making and receiving guidance from peers, you are influenced by the people with whom you work with and within this dynamic, biased beliefs can be shared. Participants spoke about their own efforts to educate, and of efforts that are made within medical education to address racial/ethnic bias, such as a presentations conducted by obstetric interns and during symposiums that aim to create awareness around pain perception and bias in healthcare. Participant 6 used an example to describe how educators sometimes reinforced racial and ethnic stereotypes about their own racial and ethnic background. “I thought it was a very interesting class from two experienced patient representatives who were both Turkish and Moroccan […]. [They] told us about sort of presentation from their perspective that people in their countries […], she had a good example, I can only do it in Dutch. But she was like (demonstrated a person shouting for pain, spoke in Dutch) to get attention and to actually sort of get help and that that is something that perhaps if you know that they had to do that in their hospitals, for example in Morocco, then they'll have to do it here as they tend to do it here as well and that we perhaps feel that it's a little bit too much for us or too over exaggerated.” (P6) MNCP working in isolation A few participants described how pain assessments are conducted by MNCPs in isolation from one another, which makes the assessment vulnerable to stereotypes. According to participant 3 and 4 for example: “[…] The reality of the pain assessment happens in the room in which I don't see the patient, or the patients' needs. (P3) “[…] I usually do not observe my colleague the midwife when she goes to [the] patient. So I only hear it during like when the shift ends and you discuss patients, some sometimes you just discuss how women express pain and then maybe, yeah, advise on pain medication. And so only I only . . . hear it in second hand.” (P4) Hierarchy The participants described how power imbalance between healthcare professionals can play a role in differential treatment. These imbalances arise due to perceived or actual differences in levels of authority between MNCPs, and result in some of them being unwilling to speak up and address issues of racial and ethnic bias as they arise. P1 explained: “[…] It's difficult from bottom up to speak up to the medical hierarchy. So, we can really work to making it a flat structure. [. . .] It's more difficult to talk to your supervisor, you feel like, ‘can I say everything or not?’ [. . .] [Sometimes because] of education or sometimes [because] of different roles in being a nurse [or a] midwife, so it might also be that if you’re a supervisor you do not hear everything from the other professional roles that [are] there.” (P1) A few participants also mentioned their efforts to speak up when they witness bias. P8 explained: “At handovers if something is being said like […] ‘she's a strong African woman, she doesn't need it’, that can be said. Usually, if I hear that now I'll try to raise my voice, speak up and say, ‘but that's an assumption or do you have a more subjective way of judging, or did she say she doesn't want it?’ But that's very hard. I can't portray myself as the person who does it all the time or is continuously aware of that. No, definitely not.” (P8) Discussion In this mixed methods study, we used Dutch maternal and newborn care (MNC) as a case to further understand racial/ethnic inequity in pain assessment, management and treatment. This study offers novel insights into racial and ethnic difference in timely care provided by maternal and newborn care professionals (MNCPs) in response to womxn’s pain expression in cases with a uterine rupture, the stereotypes and assumptions held by MNCPs associated with race/ethnicity and pain experience and expression, and how these affect their assessment, management and treatment of pain in the Netherlands. Our findings highlight the importance of further research into racial and ethnic disparities in MNC from an equity perspective. Our quantitative results indicated that in the non-Western category the response time to performed caesarean section (CS) after the first complaint of pain was significantly more often three hours or longer in the non-Western category compared to the Western category. Our qualitative analysis of interviews with MNCPs revealed the simultaneous presence and unawareness of stereotypes and assumptions among MNCPs about how womxn of different racial/ethnic groups experience and express pain, and how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment. MNCPs’ differences in pain assessment, management and treatment related to race/ethnicity were explained by most of the participants to be a result of other factors than their own racial/ethnic stereotypes and assumptions leading to discriminatory care, including womxn’s individual profile, culture, language barrier and social economic position (SEP). Finally, the participants believed that diversity in the MNC workforce and in the patient population they worked with were protective factors against bias in pain assessment, management and treatment, whereas medical education, pain assessment by an individual MNCP, and medical hierarchy were perceived as threats. The results of this mixed methods study provide a starting point to investigate racial and ethnic inequity in MNC in the Netherlands and to address the ways that these differences can be mitigated. Race/ethnicity based maternal and newborn care Race and ethnicity as a fixed biological determinant of health has been scientifically challenged and is widely considered outdated.( 46 – 48 ) In medical practice, education and research, however, race and ethnicity continue to be viewed by some as a reflection of fixed biologic differences.( 25 , 49 – 51 ) Health research using race/ethnicity as biological concepts can lead to inequitable care and unnecessary harm amongst racially and ethnically marginalised groups when translated into clinical practice.( 50 ) An example of this is the use of race and ethnicity in algorithms which individualise risk assessment and guide clinical decision making. In MNC for example, Vaginal Birth After Caesarean (VBAC)-algorithms are used to counsel womxn with a previous CS to predict the likelihood of successful vaginal birth. These algorithms suggest that the likelihood of successful VBAC is lower amongst racially and ethnically marginalised groups. As a result, womxn in, for example, African-American or Hispanic descent category could be directed into choosing an elective CS instead of VBAC, which in turn results in higher CS rates with the associated risk of morbidity.( 52 – 54 ) These algorithms are also used in Dutch MNC.( 55 – 57 ) Furthermore, studies concerning race/ethnicity in healthcare indicate unequal treatment of patients by healthcare professionals based on their race/ethnicity leading to worse health outcomes.( 27 , 28 , 58 ) This is also the case in the Netherlands.( 6 , 30 , 59 – 61 ) A study by Zemouri et al., for example, showed that almost half of Dutch patients categorized as having a migration background, reported experiencing discrimination from healthcare professionals. Concerning pain, 26% of the study participants reported that they had been told by healthcare providers that their complaints resulted from their cultural tendencies and were exaggerated.( 6 ) This is in line with the results of our qualitative results. Additionally, our quantitative results point to a significant delay in the time until a CS is performed in the non-Western category compared to the Western category, which may indicate a diagnostic lapse based on race/ethnicity. These findings are in line with existing literature that attest that pain amongst racially/ethnically marginalised womxn is often minimised and undertreated.( 33 , 35 , 62 ) Racial/ethnic neutrality and cognitive dissonance Notably, in our qualitative study most of the participants disavowed that their assessment, management and treatment of pain was negatively impacted by womxn’s race/ethnicity, while at the same time describing racial and ethnic stereotypes and assumptions regarding womxn’s experience and expression of pain. Disavowal of racial and ethnic discrimination seems to be an important facilitator of inequity in healthcare.( 63 ) This disavowal may be explained by a systemic belief of neutrality towards race and ethnicity, or cognitive dissonance. In the Netherlands, the neutral position of the Dutch general population concerning race and ethnicity is explored by Gloria Wekker in her book ‘White Innocence’.Wekker argues that as a result of four hundred years of Dutch imperial rule, a strong paradox has arisen, specifically among the White racialised population, in which race is both acknowledged and denied. Whiteness is not acknowledged as a racialised/ethicised positioning, and the Dutch think of themselves as a just and ethical nation, colour-blind and free of racism.( 64 ) This systemic racial and ethnic neutrality is not limited to the Netherlands and is thought to only increase the possibility of bias.( 65 , 66 ) The systemic neutral position towards race/ethnicity can lead to cognitive dissonance when confronted with race/ethnicity. Cognitive dissonance is the discomfort that results from a person holding contradictory beliefs or behaviours.( 67 ) People are so highly motivated to resolve cognitive dissonance, they will often disregard evidence supporting one of the beliefs. This paradox might be explained by the theory and research which indicates that humans have at least two cognitive systems. One of the systems produces explicit beliefs and attitudes by processing stimuli in a conscious, controlled, and effortful way. The second system applies implicit knowledge and responds to stimuli rapidly, effortlessly and automatically. These implicit behaviours may contribute to unequal care of which a physician is not aware.( 67 ) Some of the participants in our qualitative study reflected on implicit attitudes by addressing the process of quick decision-making, where innate beliefs about race and ethnicity might play an even more important role. Culturalization of racial and ethnic inequity The participants in our qualitative study ascribed difference in pain experience, expression, and the administration of pain relief to womxn’s culture. This culturalization of pain is based on the belief that cultural differences exist between different ethnic groups influenced by specific traits, customs, behaviours, beliefs and norms.( 30 ) Culture is believed to influence how individuals experience and respond to pain, including their ability to seek treatment and when to do so.( 68 – 70 ) Therefore, it is recommended to include the possibility of cultural differences in pain assessment, management and treatment. A holistic and culturally sensitive approach is believed to improve care within a diverse patient population.( 70 ) In this context, culture should be regarded as a dynamic concept that encompasses the experiences, practices and knowledge and actions of individuals, through which they construct an ongoing sense of themselves and an understanding of others. From this perspective, culture is the product of interactions that are continuously redefined and changed. In applied research, however, this nuance is often lost, and an essentialised approach to culture is often used when examining ethnic disparities in health and health care access. Referred to as the ‘ culturalistic fallacy’ , it is argued that such an essential approach to culture can increase the possibility of generalization and stereotyping by healthcare professionals overlooking the variability within specific groups, and the social, political and economic determinants of health disparities. This dynamic was also seen in our study, where participants often talked about cultural differences, while using racial/ethnic labels. While culture refers to a repertoire of actions, ethnicity refers to a shared belief among members of a group regarding their common descent, whether self-identified or socially assigned.( 71 ) Furthermore, the participants not only explained away differences in pain experience, expression, and the administration of pain relief with womxn’s culture, but also with their individual profile, language barrier and SEP. This approach may distract from addressing systemic racial and ethnic discrimination as the root cause of the inequity. Professional diversity and race conscious education Achieving equity in MNC requires critical reflection on the role of MNC in shaping, causing, maintaining, sustaining, and (re)producing g racial and ethnic inequity.( 58 , 72 – 74 ) In our qualitative study, the participants did so, and mentioned a lack of diversity and inclusion in medical education, research, and workplaces as threats to equity. Currently, there is a lack of diversity among physicians and midwives, which is believed to result in part from a decline in diversity from racialized and minoritized groups in the selection processes.( 75 – 78 ) It is believed that a more diverse workforce will result in higher quality of care and better healthcare outcomes. Studies show, however, that in the absence of an inclusive medical culture, where there is no room for diverse ways of seeing, knowing and doing, the education of a diverse student population will result in a homogenous workforce.( 79 – 83 ) Furthermore, race/ethnicity-based medicine is unfortunately still strongly present in medical education and practice and can reinforce racial/ethnic biases among (future) MNCPs. Students learn to biologically associate race/ethnicity with disease conditions, such as Sickle cell anaemia, hypertension and labour dystocia. Race and ethnicity can therefore be wrongly seen as independent risk factors for health and disease.( 50 , 84 ) Race and ethnicity were found to be presented in medical school lectures without context or justification and were even used as diagnostic hints in medical school exams in the U.S.( 85 ) In Dutch medical schools, the curriculum was also found to lack diversity-related content addressing the concepts of race and ethnicity as well as gender, sexuality and social position.( 86 , 87 ) It is argued that, instead of using race/ethnicity-based medicine which presumes biological differences, we should work towards race/ethnicity-conscious medicine, From this approach race and ethnicity are considered social and power constructs. By analysing structural discrimination based on race/ethnicity in healthcare we can work to reduce racial health inequities.( 50 ) Strengths and limitations This study is the first study on racial and ethnic bias in pain assessment in MNC in the Netherlands. A strength of this study is the mixed methods approach. The quantitative data was retrieved through a prospective, population based and nationwide cohort study of uterine rupture in the Netherlands. In the qualitative study, we achieved diversity among the interview participants (gender, ethnicity, and profession). A limitation of this study is the small sample size ( n = 54) of the quantitative data, which restricted the ability to perform subanalyses and achieve significant results or to conduct logistic regression analysis. This limitation persists despite NethOSS being a validated surveillance system, covering a two-year period including cases of uterine rupture which have a relatively low prevalence in the Netherlands. Furthermore, we had to rely on information that could be found in womxn’s files, and we were, due to privacy rules, not able to interview the womxn or MNCP involved in collecting the data to clarify information. Some variables, associated with racial/ethnic discrimination, such as body mass index and socio-economic position, were not routinely recorded in the womxn’s files. As a result, we were unable to use these variables in our analysis or to adjust for possible confounders. Using information from womxn’s files was specifically problematic for the variable race/ethnicity because it was registered imprecisely and inconsistently. Not only was race/ethnicity not always registered, the categories for registration in the National Perinatal Registry (Perined) consisted of countries, continents, and racial groups. Furthermore, in Perined, race/ethnicity is assigned by womxn’s MNCP, usually based on appearance, name, and/or information provided by women. In Statistics Netherlands (CBS), on the other hand, race/ethnicity is registered more consistently, based on country of origin of a person and their parents.( 42 , 88 ). At present we were unable to recover from womxn’s files how race/ethnicity was assigned or to cross-check the information with CBS as all files were anonymized. Therefore, we used a binary construction of race/ethnicity. This may have conveyed the impression that these groups are homogeneous. Looking at differences in more precise racial/ethnic categories would have allowed for a more nuanced interpretation of the results. The sampling bias in the qualitative study should also be acknowledged. Although knowledge of English in the Netherlands is at a high level, conducting the interviews in English may have impacted the willingness of MNCPs to participate, and therefore bias the sample. Lastly, this study was conducted in the Amsterdam region where there is more population diversity compared to many other cities in the Netherlands. This restricts the generalisability of the study results. We therefore, recommend further research which includes MNCPs from various regions across the Netherlands. Additionally, follow-up research into the experiences of womxn is necessary. Conclusions The aim of this study was to investigate racial and ethnic bias in pain assessment, management, and treatment in maternity and newborn care (MNC). Our mixed-methods approach revealed quantitative results indicating that caesarean section was significantly more frequently performed in more than 180 minutes after the first complaint of pain in the non-Western category compared to the Western category. The qualitative results revealed the simultaneous presence and unawareness of racial/ethnic stereotypes and assumptions among MNCPs about pain experience and expression, and provided insight in how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment. MNCP’s differences were explained by most of the participants to be a result of other factors than their own racial/ethnic stereotypes and assumptions leading to discriminatory care, including womxn’s individual profile, culture, language barrier and socio-economic position, which may distract from addressing systemic racial and ethnic discrimination as the root cause of the inequity. Our findings underscore the disavowal of the role of racial thinking and notions of ethnic differences in pain assessment, management, and treatment, and highlights the need for critical reflection on the role of MNC in shaping, causing, maintaining, sustaining, and (re)producing racial/ethnic inequity, despite MNCPs’ equitable. The results of this study provide a starting point to further investigate racial and ethnic inequity in MNC, and together, with MNC professionals and womxn, to address the ways that these differences can be mitigated. Declarations Ethics approval and participants consent Ethical approval was granted for studies using NethOSS data by the Institutional Review Board of University Medical Centre Utrecht (reference number 14-127). According to the conditions of the Medical Ethics Review Committee (METC) this study falls within the scope of non-WMO research and does not need to be authorised by the METC to proceed. All participants of the interviews were required to sign an informed consent form prior to the interview. At the beginning of the interview, participants were made aware of the nature of the study and reminded of their voluntary participation in the study in addition to their right to withdraw participation at any time during the interview. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received. Authors' contributions SK, EO, BG, AdJ and KB designed the study. Qualitative data was collected and analysed by SK and transcripts were reviewed and discussed by SK, BG, EO and AH-P. EO collected and analysed the quantitative data. AdJ and KB contributed to the development and conduct of the study. EO, BG, AH-P and SK wrote the first draft of the manuscript. BG, EO, AH-P, SK, AdJ and KB contributed to the interpretation of the data, gave feedback on earlier versions of the article and approved the last version of the article. Acknowledgements We would like to thank all healthcare givers in Dutch hospitals for cooperating with the registration process and data collection of cases of uterine rupture. We would like to thank all interviewees for their time and openness during interviews. References Morris T, Schulman M. Race inequality in epidural use and regional anesthesia failure in labor and birth: an examination of women's experience. Sex Reprod Healthc. 2014;5(4):188-94. Rust G, Nembhard WN, Nichols M, Omole F, Minor P, Barosso G, et al. Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery. Am J Obstet Gynecol. 2004;191(2):456-62. Badreldin N, Grobman WA, Yee LM. Racial Disparities in Postpartum Pain Management. Obstet Gynecol. 2019;134(6):1147-53. Guðmundsdóttir E, Nieuwenhuijze M, Einarsdóttir K, Hálfdánsdóttir B, Gottfreðsdóttir H. Use of pain management in childbirth among migrant women in Iceland: A population-based cohort study. Birth. 2022;49(3):486-96. Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW. Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007;106(1):19-25; discussion 6-8. Zemouri C, Nait Kassi A, Arrazola de Oñate W, Çoban G, Kissi A. Exploring discrimination and racism in healthcare: a qualitative phenomenology study of Dutch persons with migration backgrounds. BMJ Open. 2024;14(6):e082481. Egbe TO, Halle-Ekane GE, Tchente CN, Nyemb JE, Belley-Priso E. Management of uterine rupture: a case report and review of the literature. BMC Res Notes. 2016;9(1):492. Nair R, Nikolopoulos KI, Claydon LS. Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2017;208:71-80. Curtin SC, Gregory KD, Korst LM, Uddin SF. Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013. Natl Vital Stat Rep. 2015;64(4):1-13, back cover. Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, et al. Saving lives, improving mothers’ care core report - lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit: University of Oxford. 2023. Zwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Uterine rupture in The Netherlands: a nationwide population-based cohort study. Bjog. 2009;116(8):1069-78; discussion 78-80. Overtoom EM, Huynh TN, Rosman AN, Zwart JJ, Schaap TP, Vogelvang TE, et al. Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands. J Matern Fetal Neonatal Med. 2024;37(1):2311083. M'Charek A. Curious about race: Generous methods and modes of knowing in practice. Soc Stud Sci. 2023;53(6):826-49. Helberg-Proctor A. (Un)doing ethnicity: analyses of the socio-scientific production of ‘ethnicity’ in health research in the Netherlands. 2017. Smart A, Tutton R, Martin P, Ellison GT, Ashcroft R. The standardization of race and ethnicity in biomedical science editorials and UK biobanks. Soc Stud Sci. 2008;38(3):407-23. Duster T. A post-genomic surprise. The molecular reinscription of race in science, law and medicine. Br J Sociol. 2015;66(1):1-27. Mulinari S, Bredström A. “Black race”, “Schwarze Hautfarbe”, “Origine africaine”, or “Etnia nera”? The absent presence of race in European pharmaceutical regulation. BioSocieties. 2024;19(1):19-36. Morning ANN. The Nature of Race How Scientists Think and Teach about Human Difference. 1 ed: University of California Press; 2011. Mersha TB, Beck AF. The social, economic, political, and genetic value of race and ethnicity in 2020. Hum Genomics. 2020;14(1):37. Lu C, Ahmed R, Lamri A, Anand SS. Use of race, ethnicity, and ancestry data in health research. PLOS Glob Public Health. 2022;2(9):e0001060. Tattersall I, DeSalle R. Race? : debunking a scientific myth. 1st ed. College Station: Texas A & M University Press; 2011. xv, 226 p. p. Kennedy RF, Roy CS, Goldman ML. Race and ethnicity in the classical world : an anthology of primary sources in translation. Indianapolis: Hackett Pub. Company, Inc.; 2013. Available from: http://site.ebrary.com/id/10748802. Montagu MFA. Man's most dangerous myth: the fallacy of race. New York, NY, US: Columbia University Press; 1942. xi, 216-xi, p. Edwards CL, Fillingim RB, Keefe F. Race, ethnicity and pain. Pain. 2001;94(2):133-7. Helberg-Proctor A, Krumeich A, Meershoek A, Horstman K. The multiplicity and situationality of enacting ‘ethnicity’in Dutch health research articles. BioSocieties. 2018;13:408-33. Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(9):e0138511. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189900. Hamed S, Bradby H, Ahlberg BM, Thapar-Björkert S. Racism in healthcare: a scoping review. BMC Public Health. 2022;22(1):988. Meghani SH, Gallagher RM. Disparity vs inequity: toward reconceptualization of pain treatment disparities. Pain Med. 2008;9(5):613-23. Zemouri C. Discriminatie maakt ziek. Hoe patiënten met een migratieachtergrond door zorgdiscriminatie verslechterde zorg ontvangen. Wetenschappelijk instituut STATERA2022 [Available from: https://instituutstatera.nl/discriminatie-maakt-ziek/ Bronson E. What is Medical Racism? : YWCA Seattle | King | Snohomish; 2020 [Available from: https://www.ywcaworks.org/blogs/firesteel/what-medical-racism. Braun L. Breathing Race into the Machine The Surprising Career of the Spirometer from Plantation to Genetics: University of Minnesota Press; 2014. Davis DA. Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing. Med Anthropol. 2019;38(7):560-73. Bridges K. Reproducing race: An ethnography of pregnancy as a site of racialization: Univ of California Press; 2011. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301. Kroll C, Murphy J, Poston L, You W, Premkumar A. Cultivating the ideal obstetrical patient: How physicians-in-training describe pain associated with childbirth. Soc Sci Med. 2022;312:115365. Copeland VC, Braxter B. Black Women and Maternal Death. Encyclopedia of Social Work2022. Campbell CM, Edwards RR. Ethnic differences in pain and pain management. Pain Manag. 2012;2(3):219-30. Strand NH, Mariano ER, Goree JH, Narouze S, Doshi TL, Freeman JA, et al. Racism in Pain Medicine: We Can and Should Do More. Mayo Clin Proc. 2021;96(6):1394-400. Hirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions. J Pain. 2015;16(6):558-68. Barata C. “Mix of Races, Bad Uterus”: Obstetric Violence in the Experiences of Afro-Brazilian Migrants in Portugal. Societies. 2022;12(3):78. Goodarzi B, Helberg-Proctor A, Brewster L, van den Akker T. ‘Ras’ en etniciteit registreren in de zorg: een precaire kwestie. Medisch Contact. 2022. Yanow D, Van Der Haar M. People out of place: allochthony and autochthony in the Netherlands' identity discourse -- metaphors and categories in action. Journal of International Relations and Development, suppl Special Issue: Linguistic Approaches to Analyzing Policies. 2013;16(2):227-61. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. Clarke V, Braun V. Thematic Analysis. In: Teo T, editor. Encyclopedia of Critical Psychology. New York, NY: Springer New York; 2014. p. 1947-52. Balkenhol M. Racisme in kunst en cultuur . Cahiers Biowetenschappen en Maatschappij . 2017. p. 64-5. Borrell LN, Elhawary JR, Fuentes-Afflick E, Witonsky J, Bhakta N, Wu AHB, et al. Race and Genetic Ancestry in Medicine - A Time for Reckoning with Racism. N Engl J Med. 2021;384(5):474-80. Goodman AH. Why genes don't count (for racial differences in health). Am J Public Health. 2000;90(11):1699-702. Deyrup A, Graves JL, Jr. Racial Biology and Medical Misconceptions. N Engl J Med. 2022;386(6):501-3. Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020;396(10257):1125-8. Fullwiley D. Tabula Raza: Mapping Race and Human Diversity in American Genome Science: University of California Press; 2024. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;383(9):874-82. Vyas DA, Jones DS, Meadows AR, Diouf K, Nour NM, Schantz-Dunn J. Challenging the Use of Race in the Vaginal Birth after Cesarean Section Calculator. Womens Health Issues. 2019;29(3):201-4. Kallianidis AF, Schutte JM, van Roosmalen J, van den Akker T. Maternal mortality after cesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol. 2018;229:148-52. Vankan E, van Kuijk SMJ, Nijhuis JG, Aardenburg R, Delemarre FMC, Dirksen CD, et al. External validation of a prediction model on vaginal birth after caesarean in a The Netherlands: a prospective cohort study. 2021;49(3):357-63. Schoorel EN, Vankan E, Scheepers HC, Augustijn BC, Dirksen CD, de Koning M, et al. Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid. Bjog. 2014;121(2):202-9. Schoorel EN, van Kuijk SM, Melman S, Nijhuis JG, Smits LJ, Aardenburg R, et al. Vaginal birth after a caesarean section: the development of a Western European population-based prediction model for deliveries at term. Bjog. 2014;121(2):194-201; discussion Devakumar D, Selvarajah S, Abubakar I, Kim SS, McKee M, Sabharwal NS, et al. Racism, xenophobia, discrimination, and the determination of health. Lancet. 2022;400(10368):2097-108. Suurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot ML. Negative health care experiences of immigrant patients: a qualitative study. BMC Health Serv Res. 2011;11:10. Harmsen H, Meeuwesen L, van Wieringen J, Bernsen R, Bruijnzeels M. When cultures meet in general practice: intercultural differences between GPs and parents of child patients. Patient Educ Couns. 2003;51(2):99-106. Schinkel S, Schouten BC, Kerpiclik F, Van Den Putte B, Van Weert JCM. Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination? Health Commun. 2019;34(12):1469-81. Leal MDC, Gama S, Pereira APE, Pacheco VE, Carmo CND, Santos RV. The color of pain: racial iniquities in prenatal care and childbirth in Brazil. Cad Saude Publica. 2017;33Suppl 1(Suppl 1):e00078816. Helberg-Proctor A, Busari JO. Systemic Anti-Blackness and Racism in Healthcare: A European Perspective. Healthc Pap. 2023;21(3):25-30. Wekker G. White Innocence Paradoxes of Colonialism and Race: Duke University Press; 2016. Iacobucci G. Healthcare leaders reject “damaging” denial that institutional racism exists. BMJ. 2021;373:n911. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health C. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US) Copyright 2002 by the National Academy of Sciences. All rights reserved.; 2003. van Ryn M, Saha S. Exploring unconscious bias in disparities research and medical education. Jama. 306. United States2011. p. 995-6. Givler A, Bhatt H, Maani-Fogelman PA. The Importance of Cultural Competence in Pain and Palliative Care. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023. Peacock S, Patel S. Cultural Influences on Pain. Rev Pain. 2008;1(2):6-9. Rogger R, Bello C, Romero CS, Urman RD, Luedi MM, Filipovic MG. Cultural Framing and the Impact On Acute Pain and Pain Services. Curr Pain Headache Rep. 2023;27(9):429-36. Meershoek A, Krumeich A. Multiculturalism and the construction of ethnic identities in labour and health practices: avoiding the culturalistic fallacy in applied research. Health Care Anal. 2009;17(3):173-97. Ashley R, Goodarzi B, Horn A, de Klerk H, Ku SE, Marcus JK, et al. A call for critical midwifery studies: Confronting systemic injustice in sexual, reproductive, maternal, and newborn care: Critical Midwifery Collective Writing Group. Birth. 2022;49(3):355-9. The Lancet Series on racism, xenophobia, discrimination, and health 2022 [Available from: https://www.thelancet.com/series/racism-xenophobia-discrimination-health. Goodarzi B, editor Racism, inequity, health and well-being: an urgent call for a European stance. ECTMIH; 2023; Utrecht, The Netherlands. Tweed T, Maduro CV, Güneș NH, Poeze M, Busari JO. Diversity matters: the other doctor within the Dutch academic healthcare system. BMJ Lead. 6. England: © Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.; 2022. p. 171-4. Smedley BD, Stith AY, Colburn L, Evans CH, Institute of M. The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert WNickens, MD. Washington (DC): National Academies Press (US) Copyright 2001 by the National Academy of Sciences. All rights reserved.; 2001. Mulder L, Wouters A, Twisk JWR, Koster AS, Akwiwu EU, Ravesloot JH, et al. Selection for health professions education leads to increased inequality of opportunity and decreased student diversity in The Netherlands, but lottery is no solution: A retrospective multi-cohort study. Med Teach. 2022;44(7):790-9. Mulder L, Wouters A, Akwiwu EU, Koster AS, Ravesloot JH, Peerdeman SM, et al. Diversity in the pathway from medical student to specialist in the Netherlands: a retrospective cohort study. Lancet Reg Health Eur. 2023;35:100749. Gennissen LM, Stegers-Jager KM, de Graaf J, Fluit C, de Hoog M. Unraveling the medical residency selection game. Adv Health Sci Educ Theory Pract. 2021;26(1):237-52. Beagan BL. Neutralizing differences: producing neutral doctors for (almost) neutral patients. Soc Sci Med. 2000;51(8):1253-65. Leyerzapf H, Verdonk P, Ghorashi H, Abma TA. “We are all so different that it is just … normal.” Normalization practices in an academic hospital in the Netherlands. Scandinavian Journal of Management. 2018;34(2):141-50. Rezaiefar P, Abou-Hamde Y, Naz F, Alborhamy YS, LaDonna KA. "Walking on eggshells": experiences of underrepresented women in medical training. Perspect Med Educ. 2022;11(6):325-32. van Andel C. C linical Grade Differences Between Ethnic Minority and Majority Students: Institutional-, assessor-, and student-related factors . 2022. Amutah C, Greenidge K, Mante A, Munyikwa M, Surya SL, Higginbotham E, et al. Misrepresenting Race - The Role of Medical Schools in Propagating Physician Bias. N Engl J Med. 2021;384(9):872-8. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016;91(7):916-20. Muntinga ME, Krajenbrink VQ, Peerdeman SM, Croiset G, Verdonk P. Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation. Adv Health Sci Educ Theory Pract. 2016;21(3):541-59. Muntinga M, Beuken J, Gijs L, Verdonk P. Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum. GMS J Med Educ. 2020;37(2):Doc22. Milieu RvVe, (RIVM). Etniciteit en zorg rondom zwangerschap en geboorte: een verkenning van Nederlands onderzoek. 2007. Tables Table 1: Demographic characteristics of the population of uterine rupture cases with recorded race/ethnicity in the Netherlands (n, %) for the period April 1st 2016 – May 31st 2018 Population n % Maternal Characteristics Racial/ethnic category Western 26 48.1 Non-Western 28 51.9 Age (years) <35 36 66.7 35 14 25.9 Missing 4 7.4 BMI <30 35 64.8 30 1 11.1 Missing 13 24.1 Language Barrier Yes 10 18.5 No 42 77.8 Missing 2 3.7 Obstetric Characteristics Parity 1 40 74.1 2 14 25.9 Previous CS 1 45 83.3 2 9 14.8 Vaginal Birth After Caesarean Section Previous 3 5.6 Current 43 79.6 Uterine Rupture (UR) or Dehiscence UR 17 38.6 Dehiscence 27 61.4 Pain Relief during Labour Epidural 26 48.1 Remifentanil 7 13.0 None 21 38.9 Onset of Labour Spontaneous 39 72.2 Induction 13 24.1 Missing 2 3.7 Augmentation of Labour (oxytocin) Yes 24 44.4 No 30 55.6 Gestational Age <37 53 98.1 37 1 1.9 Table 2: Outcome characteristics of the study population uterine rupture cases ( n , %, OR) for the period April 1st 2016 – May 31st 2018 Racial/ethnic category OR (95%CI) Language Barrier category OR (95%CI) Western (n=26) Non-Western (n=28) Non-Western vs Western No (n=42) Yes (n=10) Language barrier vs non-language barrier Care processes Augmentation of Labour 13 (50) 11 (39.3) 0.45 (0.22-1.91) 19 (45.2) 5 (50) 1.21 (0.30-4.81) Missing * * * * Induction of Labour 6 (23.1) 7 (25.0) 1.11 (0.32-3.88) 11 (26.2) 2 (20) 0.71 (1.30-3.84) Missing * * * * Pain Relief Epidural 14 (53.8) 12 (42.9) 0.64 (0.22-1.88) 25 (54.8) 1 (10) 0.08 (0.01-0.65) Remifentanil 1 (3.8) 4 (14.3) 4.17 (0.43-40.00) 1 (2.4) 4 (40) 27.33 (2.60-287.41) None 11 (42.3) 12 (42.9) 1.02 (0.35-3.01) 16 (42.8) 5 (50) 1.63 (0.41-6.51) Missing * * * * Complaints of pain 10 (38.5) 15 (53.6) 1.73 (0.58-5.16) 18 (42.9) 5 (50) 1.28 (0.32-5.10) Missing 1 * 1 * Time to Caesarean Section Time Between 1 st Complaint & Decision for Caesarean Section <30 mins 7 (63.6) 3 (27.3) 0.21 (0.04-1.31) 8 (50) 2 (33.3) 0.50 (0.07-3.55) 30 – 90 mins 2 (18.2) * - 2 (12.5) * - 90 – 180 mins * 3 (27.3) - 2 (12.5) 1 (16.7) 1.40 (0.10-19.01) 180+ mins 2 (18.2) 5 (45.4) 3.75 (0.54-26.05) 4 (25) 3 (50) 3.00 (0.42-21.30) Missing 6 6 9 1 Time Between 1 st Complaint & Decision for Caesarean Section <30 mins 2 (16.7) 3 (20) 1.25 (0.17-9.02) 4 (19) 1 (16.7) 0.85 (0.08-9.44) 30 – 90 mins 6 (50) 2 (13.3) 0.15 (0.02-1.00) 7 (33.4) 1 (16.7) 0.40 (0.04-4.12) 90 – 180 mins 3 (25) 2 (13.3) 0.462 (0.06-3.35) 4 (19.1) 1 (16.7) 0.85 (0.08-0.44) 180+ mins 1 (8.3) 8 (53.3) 12.57 (1.28-123.48) 6 (28.6) 3 (50.0) 3.13 (0.55-17.84) Missing 5 2 4 1 Maternal Outcomes MOH >1000mL 6 (23.1) 7 (25.9) 1.11 (0.32-3.88) 8 (19.5) 4 (40) 2.05 (0.51-8.19) Missing * 1 1 * Uterine rupture 7 (26.9) 11 (39.3) 1.76 (0.56-5.56) 12 (28.6) 5 (50) 2.50 (0.61-10.23) Missing * * * * Perinatal Outcomes Perinatal Mortality 1 (4) 3 (10.7) 2.88 (0.28-29.64) 2 (4.9) 2 (20) 4.88 (0.60-39.91) Missing 1 * 1 * Neonatal Asphyxia 5 (19.2) 9 (32.1) 1.90 (0.54-6.68) 10 (23.8) 3 (33.3) 1.37 (0.30-6.32) Missing 1 * * * Admission to Neonatology 3 (11.5) 5 (17.9) 1.67 (0.36-7.80) 6 (13.4) 1 (10) 0.67 (0.71-6.26) NICU 1 (3.8) 2 (7.1) 1.92 (0.16-22.56) 3 (7.1) * - Missing * * * * MOH = major obstetric haemorrhage. *= no cases in this group. Red = P value <0.05. Table 3 Racial and ethnic stereotypes about pain experience and expression. Racial/ethnic group Quotes Black and African identified "[…] What I observe for example, is the way that the want or needs are vocalised. […] That white society is way more expressive like asking for pain medication as black women are less likely to do so, but I indeed I am not sure if they don't want it or they are more like. Well, whatever or whenever you as a doctor advice it. So they are more in a in a reserved attitude. Yes, I think they are asking a lot less. But I don't think that that means that they would need it a lot less.” “I have heard that black women can for example, handle pain better. […] Black women are strong, for example.” (P3) “[…] We saw quite a lot of women from, in Western Africa and who were not were not Dutch, […] and the way those women express pain is maybe different than and then white Dutch women so it's perceived differently. Maybe with less or other emotion.” […] Many of my colleagues think that like women from West Africa have a bit of more curved spine, more lordose in the back, also that when labour does not progress or it takes very long for the head of the baby to be very high and only in the last phase when the baby goes through that threshold through that curve, then the baby comes. So it takes a while but when it's there the delivery is fast and so and my many of my colleagues say Oh no, she's a West African woman, so it takes some time, but when she's there then, the baby will, then the delivery will be fast and that's something I never heard any evidence about or read somewhere, but it's like a big, yeah, big bias for me and people just tell it, ‘oh, no, that's normal for West African women’ ” “[…] We see quite some people from Nigeria and Ghana […] who just go through labour a little bit more like isolated. So not very talkative to labour or asking much, even don't ask the nurse for anything.” “[…] Another belief is that black women from Western Africa and sometimes express pain a little bit more theatrical so not insulated, but more theatrical with more body movement. And that way they can they can take on more pain and that includes like shaking the body or like smashing your own your legs or sometimes shouting, shouting more or sighing like louder, in a way to cope with the pain and in that light the healthcare professional thinks like OK she has like a good way of coping with the pain, so she does not need pain medication.” (P4) “[…] Surinam [women] can also birth very fast something that goes around, those kind of prejudices, and perhaps if you are sort of an ethnicity of which there's a prejudice that they birth very fast they might get remifentanil sooner than epidurals, for example, if you're at 5 or 6 centimetres when you're in the grey area.” (P6) “But about originally African women sometimes, healthcare providers we say like ohh she's she's like this strong African woman, she can take it, she can handle it.” “So at handovers if something is being said like she's well, she's a strong African woman, she doesn't need it, that can be said.” (P8) “When a young black woman is gone, coming for delivery, we know. Quite sure it goes. It can go really fast. For example, that's that's maybe one of the things that you did. You have the idea that they they can deliver, they can manage. But yeah, that's well, yeah. And especially the delivery will go quickly […].” (P9) “[…] A woman coming from Africa just here knows the culture that how women birth give birth in Africa. It's like you never hear them complain. They just give birth. It's part of life. They go for it and that's OK and maybe when they come here they still have that. They still think like this is just part of life. We have to go through it. We can't do anything about it. And then when you see women who have been here for their whole life or a longer period, that they know what the options are, and I think they're. How do you say it there perception or their they know there are different options for pain relief that they are more willing to ask for it or want help or things like.” (P10) “And sometimes you also hear from colleagues saying that I don't know. Maybe. Yeah, these, you know, like standard beliefs that […], yeah, someone from I don't know, Somalia might be more quiet […].” (P12) (South) Asian / Hindustani / Indian identified “I also find that, for example people with. Background from for example, Pakistan or India. I find that they also react different to pain than people from another background.” “[…] With South Asians, I more try to specify and clarify what the pain really is, and so when they're for example, during labour or during the C-section really painful, I try to specify, is that correct that's really painful […] Is it really pain or is it something different? I don't want to over treat them. And I do that more with South Asians than with other people from other backgrounds.” (P2) “What I think is that people from India or Pakistan that they use pain or they express pain with a different purpose, for a different purpose. I think it's also a way to communicate to their community that they need attention or help.” (P2) “[…] I think that I even have had [biases], especially the theatrical Hindustani women […].” (P3) “[…]I think that it has been studied because it’s joke among midwives, but I think it's studied that Indian women have a lower, they can't cope as good with pain as not Indian people.” “[…] The Indian woman say that they're, that they have, that [the pain] it’s unbearable. What they're going through and then they have two centimetres of dilatation […]” (P5) “[…] I also might have underrated pain experience, for example, by Indian people because they feel the pain very heavily and especially when I was just coming from school, not very experienced. I do think I might have underestimated their pain. But I also think that sometimes people say they are in more pain than they actually are […].” “Indian people, they have overall they feel a lot of pain very quickly. So I can imagine that they sometimes will get pain relief very early in their delivery, but also sometimes have people here, healthcare workers think well, we can probably wait a little bit longer. […] With this construction they sometimes think that they are going to die because of the pain and they are very shocked by the pain. But I do think that sometimes they get their pain relief a little bit later because […] all Indian people have that they experience a lot of pain” (P7) “ […] We say sometimes maybe with colleagues like […] Indian people that they're more like, like, yeah, experiencing pain more heavily [...].” (P10) “And sometimes you also hear from colleagues saying that, I don't know. Maybe. Yeah, these, you know, like standard beliefs that Asians are more verbal […].” (P12) White identified ‪”We call them West Fresians […] They're really strong, yeah, big build women, OK. Men and women. Yeah, they're, like, “toughen up. We're going to do this. OK.”, Yeah, and they, now I'm generalising, but they give birth easy to children of 4 kilos.” (P2) “[…] More what I observe for example, is the way that the want or needs are vocalised. That if I for example, that white society is way more expressive like asking for pain medication as black women are less likely to do so […].” (P3) “‪[…] There are some young urban professionals, for example, lawyers here in Amsterdam or fashion designers or people who are sort of quite rich, quite young age. Who really express that care is not something that we give to everybody, but we should give it to them now. […]‪And that can be of all ethnicities. But I think it's primarily white, yeah, younger professionals”(P6) “[…] That's such an American Princess, so she will need her epidural immediately.” (P8) “[…] We have a group of women who make a very big birth plan where they say, oh, I don't want this. I don't want this. I don't want this or no pain relief, nothing whatsoever. And then when we get those women, they always come from their midwife, from outside the hospital to inside the hospital. So there is a pass over. How do you say? It she comes to us. And then we see that and we say, OK, so she's going to get everything she doesn't want just because she said so hard. I don't want. […] ‪Usually those demographics are the higher educated white Dutch women.” (P10) Arabic identified “And with, for example, people, women from an Arabic background, when they say lower I have pain in my lower abdomen and I can't really find a diagnosis for that, I'm more likely to ask yeah “are there other things at home, or is there something you worry about” or trying to ask a little bit more about that than I would do in people from another background.” (P2) “[…] I can only do it in Dutch. But [the patient representatives] was like (demonstrated a person shouting for pain, spoke in Dutch) to get attention and to actually sort of get help and that that is something that perhaps if you know that they had to do that in their hospitals, for example in Morocco, then they'll have to do it here as they tend to do it here as well and that we perhaps feel that it's a little bit too much for us or too over exaggerated.” “[…] That they really exaggerate or over present their pain in order to get attention from doctors. […]” (P6) “Ohh yeah, Arabic woman women are usually very dramatic in their presentation of pain, and this affects how healthcare providers are assessing pain for sure, 100% in every other situation.” (P8) Mediterranean identified “[…] I experienced, quite similar prejudices there in terms of pain, for example, that Mediterranean fever is something that still is being discussed there quite often. Or Mediterranean presentation, we call it.” (P6) Chinese identified “[…] Chinese people who don't show their pain and who don't ask for pain [relief], I think sometimes they will be entitled to have more pain medication than they get now. […] I think they are the most difficult to assess.” (P7) Footnotes We have chosen to use the term ‘womxn’ because we are aware of the limitation of the binary English term ‘woman’ and how it highlights but one aspect of a person’s multidimensional and intersecting identity and experience and how they are positioned and position themselves in social reality. We use ‘womxn’ when referring to other studies as well as in our own result section because gender identity was not registered as part of the data collections. We have not adjusted the language when using quotes. We acknowledge that there is no consensus on inclusive vocabulary cross-culturally. In discussing the literature and previous research on racial and ethnic health inequities we have chosen to use the racial and ethnic terms and categories used in these publications. Nevertheless, it is important to note that in many of these publications, the definitions and operationalizations of these racial and ethnic categories are not provided. For this reason, in this paper we consistently use both the terms race and ethnicity or race/ethnicity to discuss bias and discrimination as this is how these terms appeared in the literature included in this paper, the database used for this study and the responses from interview participants. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2025 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 12 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviewers invited by journal 03 Jun, 2025 Editor assigned by journal 12 May, 2025 Submission checks completed at journal 07 May, 2025 First submitted to journal 06 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6600363","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466031746,"identity":"800c2c6b-73d7-4ce7-8379-28046c683d39","order_by":0,"name":"Evelien Overtoom","email":"","orcid":"","institution":"Birth Centre Wilhelmina Children Hospital, University Medical Centre Utrecht","correspondingAuthor":false,"prefix":"","firstName":"Evelien","middleName":"","lastName":"Overtoom","suffix":""},{"id":466031747,"identity":"d8d6f05c-c59f-438a-badf-eddd3358d4fb","order_by":1,"name":"Bahareh Goodarzi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYBACAzDJBsTMzAegYglQmp2gFrYEKB+mhZmQFgYeA+K0mDOwX3zwocwuX76d5+OnG3/+yJm3Jz/dzJtjx2COQ4tlA0+x4YxzyZaNzbybpXPbDIxlzjwzu827LZnBshmHww7wpEnztjEbMDPzbpDObTBInCGRANJygMHgMF4t9QZszDyPf+f8MaifIZH+jYAW9mNALYcNeJh52KRz2AwSJCRy8Nti2czDDPTLcQMJZjYz69w2Y8MZPG/Kbs7dlsyDS4s5e/tDYIhVG8j3H358O+ePnLwEe/q2G2+32ckZHG/AroeZxwC7BA92YRBgf4BbbhSMglEwCkYBCAAA/ixVRFEGyIEAAAAASUVORK5CYII=","orcid":"","institution":"Amsterdam UMC location Vrije Universiteit Amsterdam","correspondingAuthor":true,"prefix":"","firstName":"Bahareh","middleName":"","lastName":"Goodarzi","suffix":""},{"id":466031748,"identity":"ce89d457-407c-4e0b-a5d1-03ade292f949","order_by":2,"name":"Syllona Kanu","email":"","orcid":"","institution":"Athena Institute, VU University","correspondingAuthor":false,"prefix":"","firstName":"Syllona","middleName":"","lastName":"Kanu","suffix":""},{"id":466031749,"identity":"cafae039-e8b6-4d4f-8e1f-adfbf34f5c28","order_by":3,"name":"Alana Helberg-Proctor","email":"","orcid":"","institution":"Department of Anthropology, Health, Care and the Body Programme Group, University of Amsterdam","correspondingAuthor":false,"prefix":"","firstName":"Alana","middleName":"","lastName":"Helberg-Proctor","suffix":""},{"id":466031750,"identity":"e1c175a8-13d1-4ce2-a796-1c81a7b5fea1","order_by":4,"name":"Ank de Jonge","email":"","orcid":"","institution":"Amsterdam UMC location Vrije Universiteit Amsterdam","correspondingAuthor":false,"prefix":"","firstName":"Ank","middleName":"","lastName":"de Jonge","suffix":""},{"id":466031751,"identity":"58dceae1-db59-4d8c-8869-976e5003cef3","order_by":5,"name":"Kitty Bloemenkamp","email":"","orcid":"","institution":"Birth Centre Wilhelmina Children Hospital, University Medical Centre Utrecht","correspondingAuthor":false,"prefix":"","firstName":"Kitty","middleName":"","lastName":"Bloemenkamp","suffix":""}],"badges":[],"createdAt":"2025-05-06 07:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6600363/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6600363/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-025-02714-w","type":"published","date":"2025-12-08T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84214486,"identity":"fc18ded6-78e6-46e0-bf05-2e00a4d8e275","added_by":"auto","created_at":"2025-06-09 10:31:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50250,"visible":true,"origin":"","legend":"\u003cp\u003eInterview topic list\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6600363/v1/f95b999123b31e52124b6aea.png"},{"id":98244912,"identity":"d4ca06cb-e146-45d0-8590-80a492688884","added_by":"auto","created_at":"2025-12-15 16:16:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1492613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6600363/v1/5248d61f-00a4-4e91-b9cc-0d410d5df25e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“You think, like, you’re neutral but you’re not”: A mixed- methods study of racial/ethnic bias in pain assessment, management and treatment in maternal and newborn care in the Netherlands","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStudies indicate racial and ethnic inequities in pain assessment, management and treatment in maternal and newborn care (MNC). Womxn\u003csup\u003e1\u003c/sup\u003e categorized as Black, Indigenous, of Colour or non-Western\u003csup\u003e2\u003c/sup\u003e are less likely to receive pain relief in labour and the post-partum period.(\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Pain is one of the first indicators of medical conditions such as uterine rupture, which is a serious but rare obstetrical complication with risk of severe maternal, foetal and neonatal morbidity and mortality. Timely assessment of pain is imperative as the severity of maternal, foetal and neonatal morbidity and mortality in the case of uterine rupture relies on the time between rupture and the required intervention, i.e. caesarean section (CS).(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Studies in the United States (U.S.) and United Kingdom show higher prevalence of uterine rupture amongst womxn categorised as Black and Asian, and Bangladeshi, Pakistani and Black African respectively.(\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Similarly, a nationwide population based cohort study in the Netherlands showed that uterine rupture was significantly more prevalent amongst womxn categorised as non-Western, in particular the sub-Saharan African category, compared to the Western category.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The reason for the racial and ethnic difference in the administration of pain relief during labour and the prevalence of uterine rupture remains unknown.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBoth race and ethnicity can be considered to be multiple socio-scientific objects, methods, and theories used to categorise populations.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) In health education, research, and care, race and ethnicity are often used interchangeably and with unfixed definitions, leading to diverse definitions and varying interpretations of their sub-categories in different contexts.(\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) The nature of present-day categorisation in racial groups in healthcare is often biological and hierarchical in nature, based on superficial physical characteristics such as skin colour, stature, and facial features. Due to the centrality of race and race-science in genocidal eugenics movements, particularly in the Holocaust, and the discriminatory nature of race after World War II, the term \u0026lsquo;race\u0026rsquo; was considered highly problematic in many countries. In health research the term \u0026lsquo;ethnicity\u0026rsquo; was proposed in the mid-20th century as a substitute for the term \u0026lsquo;race\u0026rsquo;, encompassing a wider range of shared characteristics within populations, including both physical attributes and common cultural characteristics such as language, religion, dietary practices, and nationality.(\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Although ethnicity was introduced to move away from the biological conception of differences between populations, and to acknowledge the complex nature of their shared characteristics, it is commonly used as an equivalent to biological race in health research. This is evident in that racial and ethnic categories are used simultaneously and interchangeably, and that care differences found between ethnic categories are often attributed to biological causes.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRacial and ethnic discrimination in healthcare is known to be a determinant of health inequities.(\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) This phenomenon is referred to as \u0026lsquo;medical racism\u0026rsquo;,(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) where differential treatment is provided that is unfavourable to a group or individual based on their perceived race/ethnicity.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Clear examples are skin colour bias in SpO2 estimation and racial bias in kidney function.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Davis (2019) describes this medical racism in MNC as \u0026lsquo;obstetric racism\u0026rsquo;, identifying seven dimensions including diagnostic lapse, and neglect, dismissiveness or disrespect.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIdeas about biological differences between populations have resulted in the belief that certain groups have a higher pain tolerance during childbirth than others, coined by Davis (2019) as \u0026lsquo;obstetric hardiness\u0026rsquo;.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Historically we see the development of the notion that Black racialized womxn are the most obstetrically hardy, resulting in the stereotype that they feel less pain than other womxn.(\u003cspan additionalcitationids=\"CR34 CR35 CR36\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) This racial thinking informed shockingly unethical practices such as the infamous obstetric and CS surgeries by Marion Sims and Francois Marie Provost, who experimented on non-consenting enslaved Black racialised womxn without the use of anaesthesia.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) As a result, womxn racialised as Black today are still perceived to be \u0026lsquo;uncannily durable\u0026rsquo;, and physicians often overlook their pain based on the belief that there is less urgency for medical intervention.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Even today, the racialised misconceptions about pain tolerance bias the maternal and newborn care professionals\u0026rsquo; (MNCP) pain assessment, management and treatment.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) A frequently cited study by Hoffman et al. (2016) amongst medical students and residents in the U.S. showed that healthcare professionals hold false beliefs about biological differences between Black and White identified people, and demonstrates that these beliefs predict racial bias in pain perception, management and treatment recommendation accuracy.\u003c/p\u003e \u003cp\u003eRacial and ethnic bias in MNCPs\u0026rsquo; pain assessment, management and treatment may explain the inequity in pain relief in labour and uterine rupture due to misinterpretation of the womxn\u0026rsquo;s pain.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) A better understanding of the role of racial thinking and notions of ethnic differences in pain assessment, management and treatment in MNC is required to develop interventions to foster equitable care. In this exploratory study, we aimed to investigate 1) the association between race/ethnicity and language barrier and the difference in the response time of MNCP to pain, and maternal and perinatal outcomes, and 2) explore racial/ethnic bias in pain assessment, management and treatment among MNCP in the Netherlands.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTo further understand the role of racial thinking and notions of ethnic difference in pain assessment, management and treatment in MNC, we employed an exploratory mixed-methods design consisting of two parts: a quantitative and a qualitative study. The quantitative part is a prospective nationwide population based cohort study where cases of uterine rupture were collected through the Netherlands Obstetric Surveillance System (NethOSS) in which we retrospectively investigated the association between race/ethnicity categories and language barrier and difference in the response time to pain and maternal and perinatal outcomes up to 28 days post-partum.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The qualitative part is based on semi-structured interviews with MNCPs to investigate racial and ethnic bias in pain assessment, management and treatment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative study\u003c/h2\u003e \u003cp\u003eFor the quantitative study, we performed an analysis of data identified in a multi-centre nationwide study on uterine rupture in the Netherlands conducted by NethOSS, a registration system for maternal morbidity and mortality in the Netherlands between April 1st 2016 to March 31st 2018.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Data were collected via monthly e-mail to an assigned reporting MNCP (physician or research midwife) at every hospital with an obstetrician-led maternity unit in the Netherlands (2016\u0026ndash;2018, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;86). The MNCPs were asked to report the number of cases of uterine rupture that had occurred in the previous month. Upon notification of a uterine rupture case, anonymised copies of the medical files were requested. These files were specifically asked to include information on general history, obstetric history, current pregnancy, labour management, and maternal and perinatal outcomes. Only cases in which a race/ethnicity category was registered were included in the analyses.\u003c/p\u003e \u003cp\u003eThe determinants examined were maternal race/ethnicity categorisation and language barrier. In the NethOSS database race/ethnicity was registered according to the following predetermined categories related to race, region and country: \u0026lsquo;Caucasian\u0026rsquo;, \u0026lsquo;North African\u0026rsquo;, \u0026lsquo;African other\u0026rsquo;, \u0026lsquo;Asian\u0026rsquo;, \u0026lsquo;Asian other\u0026rsquo;, \u0026lsquo;Latin American\u0026rsquo;, \u0026lsquo;Hindustani\u0026rsquo;, \u0026lsquo;Turkish\u0026rsquo;, \u0026lsquo;Mixed\u0026rsquo; and \u0026lsquo;Unknown\u0026rsquo;. For this registry, it is unknown how patients are categorised by MNCPs, and what these terms mean to them.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) Therefore, we use these categories as information about how womxn were \u003cem\u003eperceived\u003c/em\u003e and categorised by MNCPs or as how these patients \u003cem\u003eself-identified\u003c/em\u003e when asked by the MNCPs. Most of these predetermined categories were too small to conduct statistical analysis. Therefore, for analysis of racial and ethnic bias, we re-grouped them into two broad categories: \u0026lsquo;Western\u0026rsquo; and non-Western\u0026rsquo;, categorising \u0026lsquo;Caucasian\u0026rsquo; as \u0026lsquo;Western\u0026rsquo; and all other categories as \u0026lsquo;non-Western\u0026rsquo;. In the Dutch context, the Western and non-Western categories reflect notions of belonging, who is \u003cem\u003esame\u003c/em\u003e and who is \u003cem\u003eother\u003c/em\u003e.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e In the NethOSS database language barrier was registered as \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no, based on the perceived barrier in verbal communication. Language barrier was included it is known to influence the MNCPs\u0026rsquo; pain assessment.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe following outcomes were examined: care processes, time to CS, adverse maternal outcomes, and adverse perinatal outcomes. Care processes were augmentation of labour, induction of labour, and administration of pain relief. Adverse maternal outcomes were total blood loss, hospital and/or intensive care unit (ICU) admission, medical and/or surgical therapies, and complete or incomplete uterine rupture. Complete uterine rupture was defined as uterine rupture of both the myometrium and the peritoneum and incomplete uterine rupture as uterine rupture of only the myometrium with an intact peritoneum. Adverse perinatal outcomes were neonatal asphyxia, admission to a neonatal intensive care unit (NICU) or neonatology ward due to convulsions, hypotonia, ischemia with ultrasonic abnormalities, hypoxic ischemic encephalopathy and/or multiple organ failure, and perinatal mortality up to 28 days post-partum. Neonatal asphyxia was defined as arterial umbilical cord pH\u0026thinsp;\u0026lt;\u0026thinsp;7.0, base deficit\u0026thinsp;\u0026gt;\u0026thinsp;16mmol/l, Apgar scores (AS)\u0026thinsp;\u0026le;\u0026thinsp;5 at 5 min, resuscitation, or artificial ventilation for \u0026gt;\u0026thinsp;10 min afterbirth, Thompson score\u0026thinsp;\u0026gt;\u0026thinsp;7 or Sarnat score\u0026thinsp;\u0026gt;\u0026thinsp;1. Maternal symptoms of pain were abdominal pain or pain in the area of the CS scar, in which abdominal pain was distinguished from uterine contractions by the presence of abdominal pain between contractions. The time of first complaint of pain was based on the first time abdominal pain was registered in the notes of the MNCP present during labour.\u003c/p\u003e \u003cp\u003eStatistical analysis was conducted using the IBM SPSS Statistics (Version 29). Descriptive statistics were used to describe the demographic characteristics of the dataset and are presented as the number of observations (\u003cem\u003en\u003c/em\u003e) and prevalence (%). For categorical data, differences are presented as odds ratio (OR) with 95% confidence intervals (95% CI).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative study\u003c/h3\u003e\n\u003cp\u003eThe qualitative study consisted of thematic analysis of open-ended, semi-structured interviews conducted with MNCPs in the Netherlands. We used the consolidated criteria for reporting qualitative research to report our data collection and analysis processes.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe study population included obstetricians, midwives, obstetric nurses, and obstetric residents practicing in a hospital in the Amsterdam region. Thirteen interviews were conducted in person or online at the participants\u0026rsquo; request in May 2023, and lasted from 38 to 124 minutes. Participants were recruited using e-mail invitations to hospitals\u0026rsquo; head of obstetric departments and NethOSS representatives, as well as posters distributed via social media and in hospital newsletters.\u003c/p\u003e \u003cp\u003eAll interviews were conducted by SK. The interviews were conducted in English, therefore only participants were included that were comfortable communicating in English. The interviews were guided by the study of Hoffman et al (2016) into beliefs about racialised biological differences amongst medical students and residents in the U.S. With this approach we intended to lower the chance of socially desirable answers by first reflecting with the participants on these beliefs. The participants were presented with a summary of the results of the study by Hoffman et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and were asked what results such a study might yield in the Netherlands and in their hospital, and were then asked questions about their own understanding of ethnicity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe interviews were transcribed verbatim. All interview transcripts were read and discussed by SK, BG and EO. The transcripts were thematically coded using a deductive approach following two dimensions of Davis\u0026rsquo; conceptualisation of obstetric racism (2019) \u0026mdash; diagnostic lapse, and neglect, dismissiveness or disrespect; and an inductive approach following topics that emerged from the interviews. The first transcript was coded by SK and BG independently using Atlas.ti Mac (Version 23.1.1). They discussed the difference in coding. The remaining interviews were coded by SK. The codes were then organised into themes by SK, BG and EO. In the last step, the interrelations between the themes were analysed and the overarching theme was formulated. The themes were discussed with the whole research group.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eResults of the quantitative study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 98 cases of uterine rupture in the quantitative study, race/ethnicity categories were registered in 54 cases, only these cases were included in the analysis. The characteristics of the study population are presented in Table 1. Table 2 presents the descriptive analysis of the care processes, time to CS, maternal outcomes and perinatal outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare processes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRates of augmentation of labour and induction of labour were not significantly different in the race/ethnicity or in the language barrier categories. Pain relief by epidural was significantly less often administered in the language barrier category compared to the non-language barrier category (1/10 (10%) vs 25/42 (54.8%) respectively) (OR 0.08, 95% CI 0.01-0.65). On the other hand, pain relief by remifentanil was significantly more often administered in the language barrier category compared to the non- language barrier category (4/10 (40%) vs 1/42 (2.4%) respectively) (OR 27.33, 95% CI 2.60-287.41). This difference was not significant between the non-Western or Western category.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime to caesarean section\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 25 womxn complained of pain before birth. Although the results were not significant, a trend was seen towards more time between first complaint of pain and the call for CS between the non-Western and Western category. In the non-Western category, the call for a CS was made less frequently under 30 minutes after the first complaint of pain compared to the Western category (3/11 (27.3%) vs 7/11 (63.6%) respectively), and more frequently after 180 minutes following the first complaint of pain (5/11 (45.4%) vs 2/11 (18.2%) respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCS was significantly more frequently performed after 180 minutes following the first complaint of pain in the non-Western category (8/15 (53.3%)) compared to the Western category (1/12 (8.3%)) (OR 12.57, 95%CI 1.28-123.48). No significant differences were found in the association between time between first complaint of pain and decision for CS and language barrier.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse maternal outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of major obstetric haemorrhage was similar among both the non-Western and Western category. The prevalence of complete uterine rupture was higher in the non-Western category compared to the Western category (11/28 (39.3%) vs 7/26 (26.9%) respectively). However, this difference was not significant. A similar trend was seen for the prevalence of complete uterine rupture in the language barrier category compared to the non-language barrier category (5/10 (50%) vs 12/42 (28.6%)) respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse perinatal outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore babies suffered from neonatal asphyxia born in the non-Western compared the Western category (9/28 (32.1%) vs 5/26 (19.2%) respectively), though this difference was not significant. Perinatal admission to a neonatology ward or NICU, and mortality were also not significantly different between the race/ethnicity categories and the language barrier categories.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults of the qualitative study\u003c/p\u003e\n\u003cp\u003eFor the qualitative study, thirteen semi-structured interviews were conducted and analysed. The study population consisted of three obstetricians, four obstetric residents, four clinical midwives and two obstetric nurses. Of the thirteen participants, during the interviews, two self-identified as male and three as having a non-Western migration background. Their years of experience varied between a year and a half and nineteen years.\u003c/p\u003e\n\u003cp\u003eThematic analysis resulted in four themes: racial and ethnic stereotypes; contradictory ideas about racial and ethnic bias in pain assessment, management and treatment; effects of racial and ethnic bias explained away; and assumed protection and threats.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRacial and ethnic stereotypes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStereotypes regarding how womxn of different racial and ethnic groups experience and express pain arose in eleven out of thirteen interviews, these are summarised in table 3. Three observations can be made from these stereotypes. First, the participants used racial and ethnic language interchangeably. Second, the participants talked about White identified womxn as the norm, to whom the pain experience and expression of other racial and ethnic groups was compared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] So to the way we perceive pain in usually black women is different than we perceive in or how we assess pain in, in, in white women, because that\u0026apos;s a reaction we know.\u0026rdquo;\u003c/em\u003e (P4)\u003c/p\u003e\n\u003cp\u003eThird, the participants reported being familiar with various stereotypes about specific racial and ethnic groups and their experience and expression of pain circulating in their professional settings. One common idea that\u0026nbsp;was spoken about was that South Asian, Hindustani and Indian identified womxn were believed to have a lower tolerance for pain and that they were theatrical and dramatic in their pain presentation during labour.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;]\u003c/em\u003e \u003cem\u003eI\u003c/em\u003e\u003cem\u003et\u0026apos;s a joke among midwives. . . that Indian women have a lower... they can\u0026apos;t cope as well with pain as not Indian people.\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e\n\u003cp\u003eWomxn identified as Mediterranean and Arabic were described in a similar manner. Participant 6, for example, spoke about \u003cem\u003e\u0026ldquo;mediterranean fever\u0026rdquo;\u003c/em\u003e or \u003cem\u003e\u0026ldquo;mediterranean presentation\u0026rdquo;\u003c/em\u003e which they described as:\u003cem\u003e\u0026nbsp;\u0026ldquo;\u003c/em\u003e\u003cem\u003eThey\u0026nbsp;really exaggerate or over present their pain in order to get attention from doctors.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eChinese identified womxn, on the other hand, were believed to be very\u0026nbsp;insular in their presentation of pain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBlack and (West) African identified womxn were believed to have a higher tolerance for pain, and that they often expressed pain less than womxn from other racial and ethnic groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI have heard that black women can for example, handle pain better [\u0026hellip;]. Black women are strong, for example\u003c/em\u003e.\u0026rdquo; (P3)\u003c/p\u003e\n\u003cp\u003eTwo participants expressed a feeling of shame when talking about racial and ethnic stereotypes that circulated amongst MNCPs. Participant 8, for example, explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I hear my colleagues saying these things, or and maybe I\u0026apos;ve said that them as well, and I\u0026apos;m not proud of that. But about originally African women sometimes, healthcare professionals we say like \u0026lsquo;she\u0026rsquo;s like this strong African woman, she can take it, she can handle it\u0026rsquo;\u0026rdquo;\u003c/em\u003e (P8)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContradictory ideas about racial and ethnic bias in pain assessment, management and treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough racial and ethnic stereotypes were mentioned in almost all interviews, most participants stated that they treated every womxn equally, regardless of race or ethnicity, and would always administer pain relief upon request. This apparent paradox highlights that, while participants acknowledge the existence of bias and stereotypes, they do not believe these factors impact the care that womxn receive.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] We have 24/7 access to pain medication. We counsel everybody with the same text and same tools.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I do have biases. And I am sure I\u0026apos;m not always aware of them, at the moment [\u0026hellip;]. I think everybody will say it, but I think that it does not influence my care. [\u0026hellip;] Like I think \u0026ldquo;Ohh well, maybe you are being more theatrical about your pain, but ohh well, if you want pain medication, of course you can have it.[\u0026hellip;] Yeah, I think in those instances, that I think they have less pain than they are making to believe, but that will only mean that they will get pain medication sooner [\u0026hellip;].\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Am I influenced by the ethnic background of people when I see them about their pain? I don\u0026apos;t have that idea.[\u0026hellip;] And there\u0026apos;s when people tell me that they are in pain, we talk about it and we come to a solution [\u0026hellip;].Maybe I do but I don\u0026apos;t have the idea that it influences [me].\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P9)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[\u0026hellip;] If someone is in pain, we take it seriously. So you\u0026apos;re not looking at the colour[\u0026hellip;]. (P13)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA few participants acknowledged that their unconscious bias regarding race and ethnicity and pain might influence their practice. P11, for example, explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think I treat people differently. I always tell the patients, like I cannot decide for you. Where is your pain threshold? If you need something, tell me but I will try to guide you through it, and but I can imagine that somewhere in the back of your head it might be. [\u0026hellip;]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e‪\u003cem\u003eAt least that\u0026apos;s what I hope and I and I believe that I do that, but it might be that I\u0026apos;m not aware of that I treat people differently.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P11)\u003c/p\u003e\n\u003cp\u003eSome participants explained that under certain circumstances pain medication would be actively offered to the womxn.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e‪\u003cem\u003eNo, we only give pain medication when women actively ask it, and sometimes you see that women are struggling a lot during birth and then we offer it.\u0026rdquo;\u003c/em\u003e (P5)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipant 4 explained that, due to the individualised approach, they did not believe that racial and ethnic differences in the administration of pain relief was due to racial or ethnic bias.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the participants explained that their assessment, management and treatment of pain was not affected by racial and ethnic stereotypes, and that their administration of pain relief was always guided by individual requests, they also talked about how they perceived differences in pain expression between racial and ethnic groups, and that this sometimes impeded their assessment of pain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] A reason I talked about Chinese people because I think they are the most difficult to assess. So I do think that I might have missed some signals from them, for example, but I also might have underrated pain experience, for example, by Indian people because they feel the pain very heavily. [\u0026hellip;]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7)\u003c/p\u003e\n\u003cp\u003eParticipant 2 talked about sometimes using alternative methods of enquiry to assess the pain of womxn of certain racial and ethnic groups of whom they believed that they expressed pain differently.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think with South Asians [. . .], I try to get more clarification or specification to is it really pain or is it something different? I don\u0026apos;t want to\u0026nbsp;over-treat\u0026nbsp;them, and I do that more with South Asians than with other people from other backgrounds.\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\n\u003cp\u003eAbout half of the participants also talked about how race and ethnicity was used for fast decision making in high-stress and time-constrained circumstances. As participant 6 explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are constantly [...] facing decisions which are very often [\u0026hellip;]black and white, then we may need to have some sort of internal shortcut to make these decisions based on prejudices or based on experience\u0026rdquo;\u003c/em\u003e (P6)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, participant 8 explained that MNCPs include race and ethnicity as part of data collection in their decision-making process,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026apos;s part of our data collection, so our whole profession is about collecting as much data as accurately as you can in a very short time to make sure you can help the patients or treat the patient as best as you can and so therefore we have developed a way of collecting the data by different signs, and those signs evidently make up a puzzle or an assumption in our head, and that is constructed also of our own context of people who we talk to, what we learn, what we know.\u0026rdquo;\u003c/em\u003e (P8)\u003c/p\u003e\n\u003cp\u003eParticipant 11 highlighted how these shortcuts in the\u0026nbsp;decision-making process gives room for racial and ethnic bias.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIf\u0026nbsp;he or she had already looked after some people from India, or some other ethnicities, and they [would always] ask for pain relief [the professional] would maybe easily say like \u0026lsquo;OK, just go for it\u0026rsquo; or actively promote pain relief because maybe in the back of their heads, they believe that this will be the outcome anyway.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P11)\u003c/p\u003e\n\u003cp\u003eThe participants talked about how, even though the administration of pain relief was guided by individual requests, racial and ethnic bias\u0026nbsp;might impact both the type of pain relief that is administered, and whether pain relief is administered at all. For example, participant 7 explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] Chinese people almost never ask for pain medication, so in that way I can understand that they get treated less for pain because they don\u0026apos;t show that they are in pain, and they don\u0026apos;t ask for pain medication. So, it\u0026apos;s more difficult to see if they are in pain. [\u0026hellip;] I do think I might have underestimated their pain. But I also think that sometimes people say they are in more pain than they actually are. Yeah. And it\u0026apos;s also the question - Do you give them the pain relief or not? Do you still wait? [\u0026hellip;] I think it\u0026apos;s always difficult. But I have learned that because pain is so very personal that it\u0026apos;s not up to me to judge if they are in pain, it is up to them if they want pain medication and if they want pain medication if and if they are not very in very much pain, well then for the whole labour experience it could be better to just give them the pain medication. [\u0026hellip;] But I do think, yeah, especially in the, yeah, in the first years after, after my graduation I have misjudged the pain and maybe sometimes even now I have misjudged it, yeah.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7)\u003c/p\u003e\n\u003cp\u003eSome participants expressed biological beliefs regarding the course of labour and talked about how these beliefs affected their pain assessment, management and treatment. For instance, assumptions about how quick womxn from certain racial and ethnic groups give birth influence decisions about pain relief. Specifically, if womxn are believed to biologically give birth quickly, the MNCP will administer remifentanil instead of an epidural.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eMany\u0026nbsp;of my colleagues think that women from West Africa have a bit more of a curved spine. [\u0026hellip;] So, it takes a while but when [the baby is at the curve], the delivery is fast. [\u0026hellip;]. It might impact of course when you think \u0026lsquo;OK, once she\u0026apos;s there then delivery goes fast so pain medication is not needed\u0026rsquo;. Yeah it can impact of course. [\u0026hellip;] I personally do not think that it\u0026apos;s about biological differences. [\u0026hellip;]But I do think in the Netherlands people think biological differences are also important.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P4)\u003c/p\u003e\n\u003cp\u003eParticipants stated that although MNCPs believe they treat everyone the same, beliefs about race and ethnicity, and pain experience and expression can influence their treatment of womxn. Participant 4 explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Y\u003c/em\u003e\u003cem\u003eou think like, you\u0026apos;re neutral, but you\u0026apos;re not. [\u0026hellip;] We\u0026nbsp;think that we\u0026apos;re treating everyone the same, but we\u0026apos;re not. And we don\u0026apos;t want to express that we think there are differences [\u0026hellip;] but I think they\u0026apos;re more unconscious than we think [\u0026hellip;] [It is] socially more acceptable to say everyone is the same, so we\u0026apos;re trying to express that as well, but there are many unconscious biases and beliefs that influence the way we assess pain and advise pain killers or not during labour.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffects of racial and ethnic bias explained away\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants attributed differences in the assessment, management and treatment of pain between racial and ethnic groups to reasons other than the presence of stereotypes and assumptions associated with race/ethnicity, and in doing so, insinuated that racial and ethnic discrimination does not exist in Dutch MNC.\u0026nbsp;The most commonly cited reasons were womxn\u0026apos; individual profile, culture, language barrier and socio-economic position (SEP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividual profile\u003c/p\u003e\n\u003cp\u003eIndividual profile was used to describe differences that exist between individuals, regardless of race and ethnicity. Participants 8 and 12, for example, explained how individual profile influenced their assessment, management and treatment of pain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] It\u0026apos;s not always the pain disparities between different ethnic groups, but rather between people. [\u0026hellip;] People\u0026rsquo;s pain, acceptance or pain levels or the way they deal with pain. [\u0026hellip;] We also use assumptions about people about also, whether they, what kind of life they have, what is their background, have they been to the hospital very often with this kind of pain? Do they, what is my personal relation to them? So do I feel like I should take the pain very seriously, or do I think it\u0026apos;s more of a show, a dramatic show.\u0026rdquo;\u003c/em\u003e(P8)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, if someone has intellectual disabilities and if someone is sometimes, like maybe more anxious or more afraid of labour, sometimes we do, for instance, ourselves suggest that they take pain relief early, earlier, for instance, that maybe that will help them, for instance to be more relaxed and be more trusting of the process.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P12)\u003c/p\u003e\n\u003cp\u003eP5 described that, for instance, some people do not express their needs during labour, using the example of undocumented womxn in the Netherlands, and their fear of being deported.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;]When they are saying things that they don\u0026apos;t like or if they don\u0026apos;t express themselves in the way that they should be that they are scared that you will go to the IND to tell that they are here illegal or something like that and those kind of things that you are maybe going to the police or something like that to say that they are here and they are not with the good papers..\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e\n\u003cp\u003eCulture\u003c/p\u003e\n\u003cp\u003eMany participants associated pain experience and expression to culture rather than race and ethnicity. They stated that, in their opinion, cultural differences influence how womxn respond to pain.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] There are cultures where it\u0026apos;s very common to scream a lot when you\u0026apos;re having pain or to express yourself a lot when you\u0026apos;re having pain. And there are cultures where it\u0026apos;s much more common to withhold it in yourself and to keep it small, to not overgo or not letting it [show] too much.\u0026rdquo;\u003c/em\u003e (P5)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No, I don\u0026apos;t think it really is the ethnicity. I do think it\u0026apos;s more the way how she responds to pain, which can be different in different cultures. I don\u0026apos;t think it\u0026apos;s ethnicity at itself.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] A woman coming from Africa just here knows the culture that how women birth, give birth in Africa. It\u0026apos;s like you never hear them complain. They just give birth. It\u0026apos;s part of life. They go for it and that\u0026apos;s OK [\u0026hellip;]. And then when you see women who have been here for their whole life or a longer period, that they know what the options are, and I think they\u0026apos;re\u0026hellip; How do you say it\u0026hellip; their perception or their\u0026hellip; they know there are different options for pain relief that they are more willing to ask for it or want help or things like.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P10)\u003c/p\u003e\n\u003cp\u003eParticipants 2, 7 and 8 further explained how culture might influence MNCPs pain assessment, management and treatment by suggesting that within certain cultures, the expression of pain is either understated (P7), \u0026nbsp;exaggerated (P8) or a call for attention or help (P2). In their references to culture, these participants used racial/ethnic labels.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] I think different cultures also respond differently on pain, but maybe . . . \u0026ldquo;response\u0026rdquo; is [not] the right word but how they show that they are in pain, there are very big differences. But I am a bit shocked that the treatment is different because I do think that if somebody wants pain medication and they ask for it, well, that\u0026apos;s very personal. If you feel pain or if you don\u0026apos;t feel pain, which doesn\u0026apos;t really depend on your ethnicity. [\u0026hellip;] Chinese people who don\u0026apos;t show their pain and who don\u0026apos;t ask for pain [medication], I think sometimes they will be entitled to have more pain medication than they get now. And for example the Indian people, they have overall, they feel a lot of pain very quickly. So I can imagine that they sometimes will get pain relief very early in their delivery. But also sometimes . . . healthcare workers think well, we can probably wait a little bit longer because of the culture where, well it\u0026apos;s not very nice to say, I don\u0026apos;t know how to say it in good English, but with this construction they sometimes think that they are going to die because of the pain and they are very shocked by the pain. But I do think that sometimes they get their pain relief a little bit later because it\u0026apos;s a really cultural thing, which all Indian people have that they experience a lot of pain.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So often heard things are \u0026lsquo;ohh yeah, Arabic woman women are usually very dramatic in their presentation of pain\u0026rsquo;, and this affects how healthcare providers are assessing pain for sure, 100% in every other situation.\u0026rdquo;\u003c/em\u003e (P8)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What I think is that people from India or Pakistan that they use pain, or they express pain with a different purpose [\u0026hellip;]. I think it\u0026apos;s also a way to communicate to their community that they need attention or help. So that it\u0026apos;s not only that they feel that they need to have different pain treatment or medication, but that they need, yeah, also attention or help or a cry for help.\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\n\u003cp\u003eDifferences in the administration of pain relief was also cited to be related to the birthing womxn\u0026rsquo;s unfamiliarity with Dutch cultural practices of pain relief during labour (P4), and the healthcare system (P1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Of course in the Netherlands more than 50% of the women deliver with epidural so, and depending on where the woman is from, it\u0026apos;s not even possible, or way less, so if it\u0026apos;s the woman\u0026apos;s choice, of course, that\u0026apos;s the most important thing. So [...] yes, [black immigrants] want it less than white women.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P4)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] They don\u0026apos;t really know what the options are. And they do know that maybe in their home country that pain relief is more difficult to get or everything, so they won\u0026apos;t ask as quickly as people maybe from here or like people are super well informed. So I think that might be, that might be something that they will as. [\u0026hellip;].\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P1)\u003c/p\u003e\n\u003cp\u003eThe participants described scenarios whereby womxn of non-Dutch origin perceive a power imbalance when interacting with Dutch MNCP. For example, participant 4 talked about their observation of African identified womxn, who view Dutch MNCPs as officials, and so are hesitant to ask for assistance during labour:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[Women from Nigeria and Ghana] just go through labour a little bit more like isolated, so not very talkative [\u0026hellip;] or asking much, [they] even don\u0026apos;t ask the nurse for anything and so they\u0026apos;re a bit more like, we call it in Dutch, we say \u0026lsquo;onderaan\u0026rsquo;\u0026hellip; . They see the healthcare workers as . . . very official and they don\u0026apos;t want to ask them for anything extra. So, they just undergo labour instead of actually receiv[ing] coaching from us.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P4)\u003c/p\u003e\n\u003cp\u003eParticipant 1 discussed the pitfalls of attributing pain experience and expression solely to culture,\u0026nbsp;as it may overlook many other factors that might influence someone\u0026rsquo;s health and the care they receive, such as accessibility of MNC and the quality of care provided:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] \u0026ldquo;It\u0026apos;s just their culture\u0026rdquo; is such a way how you can stereotype people and not be curious to what is really going on, what care do we provide? How is the quality of care? How\u0026apos;s our health system working? It\u0026apos;s such it can be such a lame excuse to not talk about all those more complex issues that you cannot solve tomorrow that are very difficult to tackle, but we need to look into and be uncomfortable.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\n\u003cp\u003eLanguage barrier\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLanguage barrier was stated by nine out of thirteen participants as a barrier that could result in under administration of pain relief, for example leading to a scenario where the anaesthesiologist may be unwilling to administer pain relief if the MNCP cannot effectively communicate the risks to the birthing womxn.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;]\u0026nbsp;\u003c/em\u003e\u003cem\u003eIf we can\u0026apos;t communicate well enough with them, our anaesthesiologist is sometimes having issues or doesn\u0026apos;t want to give them an epidural because they say, \u0026lsquo;well then I can\u0026apos;t counsel them good enough about possible risks, or they can\u0026apos;t tell, the patients can\u0026apos;t tell the professionals well enough when something is the matter\u0026rsquo;, so when they start to feel short of breath that maybe their peripherals too high or they have a spinal block or whatever, and they\u0026apos;re and the patients are not well enough to give those signals to the to the healthcare professionals because of language issues. [\u0026hellip;] Yeah, I think that really affects our pain assessments and treatment.[\u0026hellip;]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P2)\u003c/p\u003e\n\u003cp\u003eParticipants mentioned that the primary tool to overcome the language barrier was to use a translator available by phone, although the infeasibility of this was also highlighted due to time constraints.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If a Polish lady comes and who doesn\u0026apos;t speak a word of Dutch, it\u0026apos;s also very difficult to see if she needs pain medication, but also to explain what kind of pain medication do we have which is good for her. How do you do an informed consent if you don\u0026apos;t talk the language? You can call the \u0026lsquo;Tolk\u0026rsquo; telephone, the translator. But it also takes time.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7)\u003c/p\u003e\n\u003cp\u003eSocioeconomic Position\u003c/p\u003e\n\u003cp\u003eSEP was mentioned by seven out of thirteen participants as a determinant of differential experience and expression of pain, and MNCP\u0026rsquo; pain assessment, management and treatment of pain. Two participants posited that the occurrence of differences in pain relief administration has more to do with SEP than with race and ethnicity. In response to a question concerning the reasons for differences in pain assessment, management and treatment in the U.S, participant 5 stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think that it\u0026apos;s only racial, it also has to do with the [economic] status. But that\u0026apos;s the same as here I think, because it doesn\u0026apos;t matter where you\u0026apos;re from.\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e\n\u003cp\u003eParticipant 5 further posited that those identified as having a lower SEP have more experiences of overcoming difficult things in life and therefore may cope more easily with pain in childbirth, while conversely those whose first time it might be to experience such pain during labour and birth, may more quickly choose to use pain relief during labour.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe participants additionally spoke about their observations of womxn with more wealth access having more access to social support such as a doula (P5). Again, reflecting on the impact that social support has on how a womxn experiences labour, participant 7 posited that\u0026nbsp;in their experience the \u003cem\u003e\u0026ldquo;social environment\u0026rdquo;\u0026nbsp;\u003c/em\u003ematters a lot, as womxn who \u003cem\u003e\u0026ldquo;have a lot of support, then they might need less pain medication because they have the support system, but if they are all alone, then they might need some pain medication earlier.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7)\u003c/p\u003e\n\u003cp\u003eParticipant 6 spoke about their experiences providing care to people identified as having a higher SEP who, in contrast to those identified as having of a lower SEP, display entitlement to timely care. Similarly to participant 5, they posited that this may also coincide with a higher use of pain medication.\u0026nbsp;Although they mentioned that this phenomenon can occur in womxn of any race and ethnicity, in their experience \u003cem\u003e\u0026ldquo;it\u0026rsquo;s primarily white, younger professionals [\u0026hellip;] [who]\u0026nbsp;\u003c/em\u003e\u003cem\u003ethink they earn something and that they get something now, even though they\u0026apos;re not as much in pain and that doesn\u0026apos;t matter.\u0026rdquo;\u003c/em\u003e (P6)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssumed protection and threat\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe participants described different factors that they believed prevented or (re)produced bias in pain assessment, management and treatment. Protective factors included representation in the MNC workforce and diversity in the patient population, while perceived threats included medical education, hierarchy and MNCPs working in isolation.\u003c/p\u003e\n\u003cp\u003eRepresentation\u003c/p\u003e\n\u003cp\u003eAlmost all participants cited diverse perspectives in the workplace as being pivotal to developing a less biased worldview and providing better care to womxn of all racial and ethnic backgrounds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] I think if you treat people differently that it\u0026apos;s a part of racism and I, but I don\u0026apos;t think that they are, that it\u0026apos;s intended racism. But if you don\u0026apos;t see that anything but your own normal is normal, then you might mistreat others, or at least don\u0026apos;t give them the same treatment.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026apos;s so important that you have this diversity [\u0026hellip;] if it\u0026apos;s cultural background or ethnicity or gender or whatever so you can just talk and be uncomfortable with each other about things to make sure you talk about things so you can learn more. And I think that will make us all better humans and provide better care as well, because then there are things that I don\u0026apos;t see as well [\u0026hellip;] then I need a colleague who sees from another perspective.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P1)\u003c/p\u003e\n\u003cp\u003eThe MNCPs\u0026rsquo; own race and ethnicity were noted by the participants as important determinants of pain assessment, management and treatment. The participants described differential treatment of womxn whose race/ethnicity differed from their own, due to a lack of understanding outside of \u0026ldquo;\u003cem\u003eyour own normal\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3) and decreased empathy, stating that you will feel frustrated sooner with womxn you cannot relate to. According to one participant, professionals tend to \u003cem\u003e\u0026ldquo;care better for people who look like [them].\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P1).One participant, who self-identified as Black, explained that they felt more responsible for the outcome\u0026nbsp;when they\u0026nbsp;identified with the womxn they care for:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;]I don\u0026apos;t know if the ethnicity plays a role, but I feel an extra importance to take extra good care of my sisters [\u0026hellip;] So, if that\u0026apos;s not the case, I will be extra disappointed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3)\u003c/p\u003e\n\u003cp\u003eSome participants stated that the diversity in cities like Amsterdam is not represented in the care that is delivered or the health research that is being carried out. Participant 8, for example, explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because our care in the past decades has been mainly focused, also the research that has been formed, mainly focused on one ethnic group and now there\u0026apos;s a lot of more diversity coming in, but [it\u0026rsquo;s] still not a good representation of our population\u0026rdquo;\u003c/em\u003e (P8).\u003c/p\u003e\n\u003cp\u003eA lack of diversity in the workplace was further talked about in relation to the lack of diversity among medical students, and especially about the fact that students with a migration background are underrepresented in training for medical specialisation. Participant 3, for example, explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] 25% of the students are of also migration background, but when you go and look at the specialties, I think it\u0026apos;s also specialties in the hospital and the one[s] who become gynaecologists, who become surgeons, who become, well, a medical specialist in the hospital, they are, that is 4% that have a migration background. And so, they call it a bit of a \u0026lsquo;leaky pipeline\u0026rsquo; and we [haven\u0026rsquo;t] fully grasped why that is.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3)\u003c/p\u003e\n\u003cp\u003eParticipant 4 believed that due to the lack of diversity in the Dutch medical education system, healthcare professionals will eventually conform to the norm.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] You\u0026apos;re forced into this path of 12 years indoctrination, so we all end up like the same sausage about how to, yeah, how to do your work. [\u0026hellip;] If you are Black, but you\u0026apos;ve been trained six years by white doctors, then at the end of the road you think like a white doctor.\u003c/em\u003e (P4)\u003c/p\u003e\n\u003cp\u003eDiverse population\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany participants described that working with the diverse population of Amsterdam had accustomed them to the different needs of people with different racial and ethnic background, preventing racial and ethnic bias in pain assessment, management and treatment. They used this narrative as an argument to deny systemic racial and ethnic discrimination in the Netherlands.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] Because we have such a large amount of people from all over the world, I think we\u0026apos;re more used to that. [\u0026hellip;] So I think my opinion is different and maybe milder, more outgoing or more welcoming to other ethnicities, where my family, they are, work wise, not seeing that many people from a different background.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] The population is almost only people with different ethnicities. And so that\u0026apos;s a norm there. So that\u0026apos;s why I don\u0026apos;t think that there will be a lot of bias.\u003c/em\u003e (P3)\u003c/p\u003e\n\u003cp\u003eMedical education\u003c/p\u003e\n\u003cp\u003eThe participants spoke about medical education as an issue that reinforced racial/ethnic bias. Both participants 4 and 6 referred to the learned beliefs that healthcare professionals acquire throughout their education. In recalling a lecture where the idea of \u0026ldquo;\u003cem\u003emediterranean fever\u003c/em\u003e\u0026rdquo; was presented, participant 6 suggested that internal biases within the profession can be learned through education.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] That we sort of have internal biases that we apparently learn. Sort of, because I think our profession is something that we learn, it\u0026apos;s not something that we\u0026apos;re born with [\u0026hellip;].\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\n\u003cp\u003eTwo participants also spoke about the influence that your peers can have on how you carry out your work. Participant 1 suggested that inexperienced medical professionals may be influenced by the biased beliefs of more senior colleagues. Similarly, participant 6 explained that during collaboration in decision making and receiving guidance from peers, you are influenced by the people with whom you work with and within this dynamic, biased beliefs can be shared.\u003c/p\u003e\n\u003cp\u003eParticipants spoke about their own efforts to educate, and of efforts that are made within medical education to address racial/ethnic bias, such as a presentations conducted by obstetric interns and during symposiums that aim to create awareness around pain perception and bias in healthcare.\u003c/p\u003e\n\u003cp\u003eParticipant 6 used an example to describe how educators sometimes reinforced racial and ethnic stereotypes about their own racial and ethnic background.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I thought it was a very interesting class from two experienced patient representatives who were both Turkish and Moroccan [\u0026hellip;]. [They] told us about sort of presentation from their perspective that people in their countries [\u0026hellip;], she had a good example, I can only do it in Dutch. But she was like (demonstrated a person shouting for pain, spoke in Dutch) to get attention and to actually sort of get help and that that is something that perhaps if you know that they had to do that in their hospitals, for example in Morocco, then they\u0026apos;ll have to do it here as they tend to do it here as well and that we perhaps feel that it\u0026apos;s a little bit too much for us or too over exaggerated.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P6)\u003c/p\u003e\n\u003cp\u003eMNCP working in isolation\u003c/p\u003e\n\u003cp\u003eA few participants described how pain assessments are conducted by MNCPs in isolation from one another, which makes the assessment vulnerable to stereotypes. According to participant 3 and 4 for example:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] The reality of the pain assessment happens in the room in which I don\u0026apos;t see the patient, or the patients\u0026apos; needs.\u003c/em\u003e (P3)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] I usually do not observe my colleague the midwife when she goes to [the] patient. So I only hear it during like when the shift ends and you discuss patients, some sometimes you just discuss how women express pain and then maybe, yeah, advise on pain medication. And so only I only . . . hear it in second hand.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P4)\u003c/p\u003e\n\u003cp\u003eHierarchy\u003c/p\u003e\n\u003cp\u003eThe participants described how power imbalance between healthcare professionals can play a role in differential treatment. These imbalances arise due to perceived or actual differences in levels of authority between MNCPs, and result in some of them being unwilling to speak up and address issues of racial and ethnic bias as they arise. P1 explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] It\u0026apos;s difficult from bottom up to speak up to the medical hierarchy. So, we can really work to making it a flat structure. [. . .] It\u0026apos;s more difficult to talk to your supervisor, you feel like, \u0026lsquo;can I say everything or not?\u0026rsquo; [. . .] [Sometimes because] of education or sometimes [because] of different roles in being a nurse [or a] midwife, so it might also be that if you\u0026rsquo;re a supervisor you do not hear everything from the other professional roles that [are] there.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\n\u003cp\u003eA few participants also mentioned their efforts to speak up when they witness bias. P8 explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;At handovers if something is being said like [\u0026hellip;] \u0026lsquo;she\u0026apos;s a strong African woman, she doesn\u0026apos;t need it\u0026rsquo;, that can be said. Usually, if I hear that now I\u0026apos;ll try to raise my voice, speak up and say, \u0026lsquo;but that\u0026apos;s an assumption or do you have a more subjective way of judging, or did she say she doesn\u0026apos;t want it?\u0026rsquo; But that\u0026apos;s very hard. I can\u0026apos;t portray myself as the person who does it all the time or is continuously aware of that. No, definitely not.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P8)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e In this mixed methods study, we used Dutch maternal and newborn care (MNC) as a case to further understand racial/ethnic inequity in pain assessment, management and treatment. This study offers novel insights into racial and ethnic difference in timely care provided by maternal and newborn care professionals (MNCPs) in response to womxn\u0026rsquo;s pain expression in cases with a uterine rupture, the stereotypes and assumptions held by MNCPs associated with race/ethnicity and pain experience and expression, and how these affect their assessment, management and treatment of pain in the Netherlands. Our findings highlight the importance of further research into racial and ethnic disparities in MNC from an equity perspective.\u003c/p\u003e \u003cp\u003eOur quantitative results indicated that in the non-Western category the response time to performed caesarean section (CS) after the first complaint of pain was significantly more often three hours or longer in the non-Western category compared to the Western category. Our qualitative analysis of interviews with MNCPs revealed the simultaneous presence \u003cem\u003eand\u003c/em\u003e unawareness of stereotypes and assumptions among MNCPs about how womxn of different racial/ethnic groups experience and express pain, and how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment. MNCPs\u0026rsquo; differences in pain assessment, management and treatment related to race/ethnicity were explained by most of the participants to be a result of other factors than their own racial/ethnic stereotypes and assumptions leading to discriminatory care, including womxn\u0026rsquo;s individual profile, culture, language barrier and social economic position (SEP). Finally, the participants believed that diversity in the MNC workforce and in the patient population they worked with were protective factors against bias in pain assessment, management and treatment, whereas medical education, pain assessment by an individual MNCP, and medical hierarchy were perceived as threats. The results of this mixed methods study provide a starting point to investigate racial and ethnic inequity in MNC in the Netherlands and to address the ways that these differences can be mitigated.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eRace/ethnicity based maternal and newborn care\u003c/h2\u003e \u003cp\u003eRace and ethnicity as a fixed biological determinant of health has been scientifically challenged and is widely considered outdated.(\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) In medical practice, education and research, however, race and ethnicity continue to be viewed by some as a reflection of fixed biologic differences.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHealth research using race/ethnicity as biological concepts can lead to inequitable care and unnecessary harm amongst racially and ethnically marginalised groups when translated into clinical practice.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) An example of this is the use of race and ethnicity in algorithms which individualise risk assessment and guide clinical decision making. In MNC for example, Vaginal Birth After Caesarean (VBAC)-algorithms are used to counsel womxn with a previous CS to predict the likelihood of successful vaginal birth. These algorithms suggest that the likelihood of successful VBAC is lower amongst racially and ethnically marginalised groups. As a result, womxn in, for example, African-American or Hispanic descent category could be directed into choosing an elective CS instead of VBAC, which in turn results in higher CS rates with the associated risk of morbidity.(\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) These algorithms are also used in Dutch MNC.(\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFurthermore, studies concerning race/ethnicity in healthcare indicate unequal treatment of patients by healthcare professionals based on their race/ethnicity leading to worse health outcomes.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e) This is also the case in the Netherlands.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR60\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) A study by Zemouri et al., for example, showed that almost half of Dutch patients categorized as having a migration background, reported experiencing discrimination from healthcare professionals. Concerning pain, 26% of the study participants reported that they had been told by healthcare providers that their complaints resulted from their cultural tendencies and were exaggerated.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) This is in line with the results of our qualitative results. Additionally, our quantitative results point to a significant delay in the time until a CS is performed in the non-Western category compared to the Western category, which may indicate a diagnostic lapse based on race/ethnicity. These findings are in line with existing literature that attest that pain amongst racially/ethnically marginalised womxn is often minimised and undertreated.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eRacial/ethnic neutrality and cognitive dissonance\u003c/h2\u003e \u003cp\u003e Notably, in our qualitative study most of the participants disavowed that their assessment, management and treatment of pain was negatively impacted by womxn\u0026rsquo;s race/ethnicity, while at the same time describing racial and ethnic stereotypes and assumptions regarding womxn\u0026rsquo;s experience and expression of pain. Disavowal of racial and ethnic discrimination seems to be an important facilitator of inequity in healthcare.(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) This disavowal may be explained by a systemic belief of neutrality towards race and ethnicity, or cognitive dissonance.\u003c/p\u003e \u003cp\u003eIn the Netherlands, the neutral position of the Dutch general population concerning race and ethnicity is explored by Gloria Wekker in her book \u0026lsquo;White Innocence\u0026rsquo;.Wekker argues that as a result of four hundred years of Dutch imperial rule, a strong paradox has arisen, specifically among the White racialised population, in which race is both acknowledged and denied. Whiteness is not acknowledged as a racialised/ethicised positioning, and the Dutch think of themselves as a just and ethical nation, colour-blind and free of racism.(\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) This systemic racial and ethnic neutrality is not limited to the Netherlands and is thought to only increase the possibility of bias.(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe systemic neutral position towards race/ethnicity can lead to cognitive dissonance when confronted with race/ethnicity. Cognitive dissonance is the discomfort that results from a person holding contradictory beliefs or behaviours.(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) People are so highly motivated to resolve cognitive dissonance, they will often disregard evidence supporting one of the beliefs. This paradox might be explained by the theory and research which indicates that humans have at least two cognitive systems. One of the systems produces explicit beliefs and attitudes by processing stimuli in a conscious, controlled, and effortful way. The second system applies implicit knowledge and responds to stimuli rapidly, effortlessly and automatically. These implicit behaviours may contribute to unequal care of which a physician is not aware.(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) Some of the participants in our qualitative study reflected on implicit attitudes by addressing the process of quick decision-making, where innate beliefs about race and ethnicity might play an even more important role.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eCulturalization of racial and ethnic inequity\u003c/h2\u003e \u003cp\u003eThe participants in our qualitative study ascribed difference in pain experience, expression, and the administration of pain relief to womxn\u0026rsquo;s culture. This culturalization of pain is based on the belief that cultural differences exist between different ethnic groups influenced by specific traits, customs, behaviours, beliefs and norms.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) Culture is believed to influence how individuals experience and respond to pain, including their ability to seek treatment and when to do so.(\u003cspan additionalcitationids=\"CR69\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e) Therefore, it is recommended to include the possibility of cultural differences in pain assessment, management and treatment. A holistic and culturally sensitive approach is believed to improve care within a diverse patient population.(\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e) In this context, culture should be regarded as a dynamic concept that encompasses the experiences, practices and knowledge and actions of individuals, through which they construct an ongoing sense of themselves and an understanding of others. From this perspective, culture is the product of interactions that are continuously redefined and changed. In applied research, however, this nuance is often lost, and an essentialised approach to culture is often used when examining ethnic disparities in health and health care access. Referred to as the \u0026lsquo;\u003cem\u003eculturalistic fallacy\u0026rsquo;\u003c/em\u003e, it is argued that such an essential approach to culture can increase the possibility of generalization and stereotyping by healthcare professionals overlooking the variability within specific groups, and the social, political and economic determinants of health disparities. This dynamic was also seen in our study, where participants often talked about cultural differences, while using racial/ethnic labels. While culture refers to a repertoire of actions, ethnicity refers to a shared belief among members of a group regarding their common descent, whether self-identified or socially assigned.(\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Furthermore, the participants not only explained away differences in pain experience, expression, and the administration of pain relief with womxn\u0026rsquo;s culture, but also with their individual profile, language barrier and SEP. This approach may distract from addressing systemic racial and ethnic discrimination as the root cause of the inequity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eProfessional diversity and race conscious education\u003c/h2\u003e \u003cp\u003eAchieving equity in MNC requires critical reflection on the role of MNC in shaping, causing, maintaining, sustaining, and (re)producing g racial and ethnic inequity.(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) In our qualitative study, the participants did so, and mentioned a lack of diversity and inclusion in medical education, research, and workplaces as threats to equity.\u003c/p\u003e \u003cp\u003eCurrently, there is a lack of diversity among physicians and midwives, which is believed to result in part from a decline in diversity from racialized and minoritized groups in the selection processes.(\u003cspan additionalcitationids=\"CR76 CR77\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) It is believed that a more diverse workforce will result in higher quality of care and better healthcare outcomes. Studies show, however, that in the absence of an inclusive medical culture, where there is no room for diverse ways of seeing, knowing and doing, the education of a diverse student population will result in a homogenous workforce.(\u003cspan additionalcitationids=\"CR80 CR81 CR82\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFurthermore, race/ethnicity-based medicine is unfortunately still strongly present in medical education and practice and can reinforce racial/ethnic biases among (future) MNCPs. Students learn to biologically associate race/ethnicity with disease conditions, such as Sickle cell anaemia, hypertension and labour dystocia. Race and ethnicity can therefore be wrongly seen as independent risk factors for health and disease.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e) Race and ethnicity were found to be presented in medical school lectures without context or justification and were even used as diagnostic hints in medical school exams in the U.S.(\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e) In Dutch medical schools, the curriculum was also found to lack diversity-related content addressing the concepts of race and ethnicity as well as gender, sexuality and social position.(\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e) It is argued that, instead of using race/ethnicity-based medicine which presumes biological differences, we should work towards race/ethnicity-conscious medicine, From this approach race and ethnicity are considered social and power constructs. By analysing structural discrimination based on race/ethnicity in healthcare we can work to reduce racial health inequities.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eThis study is the first study on racial and ethnic bias in pain assessment in MNC in the Netherlands. A strength of this study is the mixed methods approach. The quantitative data was retrieved through a prospective, population based and nationwide cohort study of uterine rupture in the Netherlands. In the qualitative study, we achieved diversity among the interview participants (gender, ethnicity, and profession).\u003c/p\u003e \u003cp\u003eA limitation of this study is the small sample size (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;54) of the quantitative data, which restricted the ability to perform subanalyses and achieve significant results or to conduct logistic regression analysis. This limitation persists despite NethOSS being a validated surveillance system, covering a two-year period including cases of uterine rupture which have a relatively low prevalence in the Netherlands. Furthermore, we had to rely on information that could be found in womxn\u0026rsquo;s files, and we were, due to privacy rules, not able to interview the womxn or MNCP involved in collecting the data to clarify information. Some variables, associated with racial/ethnic discrimination, such as body mass index and socio-economic position, were not routinely recorded in the womxn\u0026rsquo;s files. As a result, we were unable to use these variables in our analysis or to adjust for possible confounders. Using information from womxn\u0026rsquo;s files was specifically problematic for the variable race/ethnicity because it was registered imprecisely and inconsistently. Not only was race/ethnicity not always registered, the categories for registration in the National Perinatal Registry (Perined) consisted of countries, continents, and racial groups. Furthermore, in Perined, race/ethnicity is assigned by womxn\u0026rsquo;s MNCP, usually based on appearance, name, and/or information provided by women. In Statistics Netherlands (CBS), on the other hand, race/ethnicity is registered more consistently, based on country of origin of a person and their parents.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e). At present we were unable to recover from womxn\u0026rsquo;s files how race/ethnicity was assigned or to cross-check the information with CBS as all files were anonymized. Therefore, we used a binary construction of race/ethnicity. This may have conveyed the impression that these groups are homogeneous. Looking at differences in more precise racial/ethnic categories would have allowed for a more nuanced interpretation of the results. The sampling bias in the qualitative study should also be acknowledged. Although knowledge of English in the Netherlands is at a high level, conducting the interviews in English may have impacted the willingness of MNCPs to participate, and therefore bias the sample. Lastly, this study was conducted in the Amsterdam region where there is more population diversity compared to many other cities in the Netherlands. This restricts the generalisability of the study results. We therefore, recommend further research which includes MNCPs from various regions across the Netherlands. Additionally, follow-up research into the experiences of womxn is necessary.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe aim of this study was to investigate racial and ethnic bias in pain assessment, management, and treatment in maternity and newborn care (MNC). Our mixed-methods approach revealed quantitative results indicating that caesarean section was significantly more frequently performed in more than 180 minutes after the first complaint of pain in the non-Western category compared to the Western category. The qualitative results revealed the simultaneous presence \u003cem\u003eand\u003c/em\u003e unawareness of racial/ethnic stereotypes and assumptions among MNCPs about pain experience and expression, and provided insight in how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment. MNCP\u0026rsquo;s differences were explained by most of the participants to be a result of other factors than their own racial/ethnic stereotypes and assumptions leading to discriminatory care, including womxn\u0026rsquo;s individual profile, culture, language barrier and socio-economic position, which may distract from addressing systemic racial and ethnic discrimination as the root cause of the inequity. Our findings underscore the disavowal of the role of racial thinking and notions of ethnic differences in pain assessment, management, and treatment, and highlights the need for critical reflection on the role of MNC in shaping, causing, maintaining, sustaining, and (re)producing racial/ethnic inequity, despite MNCPs\u0026rsquo; equitable. The results of this study provide a starting point to further investigate racial and ethnic inequity in MNC, and together, with MNC professionals and womxn, to address the ways that these differences can be mitigated.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and participants consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted for studies using NethOSS data by the Institutional Review Board of University Medical Centre Utrecht (reference number 14-127). According to the conditions of the Medical Ethics Review Committee (METC) this study falls within the scope of non-WMO research and does not need to be authorised by the METC to proceed.\u003c/p\u003e\n\u003cp\u003eAll participants of the interviews were required to sign an informed consent form prior to the interview. At the beginning of the interview, participants were made aware of the nature of the study and reminded of their voluntary participation in the study in addition to their right to withdraw participation at any time during the interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSK, EO, BG, AdJ and KB designed the study. Qualitative data was collected and analysed by SK and transcripts were reviewed and discussed by SK, BG, EO and AH-P. EO collected and analysed the quantitative data. AdJ and KB contributed to the development and conduct of the study. EO, BG, AH-P and SK wrote the first draft of the manuscript. BG, EO, AH-P, SK, AdJ and KB contributed to the interpretation of the data, gave feedback on earlier versions of the article and approved the last version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all healthcare givers in Dutch hospitals for cooperating with the registration process and data collection of cases of uterine rupture. We would like to thank all interviewees for their time and openness during interviews. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMorris T, Schulman M. Race inequality in epidural use and regional anesthesia failure in labor and birth: an examination of women\u0026apos;s experience. Sex Reprod Healthc. 2014;5(4):188-94.\u003c/li\u003e\n\u003cli\u003eRust G, Nembhard WN, Nichols M, Omole F, Minor P, Barosso G, et al. Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery. Am J Obstet Gynecol. 2004;191(2):456-62.\u003c/li\u003e\n\u003cli\u003eBadreldin N, Grobman WA, Yee LM. Racial Disparities in Postpartum Pain Management. Obstet Gynecol. 2019;134(6):1147-53.\u003c/li\u003e\n\u003cli\u003eGu\u0026eth;mundsd\u0026oacute;ttir E, Nieuwenhuijze M, Einarsd\u0026oacute;ttir K, H\u0026aacute;lfd\u0026aacute;nsd\u0026oacute;ttir B, Gottfre\u0026eth;sd\u0026oacute;ttir H. Use of pain management in childbirth among migrant women in Iceland: A population-based cohort study. Birth. 2022;49(3):486-96.\u003c/li\u003e\n\u003cli\u003eGlance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW. Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007;106(1):19-25; discussion 6-8.\u003c/li\u003e\n\u003cli\u003eZemouri C, Nait Kassi A, Arrazola de O\u0026ntilde;ate W, \u0026Ccedil;oban G, Kissi A. Exploring discrimination and racism in healthcare: a qualitative phenomenology study of Dutch persons with migration backgrounds. BMJ Open. 2024;14(6):e082481.\u003c/li\u003e\n\u003cli\u003eEgbe TO, Halle-Ekane GE, Tchente CN, Nyemb JE, Belley-Priso E. Management of uterine rupture: a case report and review of the literature. BMC Res Notes. 2016;9(1):492.\u003c/li\u003e\n\u003cli\u003eNair R, Nikolopoulos KI, Claydon LS. Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2017;208:71-80.\u003c/li\u003e\n\u003cli\u003eCurtin SC, Gregory KD, Korst LM, Uddin SF. Maternal Morbidity for Vaginal and Cesarean Deliveries, According to Previous Cesarean History: New Data From the Birth Certificate, 2013. Natl Vital Stat Rep. 2015;64(4):1-13, back cover.\u003c/li\u003e\n\u003cli\u003eKnight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, et al. Saving lives, improving mothers\u0026rsquo; care core report - lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit: University of Oxford. 2023.\u003c/li\u003e\n\u003cli\u003eZwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Uterine rupture in The Netherlands: a nationwide population-based cohort study. Bjog. 2009;116(8):1069-78; discussion 78-80.\u003c/li\u003e\n\u003cli\u003eOvertoom EM, Huynh TN, Rosman AN, Zwart JJ, Schaap TP, Vogelvang TE, et al. Predicting the risks and recognizing the signs: a two-year prospective population-based study on pregnant women with uterine rupture in The Netherlands. J Matern Fetal Neonatal Med. 2024;37(1):2311083.\u003c/li\u003e\n\u003cli\u003eM\u0026apos;Charek A. Curious about race: Generous methods and modes of knowing in practice. Soc Stud Sci. 2023;53(6):826-49.\u003c/li\u003e\n\u003cli\u003eHelberg-Proctor A. (Un)doing ethnicity: analyses of the socio-scientific production of \u0026lsquo;ethnicity\u0026rsquo; in health research in the Netherlands. 2017.\u003c/li\u003e\n\u003cli\u003eSmart A, Tutton R, Martin P, Ellison GT, Ashcroft R. The standardization of race and ethnicity in biomedical science editorials and UK biobanks. Soc Stud Sci. 2008;38(3):407-23.\u003c/li\u003e\n\u003cli\u003eDuster T. A post-genomic surprise. The molecular reinscription of race in science, law and medicine. Br J Sociol. 2015;66(1):1-27.\u003c/li\u003e\n\u003cli\u003eMulinari S, Bredstr\u0026ouml;m A. \u0026ldquo;Black race\u0026rdquo;, \u0026ldquo;Schwarze Hautfarbe\u0026rdquo;, \u0026ldquo;Origine africaine\u0026rdquo;, or \u0026ldquo;Etnia nera\u0026rdquo;? The absent presence of race in European pharmaceutical regulation. BioSocieties. 2024;19(1):19-36.\u003c/li\u003e\n\u003cli\u003eMorning ANN. The Nature of Race How Scientists Think and Teach about Human Difference. 1 ed: University of California Press; 2011.\u003c/li\u003e\n\u003cli\u003eMersha TB, Beck AF. The social, economic, political, and genetic value of race and ethnicity in 2020. Hum Genomics. 2020;14(1):37.\u003c/li\u003e\n\u003cli\u003eLu C, Ahmed R, Lamri A, Anand SS. Use of race, ethnicity, and ancestry data in health research. PLOS Glob Public Health. 2022;2(9):e0001060.\u003c/li\u003e\n\u003cli\u003eTattersall I, DeSalle R. Race? : debunking a scientific myth. 1st ed. College Station: Texas A \u0026amp; M University Press; 2011. xv, 226 p. p.\u003c/li\u003e\n\u003cli\u003eKennedy RF, Roy CS, Goldman ML. Race and ethnicity in the classical world : an anthology of primary sources in translation. Indianapolis: Hackett Pub. Company, Inc.; 2013. Available from: http://site.ebrary.com/id/10748802.\u003c/li\u003e\n\u003cli\u003eMontagu MFA. Man\u0026apos;s most dangerous myth: the fallacy of race. New York, NY, US: Columbia University Press; 1942. xi, 216-xi, p.\u003c/li\u003e\n\u003cli\u003eEdwards CL, Fillingim RB, Keefe F. Race, ethnicity and pain. Pain. 2001;94(2):133-7.\u003c/li\u003e\n\u003cli\u003eHelberg-Proctor A, Krumeich A, Meershoek A, Horstman K. The multiplicity and situationality of enacting \u0026lsquo;ethnicity\u0026rsquo;in Dutch health research articles. BioSocieties. 2018;13:408-33.\u003c/li\u003e\n\u003cli\u003eParadies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(9):e0138511.\u003c/li\u003e\n\u003cli\u003eBen J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One. 2017;12(12):e0189900.\u003c/li\u003e\n\u003cli\u003eHamed S, Bradby H, Ahlberg BM, Thapar-Bj\u0026ouml;rkert S. Racism in healthcare: a scoping review. BMC Public Health. 2022;22(1):988.\u003c/li\u003e\n\u003cli\u003eMeghani SH, Gallagher RM. Disparity vs inequity: toward reconceptualization of pain treatment disparities. Pain Med. 2008;9(5):613-23.\u003c/li\u003e\n\u003cli\u003eZemouri C. Discriminatie maakt ziek. Hoe pati\u0026euml;nten met een migratieachtergrond door zorgdiscriminatie verslechterde zorg ontvangen. Wetenschappelijk instituut STATERA2022 [Available from: https://instituutstatera.nl/discriminatie-maakt-ziek/\u003c/li\u003e\n\u003cli\u003eBronson E. What is Medical Racism? : YWCA Seattle | King | Snohomish; 2020 [Available from: https://www.ywcaworks.org/blogs/firesteel/what-medical-racism.\u003c/li\u003e\n\u003cli\u003eBraun L. Breathing Race into the Machine The Surprising Career of the Spirometer from Plantation to Genetics: University of Minnesota Press; 2014.\u003c/li\u003e\n\u003cli\u003eDavis DA. Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing. Med Anthropol. 2019;38(7):560-73.\u003c/li\u003e\n\u003cli\u003eBridges K. Reproducing race: An ethnography of pregnancy as a site of racialization: Univ of California Press; 2011.\u003c/li\u003e\n\u003cli\u003eHoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301.\u003c/li\u003e\n\u003cli\u003eKroll C, Murphy J, Poston L, You W, Premkumar A. Cultivating the ideal obstetrical patient: How physicians-in-training describe pain associated with childbirth. Soc Sci Med. 2022;312:115365.\u003c/li\u003e\n\u003cli\u003eCopeland VC, Braxter B. Black Women and Maternal Death. Encyclopedia of Social Work2022.\u003c/li\u003e\n\u003cli\u003eCampbell CM, Edwards RR. Ethnic differences in pain and pain management. Pain Manag. 2012;2(3):219-30.\u003c/li\u003e\n\u003cli\u003eStrand NH, Mariano ER, Goree JH, Narouze S, Doshi TL, Freeman JA, et al. Racism in Pain Medicine: We Can and Should Do More. Mayo Clin Proc. 2021;96(6):1394-400.\u003c/li\u003e\n\u003cli\u003eHirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions. J Pain. 2015;16(6):558-68.\u003c/li\u003e\n\u003cli\u003eBarata C. \u0026ldquo;Mix of Races, Bad Uterus\u0026rdquo;: Obstetric Violence in the Experiences of Afro-Brazilian Migrants in Portugal. Societies. 2022;12(3):78.\u003c/li\u003e\n\u003cli\u003eGoodarzi B, Helberg-Proctor A, Brewster L, van den Akker T. \u0026lsquo;Ras\u0026rsquo; en etniciteit registreren in de zorg: een precaire kwestie. Medisch Contact. 2022.\u003c/li\u003e\n\u003cli\u003eYanow D, Van Der Haar M. People out of place: allochthony and autochthony in the Netherlands\u0026apos; identity discourse -- metaphors and categories in action. Journal of International Relations and Development, suppl Special Issue: Linguistic Approaches to Analyzing Policies. 2013;16(2):227-61.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57.\u003c/li\u003e\n\u003cli\u003eClarke V, Braun V. Thematic Analysis. In: Teo T, editor. Encyclopedia of Critical Psychology. New York, NY: Springer New York; 2014. p. 1947-52.\u003c/li\u003e\n\u003cli\u003eBalkenhol M. Racisme in kunst en cultuur . Cahiers Biowetenschappen en Maatschappij . 2017. p. 64-5.\u003c/li\u003e\n\u003cli\u003eBorrell LN, Elhawary JR, Fuentes-Afflick E, Witonsky J, Bhakta N, Wu AHB, et al. Race and Genetic Ancestry in Medicine - A Time for Reckoning with Racism. N Engl J Med. 2021;384(5):474-80.\u003c/li\u003e\n\u003cli\u003eGoodman AH. Why genes don\u0026apos;t count (for racial differences in health). Am J Public Health. 2000;90(11):1699-702.\u003c/li\u003e\n\u003cli\u003eDeyrup A, Graves JL, Jr. Racial Biology and Medical Misconceptions. N Engl J Med. 2022;386(6):501-3.\u003c/li\u003e\n\u003cli\u003eCerde\u0026ntilde;a JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020;396(10257):1125-8.\u003c/li\u003e\n\u003cli\u003eFullwiley D. Tabula Raza: Mapping Race and Human Diversity in American Genome Science: University of California Press; 2024.\u003c/li\u003e\n\u003cli\u003eVyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;383(9):874-82.\u003c/li\u003e\n\u003cli\u003eVyas DA, Jones DS, Meadows AR, Diouf K, Nour NM, Schantz-Dunn J. Challenging the Use of Race in the Vaginal Birth after Cesarean Section Calculator. Womens Health Issues. 2019;29(3):201-4.\u003c/li\u003e\n\u003cli\u003eKallianidis AF, Schutte JM, van Roosmalen J, van den Akker T. Maternal mortality after cesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol. 2018;229:148-52.\u003c/li\u003e\n\u003cli\u003eVankan E, van Kuijk SMJ, Nijhuis JG, Aardenburg R, Delemarre FMC, Dirksen CD, et al. External validation of a prediction model on vaginal birth after caesarean in a The Netherlands: a prospective cohort study. 2021;49(3):357-63.\u003c/li\u003e\n\u003cli\u003eSchoorel EN, Vankan E, Scheepers HC, Augustijn BC, Dirksen CD, de Koning M, et al. Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid. Bjog. 2014;121(2):202-9.\u003c/li\u003e\n\u003cli\u003eSchoorel EN, van Kuijk SM, Melman S, Nijhuis JG, Smits LJ, Aardenburg R, et al. Vaginal birth after a caesarean section: the development of a Western European population-based prediction model for deliveries at term. Bjog. 2014;121(2):194-201; discussion \u003c/li\u003e\n\u003cli\u003eDevakumar D, Selvarajah S, Abubakar I, Kim SS, McKee M, Sabharwal NS, et al. Racism, xenophobia, discrimination, and the determination of health. Lancet. 2022;400(10368):2097-108.\u003c/li\u003e\n\u003cli\u003eSuurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot ML. Negative health care experiences of immigrant patients: a qualitative study. BMC Health Serv Res. 2011;11:10.\u003c/li\u003e\n\u003cli\u003eHarmsen H, Meeuwesen L, van Wieringen J, Bernsen R, Bruijnzeels M. When cultures meet in general practice: intercultural differences between GPs and parents of child patients. Patient Educ Couns. 2003;51(2):99-106.\u003c/li\u003e\n\u003cli\u003eSchinkel S, Schouten BC, Kerpiclik F, Van Den Putte B, Van Weert JCM. Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination? Health Commun. 2019;34(12):1469-81.\u003c/li\u003e\n\u003cli\u003eLeal MDC, Gama S, Pereira APE, Pacheco VE, Carmo CND, Santos RV. The color of pain: racial iniquities in prenatal care and childbirth in Brazil. Cad Saude Publica. 2017;33Suppl 1(Suppl 1):e00078816.\u003c/li\u003e\n\u003cli\u003eHelberg-Proctor A, Busari JO. Systemic Anti-Blackness and Racism in Healthcare: A European Perspective. Healthc Pap. 2023;21(3):25-30.\u003c/li\u003e\n\u003cli\u003eWekker G. White Innocence Paradoxes of Colonialism and Race: Duke University Press; 2016.\u003c/li\u003e\n\u003cli\u003eIacobucci G. Healthcare leaders reject \u0026ldquo;damaging\u0026rdquo; denial that institutional racism exists. BMJ. 2021;373:n911.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health C. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US) Copyright 2002 by the National Academy of Sciences. All rights reserved.; 2003.\u003c/li\u003e\n\u003cli\u003evan Ryn M, Saha S. Exploring unconscious bias in disparities research and medical education. Jama. 306. United States2011. p. 995-6.\u003c/li\u003e\n\u003cli\u003eGivler A, Bhatt H, Maani-Fogelman PA. The Importance of Cultural Competence in Pain and Palliative Care. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright \u0026copy; 2023, StatPearls Publishing LLC.; 2023.\u003c/li\u003e\n\u003cli\u003ePeacock S, Patel S. Cultural Influences on Pain. Rev Pain. 2008;1(2):6-9.\u003c/li\u003e\n\u003cli\u003eRogger R, Bello C, Romero CS, Urman RD, Luedi MM, Filipovic MG. Cultural Framing and the Impact On Acute Pain and Pain Services. Curr Pain Headache Rep. 2023;27(9):429-36.\u003c/li\u003e\n\u003cli\u003eMeershoek A, Krumeich A. Multiculturalism and the construction of ethnic identities in labour and health practices: avoiding the culturalistic fallacy in applied research. Health Care Anal. 2009;17(3):173-97.\u003c/li\u003e\n\u003cli\u003eAshley R, Goodarzi B, Horn A, de Klerk H, Ku SE, Marcus JK, et al. A call for critical midwifery studies: Confronting systemic injustice in sexual, reproductive, maternal, and newborn care: Critical Midwifery Collective Writing Group. Birth. 2022;49(3):355-9.\u003c/li\u003e\n\u003cli\u003eThe \u003cem\u003eLancet\u003c/em\u003e Series on racism, xenophobia, discrimination, and health 2022 [Available from: https://www.thelancet.com/series/racism-xenophobia-discrimination-health.\u003c/li\u003e\n\u003cli\u003eGoodarzi B, editor Racism, inequity, health and well-being: an urgent call for a European stance. ECTMIH; 2023; Utrecht, The Netherlands.\u003c/li\u003e\n\u003cli\u003eTweed T, Maduro CV, G\u0026uuml;neș NH, Poeze M, Busari JO. Diversity matters: the other doctor within the Dutch academic healthcare system. BMJ Lead. 6. England: \u0026copy; Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.; 2022. p. 171-4.\u003c/li\u003e\n\u003cli\u003eSmedley BD, Stith AY, Colburn L, Evans CH, Institute of M. The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert WNickens, MD. Washington (DC): National Academies Press (US) Copyright 2001 by the National Academy of Sciences. All rights reserved.; 2001.\u003c/li\u003e\n\u003cli\u003eMulder L, Wouters A, Twisk JWR, Koster AS, Akwiwu EU, Ravesloot JH, et al. Selection for health professions education leads to increased inequality of opportunity and decreased student diversity in The Netherlands, but lottery is no solution: A retrospective multi-cohort study. Med Teach. 2022;44(7):790-9.\u003c/li\u003e\n\u003cli\u003eMulder L, Wouters A, Akwiwu EU, Koster AS, Ravesloot JH, Peerdeman SM, et al. Diversity in the pathway from medical student to specialist in the Netherlands: a retrospective cohort study. Lancet Reg Health Eur. 2023;35:100749.\u003c/li\u003e\n\u003cli\u003eGennissen LM, Stegers-Jager KM, de Graaf J, Fluit C, de Hoog M. Unraveling the medical residency selection game. Adv Health Sci Educ Theory Pract. 2021;26(1):237-52.\u003c/li\u003e\n\u003cli\u003eBeagan BL. Neutralizing differences: producing neutral doctors for (almost) neutral patients. Soc Sci Med. 2000;51(8):1253-65.\u003c/li\u003e\n\u003cli\u003eLeyerzapf H, Verdonk P, Ghorashi H, Abma TA. \u0026ldquo;We are all so different that it is just \u0026hellip; normal.\u0026rdquo; Normalization practices in an academic hospital in the Netherlands. Scandinavian Journal of Management. 2018;34(2):141-50.\u003c/li\u003e\n\u003cli\u003eRezaiefar P, Abou-Hamde Y, Naz F, Alborhamy YS, LaDonna KA. \u0026quot;Walking on eggshells\u0026quot;: experiences of underrepresented women in medical training. Perspect Med Educ. 2022;11(6):325-32.\u003c/li\u003e\n\u003cli\u003evan Andel C. C\u003cem\u003elinical Grade Differences Between Ethnic Minority and Majority Students: Institutional-, assessor-, and student-related factors \u003c/em\u003e . 2022.\u003c/li\u003e\n\u003cli\u003eAmutah C, Greenidge K, Mante A, Munyikwa M, Surya SL, Higginbotham E, et al. Misrepresenting Race - The Role of Medical Schools in Propagating Physician Bias. N Engl J Med. 2021;384(9):872-8.\u003c/li\u003e\n\u003cli\u003eTsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016;91(7):916-20.\u003c/li\u003e\n\u003cli\u003eMuntinga ME, Krajenbrink VQ, Peerdeman SM, Croiset G, Verdonk P. Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation. Adv Health Sci Educ Theory Pract. 2016;21(3):541-59.\u003c/li\u003e\n\u003cli\u003eMuntinga M, Beuken J, Gijs L, Verdonk P. Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum. GMS J Med Educ. 2020;37(2):Doc22.\u003c/li\u003e\n\u003cli\u003eMilieu RvVe, (RIVM). Etniciteit en zorg rondom zwangerschap en geboorte: een verkenning van Nederlands onderzoek. 2007.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Demographic characteristics of the population of uterine rupture cases with recorded race/ethnicity in the Netherlands (n, %) for the period April 1st 2016 \u0026ndash; May 31st 2018\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eRacial/ethnic category\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eWestern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e48.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNon-Western\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e51.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eAge (years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026lt;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cimg width=\"11\" height=\"17\" src=\"data:image/png;base64,R0lGODlhCwARAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAALAAsAhAAAAAAAAAAAOgA6ZjoAADoAOjo6ADpmkGaQtpA6AJBmOpC225Db/7ZmOraQOraQZrbb/9vb29vb///btv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUtIBABZFlSjYBIpkk9xrC05qQQB0STlFMwLRtOx4PJXKnVbrRruhKBqDQgYIQAADs=\" alt=\"image\"\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026lt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e64.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cimg width=\"11\" height=\"17\" src=\"data:image/png;base64,R0lGODlhCwARAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAALAAsAhAAAAAAAAAAAOgA6ZjoAADoAOjo6ADpmkGaQtpA6AJBmOpC225Db/7ZmOraQOraQZrbb/9vb29vb///btv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUtIBABZFlSjYBIpkk9xrC05qQQB0STlFMwLRtOx4PJXKnVbrRruhKBqDQgYIQAADs=\" alt=\"image\"\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e24.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eLanguage Barrier\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e77.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObstetric Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eParity\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e74.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cimg width=\"11\" height=\"17\" src=\"data:image/png;base64,R0lGODlhCwARAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAALAAsAhAAAAAAAAAAAOgA6ZjoAADoAOjo6ADpmkGaQtpA6AJBmOpC225Db/7ZmOraQOraQZrbb/9vb29vb///btv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUtIBABZFlSjYBIpkk9xrC05qQQB0STlFMwLRtOx4PJXKnVbrRruhKBqDQgYIQAADs=\" alt=\"image\"\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrevious CS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cimg width=\"11\" height=\"17\" src=\"data:image/png;base64,R0lGODlhCwARAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAALAAsAhAAAAAAAAAAAOgA6ZjoAADoAOjo6ADpmkGaQtpA6AJBmOpC225Db/7ZmOraQOraQZrbb/9vb29vb///btv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUtIBABZFlSjYBIpkk9xrC05qQQB0STlFMwLRtOx4PJXKnVbrRruhKBqDQgYIQAADs=\" alt=\"image\"\u003e\u0026nbsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eVaginal Birth After Caesarean Section\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePrevious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eCurrent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e79.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eUterine Rupture (UR) or Dehiscence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eUR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e38.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eDehiscence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003ePain Relief during Labour\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eEpidural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e48.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eRemifentanil\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eOnset of Labour\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSpontaneous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e72.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eInduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e24.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eAugmentation of Labour (oxytocin)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 463px;\"\u003e\n \u003cp\u003e\u003cem\u003eGestational Age\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026lt;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e98.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cimg width=\"11\" height=\"17\" src=\"data:image/png;base64,R0lGODlhCwARAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAALAAsAhAAAAAAAAAAAOgA6ZjoAADoAOjo6ADpmkGaQtpA6AJBmOpC225Db/7ZmOraQOraQZrbb/9vb29vb///btv//2wECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwUtIBABZFlSjYBIpkk9xrC05qQQB0STlFMwLRtOx4PJXKnVbrRruhKBqDQgYIQAADs=\" alt=\"image\"\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Outcome characteristics of the study population uterine rupture cases (\u003cem\u003en\u003c/em\u003e, %, OR) for the period April 1st 2016 \u0026ndash; May 31st 2018\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRacial/ethnic category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguage Barrier category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eWestern (n=26)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eNon-Western (n=28)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cem\u003eNon-Western vs Western\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=42)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n=10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cem\u003eLanguage barrier vs non-language barrier\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare processes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAugmentation of Labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e13 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.45 (0.22-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e19 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.21 (0.30-4.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eInduction of Labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.11 (0.32-3.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.71 (1.30-3.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePain Relief\u003c/p\u003e\n \u003cp\u003eEpidural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.64 (0.22-1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.08 (0.01-0.65)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eRemifentanil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4.17 (0.43-40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27.33 (2.60-287.41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11 (42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e12 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.02 (0.35-3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16 (42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.63 (0.41-6.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eComplaints of pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15\u0026nbsp;(53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.73 (0.58-5.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e18 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.28 (0.32-5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Caesarean Section\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime Between 1\u003csup\u003est\u003c/sup\u003e Complaint \u0026amp; Decision for Caesarean Section\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt;30 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.21 (0.04-1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.50 (0.07-3.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30 \u0026ndash; 90 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e90 \u0026ndash; 180 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.40 (0.10-19.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e180+ mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5 (45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3.75 (0.54-26.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e3.00 (0.42-21.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime Between 1\u003csup\u003est\u003c/sup\u003e Complaint \u0026amp; Decision for Caesarean Section\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt;30 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.25 (0.17-9.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.85 (0.08-9.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30 \u0026ndash; 90 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.15 (0.02-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.40 (0.04-4.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e90 \u0026ndash; 180 mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.462 (0.06-3.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.85 (0.08-0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e180+ mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.57 (1.28-123.48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e3.13 (0.55-17.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMOH \u0026gt;1000mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.11 (0.32-3.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.05 (0.51-8.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUterine rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.76 (0.56-5.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e12 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e2.50 (0.61-10.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerinatal Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePerinatal Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.88 (0.28-29.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e4.88 (0.60-39.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNeonatal Asphyxia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.90 (0.54-6.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e1.37 (0.30-6.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAdmission to\u003c/p\u003e\n \u003cp\u003eNeonatology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.67 (0.36-7.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.67 (0.71-6.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNICU\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.92 (0.16-22.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMOH = major obstetric haemorrhage.\u003c/p\u003e\n\u003cp\u003e*= no cases in this group.\u003c/p\u003e\n\u003cp\u003eRed =\u0026nbsp;\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue \u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003eTable 3 Racial and ethnic stereotypes about pain experience and expression.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRacial/ethnic group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBlack and African identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026quot;[\u0026hellip;] What I observe for example, is the way that the want or needs are vocalised. [\u0026hellip;] That white society is way more expressive like asking for pain medication as black women are less likely to do so, but I indeed I am not sure if they don\u0026apos;t want it or they are more like. Well, whatever or whenever you as a doctor advice it. So they are more in a in a reserved attitude. Yes, I think they are asking a lot less. But I don\u0026apos;t think that that means that they would need it a lot less.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;I have heard that black women can for example, handle pain better. [\u0026hellip;] Black women are strong, for example.\u0026rdquo; (P3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] We saw quite a lot of women from, in Western Africa and who were not were not Dutch, [\u0026hellip;] and the way those women express pain is maybe different than and then white Dutch women so it\u0026apos;s perceived differently. Maybe with less or other emotion.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[\u0026hellip;] Many of my colleagues think that like women from West Africa have a bit of more curved spine, more lordose in the back, also that when labour does not progress or it takes very long for the head of the baby to be very high and only in the last phase when the baby goes through that threshold through that curve, then the baby comes. So it takes a while but when it\u0026apos;s there the delivery is fast and so and my many of my colleagues say Oh no, she\u0026apos;s a West African woman, so it takes some time, but when she\u0026apos;s there then, the baby will, then the delivery will be fast and that\u0026apos;s something I never heard any evidence about or read somewhere, but it\u0026apos;s like a big, yeah, big bias for me and people just tell it, \u003cem\u003e\u0026lsquo;oh, no, that\u0026apos;s normal for West African women\u0026rsquo;\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] We see quite some people from Nigeria and Ghana [\u0026hellip;] who just go through labour a little bit more like isolated. So not very talkative to labour or asking much, even don\u0026apos;t ask the nurse for anything.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] Another belief is that black women from Western Africa and sometimes express pain a little bit more theatrical so not insulated, but more theatrical with more body movement. And that way they can they can take on more pain and that includes like shaking the body or like smashing your own your legs or sometimes shouting, shouting more or sighing like louder, in a way to cope with the pain and in that light the healthcare professional thinks like OK she has like a good way of coping with the pain, so she does not need pain medication.\u0026rdquo; (P4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] Surinam [women] can also birth very fast something that goes around, those kind of prejudices, and perhaps if you are sort of an ethnicity of which there\u0026apos;s a prejudice that they birth very fast they might get remifentanil sooner than epidurals, for example, if you\u0026apos;re at 5 or 6 centimetres when you\u0026apos;re in the grey area.\u0026rdquo; (P6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;But about originally African women sometimes, healthcare providers we say like ohh she\u0026apos;s she\u0026apos;s like this strong African woman, she can take it, she can handle it.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;So at handovers if something is being said like she\u0026apos;s well, she\u0026apos;s a strong African woman, she doesn\u0026apos;t need it, that can be said.\u0026rdquo; (P8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;When a young black woman is gone, coming for delivery, we know. Quite sure it goes. It can go really fast. For example, that\u0026apos;s that\u0026apos;s maybe one of the things that you did. You have the idea that they they can deliver, they can manage. But yeah, that\u0026apos;s well, yeah. And especially the delivery will go quickly\u0026nbsp;[\u0026hellip;].\u0026rdquo; (P9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] A woman coming from Africa just here knows the culture that how women birth give birth in Africa. It\u0026apos;s like you never hear them complain. They just give birth. It\u0026apos;s part of life. They go for it and that\u0026apos;s OK and maybe when they come here they still have that. They still think like this is just part of life. We have to go through it. We can\u0026apos;t do anything about it. And then when you see women who have been here for their whole life or a longer period, that they know what the options are, and I think they\u0026apos;re. How do you say it there perception or their they know there are different options for pain relief that they are more willing to ask for it or want help or things like.\u0026rdquo; (P10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;And sometimes you also hear from colleagues saying that I don\u0026apos;t know. Maybe. Yeah, these, you know, like standard beliefs that [\u0026hellip;], yeah, someone from I don\u0026apos;t know, Somalia might be more quiet [\u0026hellip;].\u0026rdquo; (P12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e(South) Asian / Hindustani / Indian identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;I also find that, for example people with. Background from for example, Pakistan or India. I find that they also react different to pain than people from another background.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] With South Asians, I more try to specify and clarify what the pain really is, and so when they\u0026apos;re for example, during labour or during the C-section really painful, I try to specify, is that correct that\u0026apos;s really painful [\u0026hellip;] Is it really pain or is it something different? I don\u0026apos;t want to over treat them. And I do that more with South Asians than with other people from other backgrounds.\u0026rdquo; (P2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;What I think is that people from India or Pakistan that they use pain or they express pain with a different purpose, for a different purpose. I think it\u0026apos;s also a way to communicate to their community that they need attention or help.\u0026rdquo; (P2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] I think that I even have had [biases], especially the theatrical Hindustani women [\u0026hellip;].\u0026rdquo; (P3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;]I think that it has been studied because it\u0026rsquo;s joke among midwives, but I think it\u0026apos;s studied that Indian women have a lower, they can\u0026apos;t cope as good with pain as not Indian people.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] The Indian woman say that they\u0026apos;re, that they have, that [the pain] it\u0026rsquo;s unbearable. What they\u0026apos;re going through and then they have two centimetres of dilatation [\u0026hellip;]\u0026rdquo; (P5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] I also might have underrated pain experience, for example, by Indian people because they feel the pain very heavily and especially when I was just coming from school, not very experienced. I do think I might have underestimated their pain. But I also think that sometimes people say they are in more pain than they actually are [\u0026hellip;].\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Indian people, they have overall they feel a lot of pain very quickly. So I can imagine that they sometimes will get pain relief very early in their delivery, but also sometimes have people here, healthcare workers think well, we can probably wait a little bit longer. [\u0026hellip;] With this construction they sometimes think that they are going to die because of the pain and they are very shocked by the pain. But I do think that sometimes they get their pain relief a little bit later because [\u0026hellip;] all Indian people have that they experience a lot of pain\u0026rdquo; (P7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo; [\u0026hellip;] We say sometimes maybe with colleagues like [\u0026hellip;] Indian people that they\u0026apos;re more like, like, yeah, experiencing pain more heavily [...].\u0026rdquo; (P10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;And sometimes you also hear from colleagues saying that, I don\u0026apos;t know. Maybe. Yeah, these, you know, like standard beliefs that Asians are more verbal [\u0026hellip;].\u0026rdquo; (P12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eWhite identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e‪\u0026rdquo;We call them West Fresians [\u0026hellip;] They\u0026apos;re really strong, yeah, big build women, OK. Men and women. Yeah, they\u0026apos;re, like, \u0026ldquo;toughen up. We\u0026apos;re going to do this. OK.\u0026rdquo;, Yeah, and they, now I\u0026apos;m generalising, but they give birth easy to children of 4 kilos.\u0026rdquo; (P2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] More what I observe for example, is the way that the want or needs are vocalised. That if I for example, that white society is way more expressive like asking for pain medication as black women are less likely to do so [\u0026hellip;].\u0026rdquo;\u0026nbsp;(P3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;‪[\u0026hellip;] There are some young urban professionals, for example, lawyers here in Amsterdam or fashion designers or people who are sort of quite rich, quite young age. Who really express that care is not something that we give to everybody, but we should give it to them now. [\u0026hellip;]‪And that can be of all ethnicities. But I think it\u0026apos;s primarily white, yeah, younger professionals\u0026rdquo;(P6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] That\u0026apos;s such an American Princess, so she will need her epidural immediately.\u0026rdquo; (P8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] We have a group of women who make a very big birth plan where they say, oh, I don\u0026apos;t want this. I don\u0026apos;t want this. I don\u0026apos;t want this or no pain relief, nothing whatsoever. And then when we get those women, they always come from their midwife, from outside the hospital to inside the hospital. So there is a pass over. How do you say? It she comes to us. And then we see that and we say, OK, so she\u0026apos;s going to get everything she doesn\u0026apos;t want just because she said so hard. I don\u0026apos;t want. [\u0026hellip;]\u0026nbsp;‪Usually those demographics are the higher educated white Dutch women.\u0026rdquo; (P10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eArabic identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;And with, for example, people, women from an Arabic background, when they say lower I have pain in my lower abdomen and I can\u0026apos;t really find a diagnosis for that, I\u0026apos;m more likely to ask yeah \u0026ldquo;are there other things at home, or is there something you worry about\u0026rdquo; or trying to ask a little bit more about that than I would do in people from another background.\u0026rdquo; (P2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] I can only do it in Dutch. But [the patient representatives] was like (demonstrated a person shouting for pain, spoke in Dutch) to get attention and to actually sort of get help and that that is something that perhaps if you know that they had to do that in their hospitals, for example in Morocco, then they\u0026apos;ll have to do it here as they tend to do it here as well and that we perhaps feel that it\u0026apos;s a little bit too much for us or too over exaggerated.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] That they really exaggerate or over present their pain in order to get attention from doctors. [\u0026hellip;]\u0026rdquo; (P6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;Ohh yeah, Arabic woman women are usually very dramatic in their presentation of pain, and this affects how healthcare providers are assessing pain for sure, 100% in every other situation.\u0026rdquo; (P8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMediterranean identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] I experienced, quite similar prejudices there in terms of pain, for example, that Mediterranean fever is something that still is being discussed there quite often. Or Mediterranean presentation, we call it.\u0026rdquo; (P6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eChinese identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 820px;\"\u003e\n \u003cp\u003e\u0026ldquo;[\u0026hellip;] Chinese people who don\u0026apos;t show their pain and who don\u0026apos;t ask for pain [relief], I think sometimes they will be entitled to have more pain medication than they get now. [\u0026hellip;] I think they are the most difficult to assess.\u0026rdquo; (P7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e We have chosen to use the term \u0026lsquo;womxn\u0026rsquo; because we are aware of the limitation of the binary English term \u0026lsquo;woman\u0026rsquo; and how it highlights but one aspect of a person\u0026rsquo;s multidimensional and intersecting identity and experience and how they are positioned and position themselves in social reality. We use \u0026lsquo;womxn\u0026rsquo; when referring to other studies as well as in our own result section because gender identity was not registered as part of the data collections. We have not adjusted the language when using quotes. We acknowledge that there is no consensus on inclusive vocabulary cross-culturally.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e In discussing the literature and previous research on racial and ethnic health inequities we have chosen to use the racial and ethnic terms and categories used in these publications. Nevertheless, it is important to note that in many of these publications, the definitions and operationalizations of these racial and ethnic categories are not provided.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e For this reason, in this paper we consistently use both the terms race and ethnicity or race/ethnicity to discuss bias and discrimination as this is how these terms appeared in the literature included in this paper, the database used for this study and the responses from interview participants.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"race, ethnicity, pain, birth, racism, bias, stereotypes, maternal newborn care, obstetrics","lastPublishedDoi":"10.21203/rs.3.rs-6600363/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6600363/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStudies indicate racial and ethnic inequities in pain assessment, management and treatment in maternal and newborn care. Namely, racially and ethnically marginalised womxn are less likely to receive pain relief in labour and the post-partum period, and are more likely to experience severe perinatal outcomes such as uterine rupture. This inequity may be explained by racial/ethnic bias in maternal and newborn care professionals\u0026rsquo; pain assessment, management and treatment. The aim of this study was to investigate the role of racial/ethnic bias in the assessment, management and treatment of pain during labour in the Netherlands.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis mixed methods study consisted of two parts: a quantitative and a qualitative study. The quantitative part was a prospective nationwide population-based cohort study where cases of uterine rupture were collected through the Netherlands Obstetric Surveillance System (NethOSS) in which we retrospectively investigated the association between categories of race/ethnicity, language barrier, the difference in the response time to pain, and maternal and perinatal outcomes up to 28 days post-partum. The qualitative part was an explorative study to investigate racial and ethnic bias in pain assessment, management and treatment among maternal and newborn care professionals using semi-structured interviews and thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe quantitative results indicated that caesarean section was significantly more frequently performed in more than 180 minutes after the first complaint of pain in the non-Western category compared to the Western category. The qualitative analysis showed the simultaneous presence \u003cem\u003eand\u003c/em\u003e unawareness of stereotypes and assumptions about how womxn of different racial/ethnic groups experience and express pain among maternal newborn care professionals. The findings provide insight in how these stereotypes and assumptions affect decision-making about pain assessment, management and treatment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe results of this study provide a starting point to investigate racial and ethnic inequity in maternal and newborn care in the Netherlands, and to address the ways that these differences can be mitigated. Our findings underscore the disavowal of the role of racial thinking and notions of ethnic differences in pain assessment, management, and treatment, and highlights the need for critical reflection on the role of maternal and newborn care in shaping, causing, maintaining, sustaining, and (re)producing racial/ethnic inequity.\u003c/p\u003e","manuscriptTitle":"“You think, like, you’re neutral but you’re not”: A mixed- methods study of racial/ethnic bias in pain assessment, management and treatment in maternal and newborn care in the Netherlands","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 10:31:20","doi":"10.21203/rs.3.rs-6600363/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T02:26:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T21:11:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T18:40:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184726147055189301790901137308712588171","date":"2025-09-25T10:03:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288598257991802611462291698026991924706","date":"2025-09-23T01:30:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141483551326382758708905633359912127824","date":"2025-06-05T16:34:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-03T16:25:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-12T11:30:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-07T23:54:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2025-05-06T07:48:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4c601df-d586-4bd2-b14f-e5b32f1983f9","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:10:51+00:00","versionOfRecord":{"articleIdentity":"rs-6600363","link":"https://doi.org/10.1186/s12939-025-02714-w","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2025-12-08 15:57:15","publishedOnDateReadable":"December 8th, 2025"},"versionCreatedAt":"2025-06-09 10:31:20","video":"","vorDoi":"10.1186/s12939-025-02714-w","vorDoiUrl":"https://doi.org/10.1186/s12939-025-02714-w","workflowStages":[]},"version":"v1","identity":"rs-6600363","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6600363","identity":"rs-6600363","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}