Friday 21 June 2024

Vitamin D: excess birth complications suffered by ethnic Black women

 Why do Black women in England suffer from more serious birth complications?

On April 8th 2024 we read in the Guardian that ”Black women in England suffer more serious birth complications, analysis finds”. Whether “more serious” meant than the complications were more serious or that there were more of the complications was not immediately clear. I was alerted to this article because as a previously practising physician I am concerned about a group of people who are medically disadvantaged, and at an extremely important moment in their lives.

It was clarified that “Black women are up to six times more likely to experience some of the most serious birth complications during hospital delivery across England than their White counterparts”. They are "1.5 times more likely to develop pre-eclampsia”. They were “almost four times more likely to die in pregnancy and childbirth than White women”, and “Black children were twice as likely to be still-born”.

The analysis had been undertaken by the Guardian based on NHS data from 2022–23.

Professor Asma Khalil, vice president of the Royal College of Obstetricians and Gynaecologists, was asked for comments. First, she expressed lack of surprise, that it was already known. This in itself displays serious complacency. She suggested “structural racism” and the “unconscious bias of healthcare professionals”, and that the problem is “multifactorial”.

She went on to suggest that “Healthcare professionals and doctors cannot fix the problem on their own....”


Comments were also made by Dr Anita Banerjee, an Obstetric Physician with expertise in high risk pregnancies. She regarded the results as “disheartening”, and “trust is essential for reducing health inequalities”.

An NHS spokesperson suggested “more holistic support”. Vaguely correct.

The assumptions were that the problem was somehow sociological, someone else’s responsibility, but not that of medical professionals. Why is this? Where is the voice of medical scientists and responsible doctors?

It has been recognised that complications of pregnancy are more likely to occur in association of low blood levels of vitamin D. 

"Adverse health outcomes such as preeclampsia, low birthweight, neonatal hypocalcemia, poor postnatal growth, bone fragility, and increased incidence of autoimmune diseases have been linked to low vitamin D levels during pregnancy and infancy."  Reference

It is arguably not sensible or desirable for pregnant women to have low blood levels of vitamin D. It would be sensible if women were to have blood levels of vitamin D tested at least at the time of their first ante-natal clinic attendance, and ideally at pre-conception clinics or general practice opportunities. Hormone deficiencies should always be taken seriously, and this must apply to deficiency of the hormone cholecalciferol, that we know as vitamin D. It is unfortunate that the vice-president of the Royal College of Obstetricians and Gynaecologists appears to unaware of it.

In the Guardian report and commentaries by “experts”, there was not a single mention of vitamin D deficiency among ethnic Black women and their offspring. This itself is “disheartening”, especially as the two obstetric experts giving their opinions appear to be of South Asian ethnicity and are therefore likely to be seriously vitamin D deficient. But are they themselves taking a vitamin D supplement (I hope so): are they “drinking wine while preaching water”?

If our medical-scientific leaders would accept the correction of this well-recognised human hormone deficiency early in pregnancy, once again they would almost certainly demand an RCT.

It would need to be explained to ethnic Black pregnant women that their collective experience of pregnancy indicates a high incidence of misfortune, and this is probably the result of deficiency of the natural hormone that we know as vitamin D. “We are conducting a study in which half the pregnant women who participate would have the vitamin D deficiency corrected and half would receive a placebo, but no participant or obstetrician would know who was receiving which”. It is unlikely that a pregnant ethnic black woman would agree to receive the placebo.

While we wait for a randomised controlled trial (RCT) to be agreed, to be funded, to receive ethical approval, to be conducted and for the results be analysed, how many more serious birth complications will occur?

If the blood levels of vitamin D are checked early in pregnancy, are half of those with low levels going to be randomised to placebo?

But what about the proposal that racism is the cause of the excess childbirth complications among Black women in the UK? How can this be "treated"? Must Black women and their offspring continue to be disadvantaged in the process and outcome of pregnancy? How long will it take to test this hypothesis? How long will it take to organise an RCT of reduction of racism?

This of course indicates the absurdity of demanding an RCT in all circumstances of patients care. The hypothesis of racism affecting the outcome of pregnancy is assumed, but is untested and untestable. It is also preventing the serious consideration of vitamin D deficiency being the key to the health disadvantages of ethnic Black African and South Asian people, and especially the maternity disadvantages of Black women. 

This Blog post should be taken in conjuction with the previous Blog post concerning the high risk of post-appendicectomy complications of Black children.

1 comment:

  1. Great article, as usual!

    We are reminded of USA Super Athlete Tori Bowie, who died in child birth, presumably from pre-eclampsia / eclampsia, at the young age of 32, in April 2023. Great loss for America, Great Loss for the world.

    Vitamin D deficiency/insufficiency increases the risk of these conditions [.AlSubai A, Baqai MH, Agha H, Shankarlal N, Javaid SS, Jesrani EK, Golani S, Akram A, Qureshi F, Ahmed S, Saran S. Vitamin D and preeclampsia: A systematic review and meta-analysis. SAGE Open Med. 2023 Nov 22;11:20503121231212093. doi: 10.1177/20503121231212093. PMID: 38020794; PMCID: PMC10666722].

    While there are other studies that tend to show no association, when reading these articles, one has to pay attention to the serum 25- hydroxy vitamin D and dosages of supplementation, if any. It is becoming apparent, especially with with what we have seen with protection against covid-19, that the effect of vitamin D is dose dependent; i.e the higher the serum of 25 OH Vitamin D, the better the response and protection (up to a point).

    Toxicity from Vitamin D is very rare and does not happen until a serum level of 150 ng/ml (375 mmol/ml). This would require a daily dose of about 100 IU of Vitamin D for about a year. So it should be generally safe to take a daily dose of Vitamin D of 10-15,000 IU (depending on BMI) and be ok.

    However, I am not aware of any study about the safety of higher serum 25 OH Vitamin D in pregnancy. How high can we go? The reference range in the USA is 30-100 ng/ml (75-250 mmol/ml).

    Does any body has any idea?