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

Introduction

European research consistently highlights that women from migrant and ethnic minority backgrounds using maternity services have poorer than expected clinical outcomes and negative patient experiences^1,2. Specifically, studies have documented higher rates of obstetric complications among these groups, including increased risk of maternal morbidity and mortality^3,4. Adverse neonatal outcomes such as preterm births, stillbirths, and low birth weight infants are also more prevalent^1–5. In terms of negative patient experience, women from migrant and ethnic minority backgrounds often encounter multiple barriers to appropriate maternity care, including limited or lack of access to maternal health services, language and cultural differences, lack of familiarity with the healthcare system, and legal or socio-economic constraints^2,5,6. These challenges contribute to lower levels of service uptake and delayed engagement with antenatal services, which in turn can increase the risk of poor outcomes for both mother and baby². Furthermore, many women report experiences of poor communication with healthcare professionals, a lack of culturally sensitive care, and feelings of being dismissed or not listened to 2,3,6,7. Concerns around respect, dignity, and autonomy are frequently raised, with some women describing discriminatory attitudes and behaviours from staff that undermine trust in the healthcare system, further contributing to negative care experiences^2–10.

Most European countries offer publicly funded maternity care and express commitment to equity in maternal health¹¹. Shared policy frameworks and similar migration patterns—including a recent increase in refugees, asylum seekers, and other non-EU migrants—make Europe a reasonably coherent context for examining systemic drivers of inequality in maternal outcomes^11–13. One important factor shaping these inequalities is ethnicity. Ethnicity is a complex, multi-dimensional, socially constructed concept which refers to a group identity based on shared characteristics such as language, ancestry, cultural heritage, and traditions. However, identities are fluid and can evolve over time, which presents challenges for collecting ethnicity data¹⁴.

Across Europe, ethnicity is not routinely recorded, and operational definitions and coding practices for ethnicity vary widely, particularly in maternity care, which often functions as a distinct sub-system within national healthcare structures^14–16. In 2016, the European Court of Auditors urged the European Commission to develop a unified approach to ethnicity data collection across EU Member States¹⁷. While not healthcare specific, it does have implications for health systems, including maternity care. Ethnicity data is crucial for monitoring disparities, informing service design, and developing policies that promote equitable access and outcomes. Despite this, wide variation remains in legal and policy approaches to ethnicity data collection across European healthcare systems.

Outside the EU, the United Kingdom has established systematic approaches to capturing ethnicity in healthcare data within its National Health Service (NHS). Ethnicity data is routinely collected and integrated into patient records. This routine data collection extends to maternity care. For example, MBRRACE-UK conducts national surveillance and confidential enquiries into maternal and perinatal outcomes¹⁸. Such data enables the evaluation of disparities and identifies patterns of inequality or discrimination. The findings are published using standard 16 ONS NHS ethnicity categories – matched with the UK Census - and inform policy development and service reform^16,19.

Conversely, countries such as France, Denmark, Germany, and Sweden, adopt ‘colour-blind’ policies that prohibit the collection of ethnicity data entirely across all healthcare services²⁰. While this approach is intended to promote equality by emphasizing a “sameness” among citizens, it often masks the lived realities of marginalised groups. The absence of such data in these contexts undermines efforts to detect and address inequities resulting in unmeasured disparities of maternal health outcomes²⁰.

In Ireland, the legal obligation for publicly funded bodies to promote equality and human rights is grounded in the 2014 Irish Human Rights and Equality Commission's Public Sector Duty. In alignment with this legislation, both the Health Service Executive’s (HSE) National Intercultural Health Strategy and Ireland’s Migrant Integration Strategy have advocated for improved ethnicity data collection in healthcare settings¹⁵. However, ethnicity is recorded in only 14 of 97 national health and social care datasets¹⁹. Despite the legal requirement to record ethnicity data in health services, it is not routinely collected—including in maternity care, where data collection remains inconsistent across care settings. The inclusion of an ethnic identifier within existing health information systems was proposed to address these issues²¹. The approach is grounded in self-identification and uses the ethnic and cultural categories from the Irish Census, to enable consistency and comparability across datasets. Nonetheless, implementation has been inconsistent across most services, including maternity care, hindering the capacity to monitor and address ethnic disparities in maternal outcomes^15,19.

Across Europe, the evidence suggests that where ethnicity data is recorded, variations persist in coding standards, classification systems (e.g., self-identification versus proxy indicators), and the analytical use of this information in disparities research. Such inconsistencies limit the effectiveness of data-driven efforts to identify, monitor, and address ethnic inequalities in healthcare outcomes. Without robust evidence on ethnic disparities – and on the strategies to address them - maternity care systems risk perpetuating inequities that undermine women’s health, trust in services, and broader public health goals.

Preliminary searches revealed no existing systematic or scoping reviews that synthesise coding practices and analytical approaches used across Europe to examine disparities in maternity care. While several studies have investigated maternal health experiences by ethnicity, few have explicitly addressed the coding practices underlying these analyses or examined how ethnicity data is treated methodologically in both epidemiological research and quality improvement efforts. This points to a critical gap in the literature. Given these complexities, a scoping review is the most suitable approach to map the breadth and diversity of existing evidence, identify knowledge gaps, and inform future research and policy development.

Research question

We used the Joanna Briggs Institute’ (JBI) population, concept and context (PCC) framework to structure this scoping review²². Studies eligible for inclusion will focus on maternity populations within European countries, and address practices related to the collection of ethnicity data and the analytical approaches to evaluate disparities. The scoping review will address the following research question:

“In maternity care settings across Europe, how is ethnicity recorded in research studies, and how are ethnicity-related disparities analysed?”

Sub-questions:

Inclusion criteria

Methods

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews²². The review is registered with Open Science Framework (OSF) https://doi.org/10.17605/OSF.IO/XP3MV.

Discussion

To our knowledge, this will be the first review to systematically map how ethnicity is recorded, coded, and analysed in maternity care research across Europe. By synthesising current practices, the review will provide an overview of the extent to which existing research supports the identification and monitoring of ethnic disparities in maternal outcomes. The findings will identify methodological gaps, highlight areas of good practice in ethnicity data collection and analysis, and be disseminated through academic conferences, peer-reviewed publication, and engagement with service providers. The review will also inform future clinical practice and health service planning. In particular, the results will support the development of a pilot audit and feedback intervention for maternity services at Cork University Maternity Hospital, enabling systematic monitoring of disparities in maternal outcomes and serving as a reference point for evaluating progress in implementing equity commitments within maternity care, with the goal of eventual national rollout. Furthermore, the methodological approach adopted here may be applicable to other areas of healthcare where consistent ethnicity data collection and analysis is essential for monitoring and addressing inequalities.