Maternal health in Britain has undergone significant transformation since the conception of the National Health Service (NHS) and the delivery of free healthcare at the point of service.Footnote 1 An important shift can be traced in the 1970s and 1980s as attempts to increase women’s control of their pregnancy and childbirth experiences gained ever more attention. In 1974 the Oxford Consumer Group released a report that found women’s experiences of maternity services to be worse than any other branch of the NHS.Footnote 2 This prompted alarm among Community Health Councils and groups such as the National Childbirth Trust and the Association for the Improvement of Maternity Services.Footnote 3 It was during this period that the Thatcher government’s introduction of market mechanisms and neoliberal ideology sought to roll back institutional care and reconfigure patients as consumers with the right to make choices about the services they used.Footnote 4 This led to the rise of the community care movement and attempts to embed increasingly personalized care within maternity services, which ostensibly meant offering all women choice over the way their care was planned and received based on their individual needs and preferences.Footnote 5
Yet, as numerous studies and personal testimonies reveal, personalized care of this kind was unevenly experienced.Footnote 6 For example, South Asian women in Britain disproportionately faced poor outcomes in maternity and perinatal care compared to white women.Footnote 7 Between 1975 and 1985, babies of Pakistani-born mothers had the highest rate of perinatal mortality, followed by those of Bangladeshi, Caribbean, East African, West African, Indian, and Irish mothers.Footnote 8 This meant that babies born to British-Pakistani mothers were twice as likely to die soon after birth compared to those born to white-British mothers. For Britain’s postcolonial migrant populations, the NHS was commonly considered, to use the words of Beverley Bryan et al., as “the uncaring arm of the state.”Footnote 9 While Britain heavily depended on migrant labor from Africa, the Caribbean, and South Asia, these groups were paradoxically excluded from notions of entitlement to welfare state assistance and NHS care.Footnote 10
Mirroring this disavowal of race in healthcare reform, Britan’s racialized minorities, and their experiences of using healthcare systems, have received limited consideration in historical scholarship on Britain’s postwar healthcare structures. Although historians such as Julian Simpson have explored Black and South Asian healthcare professionals as contributors to the postwar welfare state, the experiences of Black and South Asian patients have received comparatively less scholarly attention. As Roberta Bivins has noted, relatively few historians “have examined British racial discourses through the lens of specifically medical events, institutions and phenomena.”Footnote 11 There are of course some notable exceptions. Bivins’s Contagious Communities examined the limits of belonging in a multi-ethnic welfare state.Footnote 12 Bivins mapped the persistence of race in medical environments through a series of postwar case studies that covered, for example, the “tuberculosis migrant” to show how medical intervention was used in the management of immigration.Footnote 13 Similarly, Grace Redhead has demonstrated how Black Britons advocated for fairer healthcare practices within the NHS in the context of sickle cell treatment. In so doing, Redhead made a vital connection between the British welfare state and the lexicon of citizenship.Footnote 14
Despite these significant interventions, South Asian women’s experiences within healthcare spaces, the specificity of their racialization in medical discourses, and their interactions with the British welfare state demand greater historical attention. Although health outcomes for Black Britons were similarly concerning, by the 1980s all three Department of Health and Social Security (DHSS)-funded campaigns focused on Britain’s South Asian communities.Footnote 15 There were several reasons for this. First, it reflected the neglect experienced by Black British communities within postwar healthcare reform. Second, following the Race Relations Act 1965, healthcare reformers increasingly focused on South Asian cultural differences in the hope that mutual understanding might nurture a multicultural society.Footnote 16 Third, South Asian migrant families were deemed particularly problematic by the postwar British state. As scholars such as Radhika Natarajan have shown, “the illegibility of South Asian family forms” shaped British immigration policy: by inventing “the bogus child,” who became the target of immigration reforms, the Home Office sought to limit the arrival of South Asian dependent migrants in a move that served to deny family reunification.Footnote 17 At the same time, the medical profession widely considered South Asian women to be passive, oppressed by their husbands, and controlled by domineering in-laws. By the 1980s, then, South Asian families, and in particular South Asian mothers and their children, were increasingly on the state’s radar and therefore subject to greater intervention and surveillance.
The “Asian Mother and Baby Campaign” (AMBC) was one such state response to health inequity. The AMBC was set up by the DHSS in conjunction with the Save the Children Fund (SCF) and the Health Education Council. The campaign was established in 1984 and ran out of central funding in 1988. It was set in motion at a time when migrant health was subject to intense scrutiny and care for mothers and babies was identified as one of the government’s priority areas. In seeking to increase awareness of NHS services and procedures, the AMBC captured a shift in healthcare reform from the community-based initiatives of the immediate postwar years to an emphasis placed on health education and individual choice in Thatcher’s Britain.Footnote 18 By using the SCF and DHSS archives, as well as original oral history interviews, this article demonstrates how the AMBC’s efforts to improve maternal and perinatal health among Britain’s South Asian population served to uphold medical hierarchies and construct post-imperial racial formations. It argues that while the AMBC was designed to make healthcare more accessible, its attempt to “medically integrate” South Asian women helped to pathologize them and place them under medical surveillance.Footnote 19 As the testimonies of healthcare professionals, users of the campaign, and women’s health activists show, the AMBC’s vision for healthcare reform was tied to racialized and class-based discourses around citizenship and belonging.Footnote 20 The campaign, and the literature it produced, created knowledge systems that were oftentimes at odds with community-based expertise and negatively influenced South Asian women’s experiences of maternity care. Interrogating the AMBC thus reveals the centrality of healthcare spaces to maintaining racial difference and exposes the limits of health citizenship, welfare state inclusivity, and multiculturalism ideals in late twentieth-century Britain.Footnote 21
Healthcare Reform and the “Asian Mother and Baby Campaign”
A vast body of actors and organizations directed their attention to maternity and perinatal care prior to the introduction of the 1984 “Asian Mother and Baby Campaign.”Footnote 22 In the 1970s the National Childbirth Trust, a registered charity and self-proclaimed “consumer council” for childbirth and support in early parenthood, reported that it was mostly middle-class women who could access education for childbirth.Footnote 23 It advocated for the need to develop classes that addressed the needs of women it identified as underprivileged: women in areas of poor housing and from low-income and ethnic minority groups.Footnote 24 In 1977 an “Outreach” early parenthood education program targeted South Asian women in the London Borough of Brent. The group claimed that “Asian women [had] special problems. They experience[d] the British health system as alien and frightening.”Footnote 25 Community resources were deemed insufficient to help these women navigate medical spaces. As one writer in the South Asian feminist journal Mukti explained: “Back home I would have a lot of help to bring up the children … Relations and friends would have been involved in raising my children.”Footnote 26 The National Childbirth Trust made similar observations about the differing layers of support available to South Asian women in Britain: “In their countries of origin, they are accustomed to a system where guidance was personal and came from members of the family and from a well-known midwife. Special information therefore needs to be presented to Asian expectant mothers.”Footnote 27 Differences in diet, language, and culture were identified as areas worthy of consideration. According to the activist Sheila Kitzinger, South Asian “women welcome the chance to learn about their own bodies and how to communicate with professionals in the Health Services to maneuver their way through what is sometimes like an obstacle race in order to get healthcare suited to their needs.”Footnote 28
By the late 1970s, calls to enhance support for South Asian maternal health caught the attention of the national government. Commissioned by the Labour Party, the Social Services Committee published the 1980 Short Report, which recommended that health authorities make “positive efforts to seek out pregnant women in the minority ethnic groups, using every means in their power.”Footnote 29 In the same year, a “Mother and Baby Campaign” was launched by the Health Education Council to increase public awareness of the importance of early antenatal care, healthy eating, and the need to cut out alcohol and smoking during pregnancy. This involved the distribution of the 1982 “Guide to Healthy Pregnancy,” a booklet and flexidisk record with Dr Miriam Stoppard answering questions about pregnancy, which was also advertised in local newspapers and women’s magazines. Although this material was for general distribution, an effort was made to get it into the hands of South Asian women, with advertisements appearing in South Asian outlets such as Garavi Gujarat, Panjabi Times, and Azad Weekly.Footnote 30 The campaign’s ability to reach minoritized communities, however, was limited. This was reflected in the Health Education Council Publicity Unit’s survey as well as the Social Services Committee’s 1984 follow-up report that echoed concerns relating to high perinatal and neonatal mortality rates among Britain’s South Asian population. This time the authors of the report called out the DHSS for its inability, and seeming unwillingness, to act. In response to the disparities faced by South Asian mothers, policymakers thus stressed the need for accessible and appropriate maternity and perinatal care for all Britons, emphasizing that this included its racialized minorities.
The AMBC was launched nationally on 12 September 1984 at Admiralty House in Whitehall by Princess Anne and the minister for health Kenneth Clarke. The £1.2 million project was financed by the Department of Health to promote equal access to health services and initially emphasized issues relating to the health of South Asian mothers and their babies. In particular, it highlighted perinatal mortality rates in some South Asian communities that were significantly higher than in the population at large. At the launch of the campaign, Clarke noted that the perinatal mortality rate for babies of mothers born in Pakistan was 26.3 per thousand, compared to 12.9 per thousand for babies of white British-born mothers.Footnote 31 For mothers born in India and Bangladesh the figure was 15.7 per thousand.Footnote 32 Clarke observed: “those are really very worrying figures—the discrepancy is far too wide.”Footnote 33 It was these statistics, he explained, that had prompted a national “Asian Mother and Baby Campaign.” He hoped the campaign would persuade South Asian mothers to make better use of obstetric facilities provided by the NHS. The medical and political necessity for the DHSS and health authorities to take action over perinatal mortality rates thus legitimized the campaign.
Veena Bahl, an East African Asian health advisor to the Department of Health and a registered nurse, was tasked with directing the campaign. Bahl had previously worked on a campaign to “Stop Rickets” among Britain’s South Asians, which ran from 1981 to 1983. This previous work had ostensibly revealed that South Asian families were often unable to make full use of health services partly because those providing the services were frequently insufficiently aware of the needs of racialized minorities and partly because of the cultural barriers between them and the health service.Footnote 34 The “Stop Rickets” campaign team found that publicity about health services was not reaching minority groups. The AMBC’s design therefore mirrored previous initiatives.Footnote 35 As a response to public health concerns, it was part of wider efforts by healthcare reformers to address inequity in healthcare experienced by Britain’s racialized minorities.Footnote 36
In addition to the medical and political import of the AMBC, Bahl explained the cultural dynamics at play. According to Bahl, South Asian women in 1980s Britain came “from a culture in which pregnancy [was] not generally a medical concern.”Footnote 37 South Asian babies were therefore deemed “at risk” by the NHS because, according to Bahl, “those women who were persuaded to attend clinics could not understand what was going on, and were often confused and frightened by the attitudes of doctors and hospital staff.”Footnote 38 It was understood by the campaign team that South Asian women found it difficult to get care early enough in pregnancy and that, unlike in the case of other minoritized groups such as the West Indian community, serious attention had to be paid to language and cultural barriers that were preventing these women from making full use of NHS services.
The AMBC consequently set out to ensure antenatal care and procedures were accessible to South Asian women. It had four key aims: to encourage early diagnosis of pregnancy and uptake of maternity services, including education in parentcraft; to improve communication between expectant mothers and health professionals; to help health professionals gain the cooperation of South Asian families; and to help South Asian families to become fully aware of the maternity services available to them and of the reasons for using them.Footnote 39 To achieve these aims, the AMBC embarked on an educational and publicity campaign in areas with substantial British South Asian communities. This was consistent with wider efforts to focus on health education by the Thatcher government. Publicity was directed through the South Asian press, as well as television and local radio programs, such as the BBC1 radio show “Gharbar.” It included the use of several radio jingles and the insertion of commercials at the start of popular South Asian films. Since there was a perceived need for relevant information and advice about postnatal depression, family planning, and eating during pregnancy, the campaign team produced videos in South Asian languages. In so doing, the campaign sought to create a “machinery for cooperation” between authorities and communities.Footnote 40
The second key feature of the AMBC was a two-year linkworker scheme, which became the main thrust of the campaign. The DHSS provided funding to employ a total of 96 linkworkers in areas with large British South Asian communities. These linkworkers were specially trained women of South Asian heritage—usually with personal experience of the maternity services—who spoke English and one or more South Asian languages fluently. Linkworkers did not have any medical training; instead, they were given a two-week induction with a campaign trainer. Their role was to provide a link between expectant mothers and health professionals, helping to explain expectant mothers’ feelings and worries and giving vital health information on behalf of health professionals.Footnote 41 As such, linkworkers were introduced first in health authorities in Birmingham and then in Leicester, Bradford, Blackburn, Bolton, Newham, Wandsworth, Luton, Brent, Dewsbury, Huddersfield, Wolverhampton, and Walsall.Footnote 42 When they worked with doctors, linkworkers offered linguistic help so that detailed information could be passed to the patient. They also provided sensitive assistance to help patients feel comfortable. On occasion, linkworkers also offered insight into cultural differences. To the women they worked with, linkworkers provided translation and interpretation; emotional support; help with vegetarian or halal meals in hospitals; health and reproductive education; and guidance on health procedures, social services, and welfare benefits. They helped to set up and run mothers’ and parents’ groups and often accompanied women to clinics and hospitals. They remained available to these women and their babies for up to six weeks following birth. The campaign therefore focused on linkworkers as vital facilitators. Linkworkers helped to bridge language and cultural differences, interpret nonverbal signals, and alleviate anxieties and apprehensions on both sides.Footnote 43 Altogether, sixteen districts were involved in the campaign. Nine of those decided to continue the scheme in some form or another after central government funding ran out in 1988.
The campaign served to generate good publicity for the Thatcher government, which had been condemned for passing the 1981 British Nationality Act. The Act, which ended birthright citizenship, also overturned the nationality legislation introduced in 1948 by distinguishing Britain from its colonies and, in the process, equating Britishness with whiteness. As the journalist Diane Smith observed, the AMBC offered valuable publicity for the Conservative Party at a time when its discussions on repatriation and unemployment among racialized communities had “created bad press for the government on racial issues.”Footnote 44 Labour Party politicians such as Renee Short, member of Parliament for Wolverhampton North-East, had in fact been pressing the Conservative government to take action on health disparities among Britain’s racialized communities for some time.Footnote 45 Critics of the campaign thus considered the campaign as an attempt by the Conversative government to “create a two-pronged attack on their poor image at very little cost.”Footnote 46 So important was this publicity that when researchers found that South Asian women were less likely to be treated by GPs with obstetric qualifications and less likely to get antenatal care, Clarke rejected pleas for strengthening resources. He stated that the “government would not instruct authorities how to improve services to minorities, it would rely instead on health education and the enthusiasm and cooperation of local Asian communities.”Footnote 47
From an institutional perspective, healthcare professionals praised the campaign’s material value. Feedback received by the campaign team indicated that its work relating to publicity and health promotion was ineffective, but that the linkworker scheme had successfully improved patient care.Footnote 48 This can also be traced in the annual evaluations carried out by a research team at the University of Leicester on behalf of the AMBC’s committee and the SCF. These findings showed that the initial response among clinical teams to linkworkers was hostile, but that this soon shifted toward a grudging acceptance. At first, some health professionals believed that linkworkers were insufficiently qualified to advise them. Others felt threatened by their presence.Footnote 49 However, once the campaign was established, the majority of health professionals who had worked with linkworkers stated that they were satisfied with the help they received from them. In a survey distributed by the research team, most respondents thought that their advice to South Asian patients became clearer and less threatening with the assistance of linkworkers.Footnote 50 Health professionals also celebrated the cost effectiveness of the campaign: they ended up spending less time per home visit, they paid fewer visits, and they were almost certain that they achieved better outcomes.Footnote 51
Health Citizenship and Community Activism
In terms of its ability to strengthen health citizenship, the campaign received a mixed response. Linkworkers were well-regarded by their South Asian patients. As one oral history interviewee, Nasrine Aktar, explained:
I was 18 when I was pregnant with my first child. The staff were all very nice and I had a good experience. I stayed in hospital for about 3 days and they taught me everything. It was very helpful.Footnote 52
Nasrine felt cared for and connected to the linkworkers who supported her. They did not treat her as an outsider or as someone who did not belong. This was important given that the AMBC’s annual evaluations revealed health professionals’ reluctance to assist South Asian women in gaining access to welfare provision. These reports found that some nurses and midwives placed a heavy emphasis on the allocation of, or competition for, resources, which they felt were unfairly being used to support South Asian women. One midwife stated: “I feel that money being spent should be used to benefit the whole population. There is a lot of poverty among the white population and also West Indian population and I feel these groups are being left out in the cold.”Footnote 53 Others commented that South Asians were well-versed in draining welfare services: “Asians are very good at getting welfare benefits and using the system. They don’t need so much help.”Footnote 54 In contrast, South Asian patients reported that linkworkers went out of their way to offer help and guidance.
Although it was not the intention of the project, the information offered by linkworkers became a way of empowering patients. Centralized healthcare was mediated by linkworkers so as to provide welfare support at a time when the Thatcher government was seeking to reduce institutional care. As the campaign sought to bring informal structures of care into the NHS, linkworkers played a key role in helping diasporic communities negotiate their orientation toward welfare politics and arguably assert their right to healthcare as citizens within formal state structures. They did so by encouraging an albeit specific neoliberal vision of citizen participation, which championed individual experience and equated access to healthcare with social democratic ideas of equitable treatment. Linkworkers highlighted issues that affected South Asian mothers, such as ensuring the availability of long dressing gowns in order to address concerns about modesty, communicating dietary requirements, negotiating suitable visiting times, and allowing the presence of female relatives during labor. In turn, women were able to ask for more information on cervical smears, breast examinations, rubella, postnatal depression, and disability.Footnote 55 This enabled health authorities to provide more sensitive and appropriate services beyond obstetrics care. Health authorities subsequently approached maternity services with an awareness of the varying needs of Britain’s diverse populations. One health authority began providing books in South Asian languages in their antenatal clinics.Footnote 56
Operating as a new tier of welfare officers, linkworkers, through the consultative process, stressed the right to make choices about labor or the right to learn how to use the welfare state. This is highlighted in one of the evaluation reports conducted by the AMBC committee, which stated:
I think the areas where they can be most useful are child development, housing difficulties, welfare rights, day care arrangements, what social services offer to the Asians etc, there were so many issues regarding the Asians which we didn’t know existed, and here the linkworkers participated in letting us know about such problems.Footnote 57
In supporting South Asian women to gain access to welfare services, it can be argued that linkworkers helped to reshape the state-citizen relationship. Linkworkers highlighted that South Asian women were only notionally recognized as British citizens and they oftentimes systematically lacked the material, political, and economic resources to exercise the rights enjoyed by most citizens. In their capacity as unofficial welfare officers, linkworkers subsequently helped to reconfigure health citizenship not as something bestowed upon South Asian women in Britain, but as a process enacted by citizens through their interaction with British institutions such as the NHS as well as housing and social service structures. Although this was in many ways an unintended consequence of the campaign, it was particularly significant given that British immigration law during this period subjected migrant populations to medical inspection. There were a number of cases in the late 1970s of South Asian women forced to undergo intimate gynecological examinations to test whether they were virgin fiancées or attempting to enter the country illegally.Footnote 58 These “virginity tests” and other forms of medical border controls were used to exclude non-white communities on health and sexual grounds.Footnote 59 Fed by media campaigns at the time, migrants’ health and reproductive practices bolstered anti-migrant rhetoric. Moreover, South Asian migrants were not only treated with suspicion, but were viewed as vectors of disease, such as tuberculosis.Footnote 60 In this context, linkworkers played an important role in countering images of the NHS and Britain’s medical services as unsafe, unwelcoming spaces for South Asian women. Instead, they sought to promote social change through the enactment of citizen participation in medical spaces. Linkworkers also went into the homes of patients and accompanied them to their appointments in hospitals or during labor. They facilitated greater use of obstetric facilities and encouraged the South Asian women they worked with to constitute themselves as citizens able to access universal healthcare. In this way, the campaign enabled British South Asian women to engage with, negotiate, and reconstruct more expansive ways of thinking about health citizenship.
There were, however, limitations to the campaign’s embrace of community expertise. While the campaign invited South Asian women to work within NHS structures as linkworkers, they did so as peripatetic workers. From the outset of the AMBC, observers critiqued the terms of employment that were offered, which did little to provide stable employment nor long-term collaboration with underrepresented communities. The linkworker scheme was originally meant to be administered by the SCF. However, the SCF’s in-house union decided to oppose its involvement due to the terms of the contracts on offer, which were originally only for one year. The Health Education Council’s union similarly opposed the Council’s association. Even after the DHSS funded the campaign, there was real concern about the poor salary of linkworkers, which was roughly £90 a week.Footnote 61 One writer outlined that the campaign was in the business of creating exploitative, low-paid jobs for South Asian people without giving them much support.Footnote 62
[The linkworker] is in fact in a totally subordinate position coming right at the bottom of the National Health hierarchy. The linkworker’s salary keeps her firmly in her place: £4,883 [equivalent to £15,213 in 2025] excluding London weighting for a 36-hour working week. She is employed on a fixed 2-year contract and will probably be jobless at the end of it.Footnote 63
In addition, linkworkers would often work overtime, on weekends, and would accompany clients at births on request on a voluntary basis. Unsurprisingly, then, low salaries combined with the temporary nature of the campaign created anxiety and demoralization. Toward the end of the campaign a number of linkworkers resigned. Others observed that inadequate staff facilities created an image of linkworkers as merely low status helpers rather than trained healthcare workers.Footnote 64 The precarity of their roles meant that initiatives of this kind failed to increase the proportion of underrepresented racialized minorities among health professionals or create a healthcare workforce with the ability to deliver long-term quality care for Britain’s minoritized communities. While South Asian women were invited into medical spaces through tremendous effort on the part of the campaign team and linkworkers, it would thus be misleading to suggest that the temporary employment of linkworkers during the campaign transformed the NHS into a paragon for welfare inclusivity.
Moreover, although the AMBC ostensibly signaled a shift from the state’s investment in the “health of the white nation” to a commitment to the “health of a multi-racial Britain,” its ambitions were limited by its failure to fully embrace community and grassroots views, or to embed them within NHS structures in a meaningful way. An article published in New Life, which labeled the AMBC’s publicity campaign “an intrusion,” claimed that the campaign was “highly dangerous and patronising.”Footnote 65 It explained that strong opposition had been voiced by many health groups, doctors’ unions, and South Asian women’s groups. Elsewhere, the Leeds Community Relations Council wrote to Bahl to caution against the campaign’s design, which it felt was open to misinterpretation and could create the impression that it was only South Asian mothers and babies who were at risk.Footnote 66 Similarly, the Camden Committee for Community Relations also expressed its apprehensions. In a letter to Clarke, its leadership wrote: “The health service seems to be educating the Asian community to use the services provided … without doing anything to assure that the community receives a more equal share of the health service.”Footnote 67 In response to these criticisms, a selection of community members were invited to join a working group on “Asian health,” but when grassroots and community experts raised concerns, they were roundly dismissed for “espousing the propaganda of the radical left.”Footnote 68
This detachment from community organizing also caused friction between the campaign staff and the SCF. As one report suggests, there were serious divisions on the issue of control over the management of the campaign and the definitions of its priorities. The SCF favored a decentralized model of change that would “facilitate participation from voluntary organisations and legitimise their claims.” In contrast, for the DHSS, keeping control over the initiative was of paramount importance. The AMBC’s policy was demonstrably to target some factors that led to healthcare inequalities in the hope that institutional change at the policymaking level would follow.Footnote 69 But for observers, such as the SCF, it demonstrated that top-down interventions were not always the best way to effect change.Footnote 70 Community-based approaches that followed the model of health advocacy found, for example, in parallel community campaigns in London’s Tower Hamlets and the Hackney Multi-Ethnic Women’s Health Project established in 1980 were judged to be more effective.Footnote 71 These campaigns recruited project workers through the Community Health Council where they had more autonomy. Health advocates were able to develop procedures to meet women’s needs. They were able to articulate the needs of communities because they were accountable first and foremost to patients rather than health professionals. Similarly, the Family Service Unit’s work in the early 1990s tells us that in order for all groups in society to have equal access to quality services, maternity services had to move toward a more community-oriented approach. For the Family Service Unit, the policy implications of decentering grassroots support for South Asian women’s maternal health reduced efficacy. This led to the conclusion that the AMBC should have paid more attention to health advocacy, such as improving service provision and tackling structural discrimination rather than attempts to change the attitudes of South Asian women.Footnote 72 Thus, while linkworkers helped to make inroads in expanding health citizenship to migrant women, the AMBC was subsequently described by researchers, such as Yvette Rocheron, as “piecemeal reform,” which failed to effect long-term change.Footnote 73
Race and Racism
The experiences of South Asian women during the AMBC offer important insight into healthcare reform and constructions of post-imperial racial formations in late twentieth- century Britain. This is because tensions relating to racial, cultural, and class-based differences were deeply felt by the linkworkers and the women they worked with. Despite the AMBC’s ambitions, there was a noticeable gap between the campaign’s stated aims and its lived realities. The AMBC was conceived as a pilot-scheme that could “lead to the development of a coherent approach to healthcare provision for a multi-racial Britain.”Footnote 74 Yet, given its preoccupation with cultural differences, health and anti-racist activists claimed that the campaign strengthened stereotypes of the typical South Asian mother: a woman who was unable to speak a word of English and was entirely subjugated and oppressed by her husband and in-laws.Footnote 75 Within the AMBC, “Asian” was understood to include Pakistani, Bengali, Indian, and East African Asian communities, yet statistics referencing Pakistani mothers were frequently used to explain the urgent need for intervention. This meant that while NHS policymakers consistently referred to “ethnic minority health” in an attempt to avoid racialization, once campaigns like the AMBC entered healthcare spaces, racialized categories were imposed on complex and heterogenous communities. This served to obscure the internal cleavages of Britain’s South Asian population and contributed to the racialization of “Asian” women in Britain. Bahl herself recognized: “In one antenatal clinic, as soon as a woman got up wearing Asian dress, the voice of a midwife would automatically rise, as if the woman wouldn’t understand—yet sometimes the woman was a lawyer or teacher, speaking perfect English.”Footnote 76 She also noted that South Asian names were deemed difficult to pronounce so nurses would “just call the baby Patel or Singh.”Footnote 77 Similarly, in an oral history interview I conducted, Gurdeep Kaur explained that a lot of East African Asian women could speak English fluently. Those who needed more support were oftentimes accompanied by family members. Other interviewees, such as Anwar Khan, explained that although some women certainly welcomed translators, others “got on ok with the English they knew.”Footnote 78 Health professionals’ responses to the AMBC therefore did little to dismantle the view that South Asian women comprised a homogenous block.Footnote 79 In this way, the campaign perpetuated an image of British South Asian mothers that became a corporeal shorthand for difference while homogenizing a diverse population.
The campaign’s focus on language barriers similarly reinforced attitudes that migrant populations were unwilling to assimilate and were perpetually foreign.Footnote 80 This was instantiated by the campaign and maintained within NHS practice. Examples of discriminatory attitudes were captured by the campaign’s follow-up study and showed a propensity among healthcare professionals to connect language skills to poor health outcomes. Typical comments made by midwives included:
They should have training in our ways; they decided to live in our country.
They should, as we would be expected to, learn to communicate themselves in the national language.
I am trying to give healthcare to mothers; if they cannot take the trouble to learn English it is their loss.
I receive the best training available. If Asian women learned English, there would be no problem.Footnote 81
These statements reflected the view among healthcare professionals that South Asian women’s perceived refusal to integrate posed a threat to British progress and to the healthcare providers’ own professionalism, without acknowledging the limited availability of free language training during this period. They reinforced the DHSS’s position that, rather than improving the material conditions of those living on the margins, assimilative education could solve inequalities in health provision.
The scheme thus sharpened perceived difference and reinforced notions of unassimilable communities. Critics of the campaign argued that the stereotypical assumptions on which NHS and AMBC structures operated subsequently influenced the care South Asian women received. South Asian women were observably denied equal access to maternity services through attitudes that equated lack of English proficiency with a lack of intelligence. Many health workers assumed that South Asian people were somehow backward in their attitude toward antenatal care, breastfeeding, and looking after young mothers. At the same time, many women felt their needs were ignored because of perceptions that they would not make a fuss or be able to make a complaint. Savita Patel, a young mother, remembered that she was treated like a “silent doll.” When she asked for vegetarian food, a healthcare assistant brought her sardines and did not understand why Savita had not eaten them. Savita revealed: “They think you are a burden because you don’t speak English, or simply because you are different.”Footnote 82 Dismissed as linguistically and intellectually lacking, these women were rendered by some healthcare professionals as in the nation but not of the nation.
It is unsurprising, then, that a sizable number of activist and community groups came together to protest against what they described as the campaign’s “racialist” outlook.Footnote 83 At a time when Black and South Asian activists mobilized together under the banner of “political Blackness” and spearheaded numerous campaigns relating to reproductive justice, they claimed:
Racism is a concrete issue for all black people in Britain. One of the most fundamental ways in which racism is manifested is through the health service. It needs to be addressed directly.
Black people have been made scapegoats for the failure of the service. Our visibility, our culture, our language, our religion and background are seen to be the cause of our ill health, as defined by white professionals, white structures, white treatment in white hospitals with white medicine. We now want to examine the real cause.Footnote 84
Some of the controversy that surrounded the “Stop Rickets” campaign, specifically its perceived victim-blaming model, had, according to community groups, been reproduced by the AMBC. An article published in the South Asian journal Mukti claimed: “It’s perfectly clear that it is Asian women who are being treated as problematic. Not only are we defined as the problem but also as the cause and the victim.”Footnote 85 For this reason, the campaign was understood by activists as an attempt to educate South Asian communities in the norms of “white parentcraft.”Footnote 86 Although South Asian women faced misdiagnoses, delayed diagnoses, the withholding of care, and deaths at a disproportionately higher rate than their white counterparts, the prevailing view among caregivers was that South Asian women were themselves chiefly to blame for problems in the delivery of antenatal care. Rather than addressing the paucity of research on the experiences of women of color, healthcare campaigns like the AMBC upheld medical hierarches that considered the white female body as the standard for maternal health.
Users of the campaign, as well as the linkworkers, identified similar issues. They highlighted attitudes that were oftentimes hostile, discriminatory, and racist, yet little was done to meaningfully address structural and institutional discrimination. The following comments were typical of those made by white nurses and doctors to linkworkers:
We are a superior race, they should accept the service that we’re giving, it’s better than anything they can expect at home (Westminster hospital).
All Asians are from peasant stock and have low IQs (Leicester hospital).
They should only be allowed into this country with a contract to learn English within 6 months (Wolverhampton hospital).Footnote 87
In addition, critics observed that so pervasive was ward folklore of “birth coming easy” to so-called “Third World women” and of “babies in the field in 10 minutes” that women’s needs were often ignored.Footnote 88 At the same time, maxims about low pain threshold and insensitive remarks about large families and child-rearing practices were casually and frequently tossed around, demonstrating surviving traces of exclusionary, colonial logics.Footnote 89 This continued a tradition of imperial maternal health that sought to bring medical relief to imperial subjects through the provision of healthcare to South Asian women.Footnote 90 There are, for example, parallels with the establishment of the Dufferin Fund in 1885, which had been dedicated to improving women’s healthcare in India. The fund provided scholarships to train Indian women as hospital assistants. As Geraldine Forbes has observed, the initiative was concerned less with women’s welfare and more with generativity and safeguarding the colonial state’s economic and political power.Footnote 91 In a similar manner, by institutionalizing a particular image of South Asian mothers in Britain, the AMBC demonstrated how racial hierarchies of difference were embedded within post-imperial geographies.
For South Asian feminists, healthcare initiatives during this period pushed the expectation that South Asian women should assimilate not just to the British way of life, but to notions of white motherhood.Footnote 92 Campaigns like the AMBC, despite their inclusivity agenda, did little to support what the cultural theorist Stuart Hall has described as “multicultural drift,” a gradual process where Black and South Asian populations gained greater visibility and embeddedness within British society.Footnote 93 Instead, since the campaign focused on “lifestyle drift,” that is, on narrow behavioral explanations and lifestyle interventions (mainly cultural) relating to individual behavioral change, it arguably pathologized South Asian women. The campaign’s emphasis on cultural difference ultimately served to structure stereotypes of British South Asians. In this way, it demonstrated the limitations of campaigns for welfare inclusivity. According to anti-racist activists:
Implicit is the distorted, invidious, racist logic that the victim is the cause. What you have created is a de-facto segregated, problematic pregnancy enclave … The real barrier is racist codes of communication, consistently and constantly directed at us as problems. You do not question or examine your modes of operation.Footnote 94
It is interesting to note that South Asian women’s long history as “ayahs” did not factor into discourses on South Asian motherhood. An early history of South Asian women’s migration to Britain can be traced in the migratory journeys of “ayahs”—South Asian maids and nannies who journeyed to Britain in their thousands in the late nineteenth and early twentieth centuries with British families returning from the colonies. Not only did these women create, as Olivia Robinson noted, a “global network of working women of color who leveraged opportunities for themselves and demonstrated considerable independence and assertiveness,” but they also revealed how in this specific colonial context South Asian women were believed to be “innately suited to childcare.”Footnote 95 The valorization of particular types of civic contribution—that is, care-work for white British children—stood in stark contrast to the devaluing of South Asian mothering in Britain. As South Asian women in postwar Britain became sites of racial inscription, there was, therefore, an ideational shift from “trusted ayahs” to “uninformed mothers,” demonstrating the ways in which contemporary racializations and their mutations are constituted in the face of changing historical circumstances.
In this context, the AMBC was criticized for focusing its attention on racial difference rather than tackling racial discrimination. Although South Asian mothers were themselves held responsible by healthcare reformers for high perinatal mortality rates, numerous studies provided statistics that proved that South Asian women did in fact take up maternal services and did book early enough to use these services.Footnote 96 Instead, these studies suggested, structural racial discrimination resulted in disparities in care. This was also captured in the study carried out by the University of Leicester, as a substantial proportion of midwives and health visitors felt that their training had not equipped them adequately for the delivery of care to South Asian families. Some explained that they had been trained to care only for white English families, which meant that they did not always understand South Asian women’s needs. The campaign subsequently organized a conference on “Racism and the NHS.” Yet at the conference, the linkworkers were told that it was up to them to combat racism in the NHS. Health professionals were also given information about bad practice. Despite this, one midwife claimed:
More could be done to combat racial prejudice among staff which is more prevalent and deeply ingrained than is generally realized. In spite of their caring image, the nursing profession is no less susceptible to racism then is the community at large. Proper care is not possible when the patient is regarded with scorn and distaste.Footnote 97
Relatedly, some linkworkers reported they were hesitant to translate health professionals’ instructions when they revealed a remarkable degree of insensitivity and intolerance toward the racial position of linkworkers and their clients. This oftentimes applied to comments such as: “She should have less children” or “has she thought about family planning? She shouldn’t have any more children if she cannot speak English.”Footnote 98 South Asian women were generally characterized as repressed and submissive, as victims of male control and of unchanging tradition. If we are to understand the AMBC as a healthcare intervention in reproductive care, it is evident, as these testimonies suggest, that South Asian women were subject to surveillance and discipline. When linkworkers entered healthcare settings, healthcare professionals attempted to use them to control South Asian women’s fertility and influence their family planning decisions. The experiences of linkworkers and the South Asian women they worked with thus illustrate how the deployment of the linkworkers was intended to encourage South Asian families to conform to specific “Western” norms of medical care and the nuclear family, and therefore should be understood within a context not only where racial prejudice and racist practice was widespread, but where medicalized systems of control were being implemented. Like the “Stop Rickets” and tuberculosis tests, the campaign was a way to bring South Asians more fully into NHS systems of surveillance.Footnote 99
Rather than concentrating on broader socio-political factors that shaped their lives, the structures of exclusion reinforced by healthcare professionals were criticized by activists for singling out South Asian women. As one of the researchers at the University of Leicester, Yvette Rocheron, noted, the campaign served to create a “pathology of ethnic minority health.”Footnote 100 This in turn created space for discriminatory stereotypes, such as the “Mrs Bibi, or Mrs Begum Syndrome,” a derogatory term used by physicians that characterized South Asian women as being overly dramatic and untruthful. The AMBC’s discussions of maternity thus did little to dismantle epistemologies and racial categorizations derived from colonialism. Further still, it played a crucial role in the ideological constructions of racialized communities in late twentieth-century Britain. In so doing, the campaign neglected the wider structural determinants that shaped healthcare outcomes.
Class
The AMBC raised a number of questions: why an ideational shift from South Asian “trusted ayah” to “uninformed mother”? Why a campaign for South Asian women rather than for both Black and South Asian women? Why did the DHSS fund a campaign concerned with “ethnic minority healthcare inequality” when the welfare state was in retreat? In order to address these questions, it is important to consider how issues relating to class and NHS resources were negotiated.
The 1980 Black Report was released in the same year as the first Short Report. Following an investigation chaired by Sir Douglas Black, the report documented the extent of health inequality in the UK. It found that within the general population there were differences in mortality rates across the social groups, with those in lower social groups suffering higher rates of mortality. The report recommended increased government intervention and spending in community health and primary care and, importantly, on broader social policy, such as child benefit, housing, and working conditions.Footnote 101 The need for structural change only increased in the 1980s as inequality rose faster in the UK than in any other OECD (Organisation for Economic Cooperation and Development) country and wage inequality reached an all-time high.Footnote 102 An Institute for Fiscal Studies report showed that the rapidly growing numbers in poverty from 1980 onward were dominated by families with children.Footnote 103 The national child poverty rate also rose substantially, from 13 percent in 1979 to a peak of 29 percent by 1992.Footnote 104 However, due to the scale of expenditure proposed by the Black Report, the Conservative government did not endorse its recommendations. Instead, as the AMBC has shown, the Conservative government championed health education. To use the words of Anna Davin: “the solution to a national problem of public health and of politics was looked for in terms of individuals of a particular role: the mother.… The inadequacy of individuals was a more acceptable explanation for infant mortality than the shortcomings of society.”Footnote 105 Davin’s work, which observed these discourses around the turn of the twentieth century, shows that there had, for over a century, been a tension between the individual and the state over who should be made responsible for raising the next generation. These discussions have been reworked over and over since the 1870s and, in different historical moments, racialized communities such the Irish, the Welsh, and in the case of the AMBC, South Asians.Footnote 106
In the British postwar context, healthcare reformers reworked long-standing debates about infant mortality, mothering, and national health to focus on South Asian mothers. It was perceived that informed South Asian mothers “would be better at extracting maximum utility from the NHS.”Footnote 107 The AMBC thus held South Asian mothers solely responsible for navigating poor-quality housing, food, and working conditions. Public health interventions were designed to educate them in how to navigate economic inequalities that were largely out of their control. In this way, the production of educational materials and the employment of temporary linkworkers avoided tackling widening economic inequality that required long-term investment. It also neglected the needs of Black British mothers because concerns relating to acculturation and rigid behavioral choices that lay at the heart of the AMBC, such as language barriers and oppressive in-laws, could not be applied to Black British women. Rocheron argues this reflected the state’s strategy to transform cultural antagonism into cultural pluralism: it was hoped that the removal of cultural barriers between South Asian patients and health professionals would dissolve racist practice.Footnote 108
Along these lines, the campaign spoke volumes on how social determinants of health outcomes went unacknowledged by healthcare reformers. As Dr Carlos Ferreyra of the Community Health Group of Ethnic Minorities in Ealing set out: “perinatal mortality figures for the ethnic communities are nothing exorbitant compared to figures for social classes four and five in this country.”Footnote 109 Ferreyra explained that disparities in health outcomes correlated with the fact that the majority of racialized communities were in the lower social classes. In contrast, the infant mortality rate for a baby born to a British-Kenyan or Ugandan Asian mother in social class one (professional workers) would have been no different from the infant mortality rate for the population as a whole. The AMBC failed to fully grapple with these class determinants. This shows that without addressing the complex interplay between race, socioeconomic determinants of health, and health outcomes, the campaign served to solidify characterizations of class and racial difference.
Culturally Adapted Care?
The AMBC is indicative of how healthcare initiatives shaped popular ways of understanding race, citizenship, and multiculturalism in late twentieth-century Britain. The campaign deployed a publicity and linkworker scheme that sought to help South Asian mothers navigate “alien” healthcare environments, mediate relationships with medical professionals, and gain access to welfare services as a right. As levers for support, South Asian linkworkers offered a vital service in inviting women into medical spaces and encouraging specific neoliberal forms of health citizenship that privileged individual experience over community-based initiatives. Yet, even with this support South Asian women experienced deep-seated discrimination relating to class and racial difference. Moreover, despite political and social science research indicating that quality of housing, food, and working conditions significantly impacted health outcomes, the solution to health disparities, according to healthcare reformists, was an educational campaign for South Asian mothers. The AMBC emphasized effective bodily management, such as managing diet and seeking early medical support. This fed into the long-standing ideological construction of motherhood, in that women as mothers were held responsible for navigating not just medical spaces but also structural economic, social, and political inequalities.
Additionally, as personal testimonies reveal, the AMBC contributed to pathologizing South Asian women in Britain. The image of British South Asian women it projected was oftentimes at odds with the realities of a complex and heterogenous diaspora population. Through its disavowal of these concerns, the AMBC served to reinforce disparities in care within NHS structures. It failed to fully grapple with the etiology of health inequalities, the paucity of literature on South Asian women’s antenatal needs, and the sources of these disparities that were rooted in historic and contemporary inequities. Since the campaign was a temporary measure, racial stereotyping within clinical encounters and competition for resources continued to shape differences in healthcare experiences and provision. By detaching grassroots, community networks from maternity care, South Asian mothers were treated as in the nation, but not necessarily as of the nation. In this way, campaigns like the AMBC demonstrate how top-down, consumer-driven approaches to healthcare reform in an age of multiracial, multicultural, and neoliberal Britain came to shape the construction of post-imperial racial formations.
Saima Nasar is Senior Lecturer in History at the University of Bristol. I would like to express my gratitude to the anonymous reviewers of this article, Nadja Durbach, Tammy Proctor, James West, and Sadiah Qureshi for their helpful feedback. I would also like to thank Yvette Rocheron and all the women who were interviewed for this project. The research for this article was generously funded by The Leverhulme Trust. Please address any correspondence to saima.nasar@bristol.ac.uk
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