Contributor: Ellie Stang, MD
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While the Senate recently passed a bill that would recognize Juneteenth as a new national holiday, there is still much work to be done to ensure Black Americans have an equal start in life without experiencing the devastating effects of racism. This is true for all babies of color – Black infants especially - and the challenges they face even prior to birth.
Bias impacts a child’s health even before birth and gradually affects long-term well-being and health. This truth is reinforced annually, in updated metrics that reveal persistently high preterm birth rates and low birth weights in Black infants. While overall infant mortality rates are decreasing, a wide range in mortality by race shows Black infants are still disproportionately affected. Today, Black babies are more than twice as likely as their white counterparts to die before their first birthday.
And the Black maternal mortality rate due to pregnancy-related complications is 3 to 4 times higher than that of white women, even when adjusted for education and socioeconomic status. Even a celebrity like Serena Williams had to fight to be taken seriously when she complained of shortness of breath, despite having a previous history of pulmonary embolism.
Systemic racism and its life-altering effects – discrimination, implicit bias, medically inappropriate variations in care, and social determinants of health (SDOH) – have been woven into the very fabric of our society, from its founding to early medical practice and scientific research. Indeed, Dr. Maria Trent, a professor of pediatrics at Johns Hopkins School of Medicine, said of racism: “It's taught, it’s passed down, but the impacts on children and families are significant from a health perspective.”
It is high time we work to disrupt this cycle. As the pandemic continues amidst a long road to recovery, we must take the opportunity to reframe the delivery of healthcare in the U.S. to effect meaningful change. By embracing antiracist ideas and policies, providers can actively challenge deeply rooted effects of racism and bias wherever they arise, whenever they are encountered. Here are a few antiracist principles that individuals and care teams alike can adopt:
Examine our own implicit biases to eliminate variations in care
While implicit bias can sometimes be hard to recognize, it is all too common: a recent study found two out of three clinicians hold implicit bias against Black and Latinx patients. This has been shown to result in different standards of care and treatment options offered to patients based on race: doctors were shown to be more likely to recommend advanced medical treatments for their white patients than they were for their Black ones. Black Americans are consistently undertreated for pain relative to white patients – which tracks back to studies that reveal nearly 50% of medical students and residents hold false beliefs about supposed biological differences between Black and white patients, such as higher levels of pain tolerance. On a national scale, recognizing how implicit bias can shape care plans – and an individual’s outcome – will be critical when working toward more equitable care delivery. Scholars posit the heart of racism is denial and unless addressed head-on, harmful inequities will be perpetuated.
Many academic and health institutions nationwide are taking first steps to “dismantle racism at every level,” including: The American Academy of Pediatrics, The American Medical Association, The American Public Health Association, The American College of Obstetricians and Gynecological Health and The American Psychological Association, just to name a few.
As the face of healthcare, today’s clinicians are uniquely positioned to address health care inequities. Firstly, culturally sensitive clinicians will engage in implicit bias testing and training. Understanding and acknowledging one’s personal implicit biases is a powerful – and necessary – first step when preparing to actively work against them. Next, cultivating a sense of inclusiveness and cultural sensitivity in the office – and outside of it – are key. To this end, this summer the American Medical Association offered a clear set of guidelines on how to establish practice-specific, anti-discrimination policies. Practice managers can work to actively hire a diverse and culturally representative group of clinicians, nurses, and staff members, which contributes to patient comfort and trust.
The import of active listening during appointments cannot be overstated – by being open to patients and taking the time to understand their backgrounds, clinicians can learn much more about where and how to provide the best types of care. This aids discovery of critical health, nutrition, housing, education, and safety needs – all of which contribute to long-term health and wellness. Importantly, the willingness to continue learning and growing along with other providers, patients, and local community and advocacy groups is key in the charge to embrace inclusiveness, eliminate racial bias, and achieve equitable health outcomes for all.
Make room for representation to improve patient-provider relationships
A core tenet of healthcare is trust. Yet, trust amongst the Black community in our healthcare system remains a challenge. In a recent poll, 7 out of 10 Black Americans report being treated unfairly by the healthcare system. Fifty-five percent (55%) said they outwardly distrust it. Those with greater mistrust are more likely to also report being in generally poor health. By working to improve the patient-provider relationship and Black patients’ experiences, clinicians can help foment a continuum of care and ensure more equal preventive, prenatal, and well visits.
For new mothers, building a relationship with the delivery team can make a huge difference in improving birth outcomes. Providers who make an effort to understand the history of disproportionately high maternal mortality rates among Black women and other women of color can better solve for a new mom’s fear and safety concerns before she goes into labor.
OB-GYNs and health systems nationwide are working to help create safe and trusted environments for all patients. Part of these efforts involves making room for more voices in the delivery room: midwives and doulas act as teachers, friends, and care advocates for soon-to-be moms. It is empowering to access support, resources, and information aligned with a mom’s individual needs. A recent study showed states with higher midwife integration scores saw significantly lower rates of preterm and low birth weight babies.
Patients who feel heard, represented, and understood are better able to ask for and receive dedicated care. Diverse hiring practices in medical settings helps ensure a variety of races, ages, genders, ethnicities, orientations, and perspectives are represented – and that care teams can adequately meet the unique individual needs of their patients. Increased patient satisfaction, deeper trust, developed patient-physician partnerships, and improved health outcomes are all associated with greater diversity in the medical workforce. In fact, studies reveal some patients who share a racial or ethnic background with their physician report higher levels of provider satisfaction.
When given a choice, patients often select doctors who “look like them.” When in racially concordant healthcare relationships, they feel more comfortable participating in conversations about their care. Recently, researchers combed through two decades of Florida birth data and uncovered an interesting association: when Black babies were cared for by Black doctors after birth, their mortality rate was cut in half, as compared to that of White newborns. While additional research in reproductive health equity is needed to further understand the causal links between representation and quality care, it reinforces the call to continue diversifying the physician and nursing workforce and help eliminate racial disparities in both newborn mortality – and healthcare overall.
Expand a sense of community
Barriers to healthcare can feel insurmountable, from lapses in insurance coverage, to workday scheduling conflicts, unmet childcare needs, and a lack of connection with available providers. Hospitals, healthcare institutions, providers, payers, and policymakers can begin to build meaningful relationships with their local communities to fill gaps in need and build trust.
Local entities have deep connections to the community and are often best positioned to make measurable improvements in maternal and infant care. Studies show frequent and quality prenatal care results in a marked improvement on both maternal and infant outcomes. For example, payers can forge partnerships with local organizations working to extend prenatal and postpartum care such as Commonsense Childbirth (CC), in Florida. CC’s community-sponsored group prenatal care classes result in reduced rates of preterm birth, NICU admissions, and ED use during pregnancy. CC’s Easy Access Clinics are designed to provide accessible and affordable healthcare to uninsured, underinsured, low-income, and poor pregnant and postpartum women. While the model is proving successful in Orange County, Florida, there is an opportunity to expand their model of care to other communities in need.
In areas where healthcare resources are limited, implementing innovative care options can help expand a sense of community by forging virtual healthcare relationships and reducing barriers to life-saving care. Access to care impacts over ten million women in the United States who live in OB-GYN “deserts," where obstetricians are scarce, or nonexistent. Rural residents are 9% more likely to experience significant maternal mortality than their urban counterparts. Telemedicine and health monitoring apps help share education information and track nutritional intake, pregnancy milestones, and more. The promise is manifold: televisits reduce the need for travel, enable at-home monitoring for blood pressure and hypertension, and facilitate access to specialists when needed. It also provides a lifeline during the postpartum period, by extending resources for lactation services, mental health, monitoring of complications, and more.
Forward-thinking payers can help by financially supporting similar programs and alleviating cost considerations, such as providing a smartphone, tablet, or a calling card, supplying necessary home monitoring equipment, and offering access to costly mental health services, that do not often accept public insurance options. Along with the medical community, they can also push for action to be taken to reduce the disparities which result from the digital divide and insufficient digital literacy. When working with those closest to the specific needs of an area, healthcare efforts have the potential to go further and provide help where it is truly needed.
Celebrating differences to champion equal care
While we all work together to reinvent our healthcare system in the year ahead, we need to also work actively to dismantle barriers to healthcare and medically inappropriate variations in care that impede both access and the quality of care.
The future of healthcare should be one that is equally bright for all women and their children. It will truly be a labor of love. By addressing our implicit biases, variations in care, and the wide-ranging health inequities that plague our communities today, we can take tangible steps toward ensuring survival and healthier futures for our Black mothers and their newborns.
Contact Ellie at: [email protected]