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Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery–Addressing systemic racism and other social determinants of health as causes of obstetrical disparities
The Centers for Disease Control and Prevention define social determinants of health as “the conditions in the places where people live, learn, work, and play” that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.
The effect of social determinants of health (SDOH) (Figure 1) and systemic racism on obstetrical healthcare and outcomes is one of the most important challenges in reproductive healthcare today. Despite individual and systematic efforts to understand social determinants of reproductive health and to dismantle the associated obstetrical health disparities, there remains a need for changing care delivery to achieve equitable and desirable health outcomes among obstetrical patients.
The purpose of this document is to review the effects of SDOH and systemic racism on reproductive health outcomes (Table 1) and to recommend multilevel approaches to mitigate the disparities in obstetrical outcomes (Table 2).
Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care.
US Department of Health & Human Services, Office of Minority Health. HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. 2016. Available at: https://www.minorityhealth.hhs.gov/assets/pdf/hhs/HHS_Plan_complete.pdf. Accessed May 6, 2022.
Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (Distance).
Implement universal screening for SDOH during pregnancy and the postpartum period and establish partnerships with social services and community-based organizations to address identified needs.
Recognize groups that are at higher risk for adverse outcomes because of racism, rather than citing race as an independent risk factor for such outcomes
Society for Maternal-Fetal Medicine Society for Maternal-Fetal Medicine Special Statement: Race in maternal-fetal medicine research- Dispelling myths and taking an accurate, antiracist approach.
Dave DM, Decker SL, Kaestner R, Simon KI. The effect of Medicaid expansions on the health insurance coverage of pregnant women: an analysis using deliveries. Inquiry 2010–11;47:315–330.
Local public health delivery of maternal child health services: are specific activities associated with reductions in black-white mortality disparities?.
Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.
Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14.
National Perinatal Epidemiology Unit, University of Oxford,
Oxford2016
This document primarily focuses on disparities between Black and White individuals born in the United States. We acknowledge the presence and importance of disparities affecting other racial minority groups, particularly American Indian, Alaska Native, Southeast Asian, and Pacific Islander people, and disparities based on religion, sexual orientation, gender, economic deprivation, country of origin, and the intersection of historically marginalized identities minority statuses. The concepts and tools presented here are applicable beyond disparities between Black and White individuals and should be considered in that context, including the potential application of similar tools to address disparities in obstetrical care for marginalized groups other than Black persons.
Defining the problem
What are social determinants of health?
The Centers for Disease Control and Prevention (CDC) define SDOH as “the conditions in the places where people live, learn, work, and play” that can affect health outcomes (Figure 1). SDOH include but are not limited to factors that may affect access to healthcare, such as access to stable and safe housing; access to clean water, food, other supplies, and translation services; access to education and transportation; and employment status.
SDOH extend beyond sociodemographic risk factors (eg, race, socioeconomic status, education level, and marital status) and health behaviors (eg, smoking, nutrition, and prenatal care utilization), although many of those risk factors, including exposure to racism and lower socioeconomic status, are the key drivers affecting many SDOH.
It is important to note these differences between SDOH and demographics because compared with demographic data sets, data sets on SDOH remain limited. As national organizations begin to emphasize the importance of screening for SDOH, more information will be available to analyze the association between SDOH and reproductive health outcomes.
What is the role of systemic racism on health outcomes?
Although race is frequently cited as an SDOH and a risk factor for adverse obstetrical outcomes, it is exposure to systemic racism that is the critical factor. Systemic racism is a root cause of the power and wealth imbalances that affect SDOH, creating disproportionate rates of comorbidities and adverse outcomes in communities of racial and ethnic minority groups
(Figure 2). Exposure to systemic racism encompasses socioeconomic inequalities such as access to education, healthy lifestyle opportunities, and healthcare.
Crear-Perry J. Root causes of poor maternal health outcomes for Black and Indigenous people. Workshop on Advancing Maternal Health Equity and Reducing Maternal Mortality; Virtual; 2021.
present a socioecological model to demonstrate the role of racism on the sexual and reproductive health outcomes among Black people and provide health considerations that promote equity. This model describes institutional, personally mediated, and internalized racism, all of which play key roles in the trajectory of sexual and reproductive health experiences and outcomes through discrimination, substandard medical care, and unnecessary surgeries that are independent of socioeconomic status, insurance coverage, and access to care. Only recently has institutionalized racism been recognized and identified as a fundamental cause of health inequities and was rarely explicitly highlighted before 2015.
Although extensive research demonstrates racial disparities in health outcomes, research documenting the negative influence of racism on Black individuals’ reproductive and overall health remains sparse.
Explaining the black-white disparity in preterm birth: a consensus statement from a multi-disciplinary scientific work group convened by the March of Dimes.
Racism, African American women, and their sexual and reproductive health: a review of historical and contemporary evidence and implications for health equity.
Community-informed models of perinatal and reproductive health services provision: a justice-centered paradigm toward equity among Black birthing communities.
that proposes that disparities in birth outcomes experienced by Black individuals are driven by historic and structural racism and injustices that can only be remedied through a shift in power dynamics between the system and the community.
How do social determinants of health influence prepregnancy health, and what is allostatic load?
In addition to the effects of SDOH and systemic racism on reproductive health outcomes, there has been increasing evidence to support early health deterioration among Black individuals when compared with White individuals.
This disparity is known as allostatic load, which represents increased “weathering” or “wear and tear” caused by the high effort required to cope with acute and chronic stressors over the life course. Increased allostatic load is associated with an increased risk for chronic disease and comorbidities, including hypertension, abdominal obesity, and cardiovascular disease.
This weathering is not explained by racial differences in poverty and appears to affect Black individuals more negatively than their White counterparts.
Black women experience race-related discrimination that affects all Black individuals, in addition to gender discrimination, sexual harassment, and sexism, suggesting that the accumulation of stress over the life course may be intersectional. Of all the demographic groups, Black women have the highest documented allostatic load. This disparity reflects the cumulative physiological effects of stress over the life course as a consequence of experiencing social, structural, and environmental stressors that are frequently the product of racism.
The concept of allostatic load has guided the exploration of how chronic stress before pregnancy may contribute to birth outcome disparities. This hypothesis proposes that the cumulative effects of racism, economic disadvantage, and the associated stress throughout a Black woman’s lifetime erode her health and put her at higher risk for poor obstetrical outcomes with increasing age.
Biologically, Black women are 7.5 years older than White women of the same chronological age as measured by telomere length, with perceived stress and poverty accounting for 27% of this difference.
Do US Black women experience stress-related accelerated biological aging?: a novel theory and first population-based test of black-white differences in telomere length.
A recent study measuring allostatic load biomarkers at a maximum of 4 months before pregnancy found that each unit of increase in allostatic load was associated with increased odds of preeclampsia (62%), preterm birth (44%), and low birthweight (39%).
Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility.
In addition to higher allostatic load, disparate community conditions and experiencing discrimination negatively affect prepregnancy health. Systemic racism is associated with housing discrimination and food deserts as a consequence of historic housing polices known as redlining and a lack of availability of grocery stores.
Racial residential segregation among Black persons has also been independently associated with adverse pregnancy outcomes. One study of 4770 non-Hispanic Black persons using census tracts data demonstrated a higher level of preterm birth in high residential segregation areas compared with low segregation areas (15.5% vs 10.7%; P<.001).
Which perinatal outcomes have the greatest association with social determinants of health and systemic racism?
Multiple studies have shown that increases in specific obstetrical-related morbidities and mortality are associated with SDOH and exposure to racism. This section focuses on the different perinatal outcomes associated with SDOH and systemic racism.
Maternal mortality and severe maternal morbidity
Black women are more than 4 times more likely to die from pregnancy-related complications,
The pregnancy-related mortality ratio for Black women aged 40 years or older in one cohort approached 150 maternal deaths per 100,000 live births vs 40 per 100,000 live births among White women in the same age group.
The adjusted risk for severe maternal morbidity (SMM) in California between 1997 and 2014 was higher for non-Hispanic Black women than for non-Hispanic White women.
Comorbidities, cesarean delivery, and other factors including educational attainment did not fully explain these disparities in SMM, which remained persistent over time.
Instead, evidence for the persistence of SMM disparities among Black individuals after comorbidity risk adjustment indicates that factors other than comorbidities (eg, lower-quality healthcare and social factors) are likely to be additional contributors to disparities. Black individuals with chronic medical conditions experienced higher rates of adverse outcomes in pregnancy than White individuals with similar conditions.
In racial and ethnic minorities, being overweight and obese and having hypertension, diabetes, and anemia are more frequently seen before pregnancy, and these conditions are associated with several pregnancy complications, including preterm birth, stillbirth, macrosomia, gestational diabetes, and cesarean delivery.
Racism and SDOH contribute to the Black-White disparities in the prevalence of these preexisting conditions that increase a pregnant person’s risk for maternal morbidity and mortality.
Explaining the black-white disparity in preterm birth: a consensus statement from a multi-disciplinary scientific work group convened by the March of Dimes.
The overall rate of preterm birth in the United States in 2019 was 10.23%. Black (14.39%), American Indian or Alaska Native (11.59%), and Native Hawaiian or Other Pacific Islander (11.15%) women have the highest risk for preterm delivery as opposed to non-Hispanic White (9.26%), Asian (8.72%), and Hispanic women (9.97%).
A March of Dimes scientific workgroup concluded that exposure to racism is “a highly plausible, major upstream contributor to the Black-White disparity in PTB [preterm birth] through multiple pathways and biologic mechanisms.”
Explaining the black-white disparity in preterm birth: a consensus statement from a multi-disciplinary scientific work group convened by the March of Dimes.
Although the infant mortality rate in the United States has decreased substantially over time, the decline has not been uniform across the population. The Black infant mortality rate persistently remained 2.2 times higher than the rate for non-Hispanic White infants, whereas the non-Hispanic White infant mortality decreased during the same time period.
Black pregnant individuals are also more likely to experience a stillbirth than non-Hispanic White pregnant individuals. In 2004, the overall fetal death rate (death at 20 weeks of gestation or later) was 6.2 deaths per 1000 live births and fetal deaths; the rate for Black infants (11.3 per 1000) was more than twice that of non-Hispanic White infants (5.0 per 1000).
Black women are also more likely to experience fetal growth restriction, a significant contributor to neonatal morbidity and mortality, than women of other races and ethnicities.
Socioeconomic and educational disparities have a complex and variable relationship with these highlighted disparities in outcomes. Although higher levels of education are associated with a decreased risk for infant mortality, at lower levels of educational attainment, the risk for infant mortality remains higher for non-Hispanic Black women when compared with non-Hispanic White women.
When compared with data on educational attainment, the relationship between the preterm birth disparity and socioeconomic status appears paradoxical. A large population-based survey of more than 10,000 women who gave birth within a 7-year period demonstrated that, in the most disadvantaged subgroups, Black and White women are at a similar risk for preterm birth; however, among the more socioeconomically advantaged subgroups, Black individuals are at higher risk for preterm birth than White individuals.
Which disparities are seen in the receipt and quality of obstetrical care?
Prenatal care
There are 3 major categories of delays in care that affect maternal outcomes worldwide: delay in seeking care, delay in arrival, and delay in the provision of adequate healthcare.
SDOH and racism play a role in causing delay at each level. Although early initiation of prenatal care has been associated with improved obstetrical outcomes, racism and discrimination create barriers to accessing care in a timely fashion and to optimizing system engagement.
As a result, these barriers prevent Black women from equitably initiating and receiving adequate prenatal care by the end of pregnancy when compared to White women,
with 9.6% of Black women and 13.0% of American Indian or Alaska Native women receiving late (starting in the third trimester) or no prenatal care compared with only 4.5% of White women in a 2019 study.
Racism and discrimination continue to play roles in the care experienced during pregnancy after prenatal intake, further reducing the chances of receiving optimal care.
More than 40% of women reported communication problems in prenatal care, with Black and Hispanic women having higher odds of perceived discrimination owing to race or ethnicity than White women.
In the prenatal setting, Black women reported perceptions that their healthcare provider made negative stereotypical assumptions about their status regarding insurance, marriage, and substance use, leading to unfair treatment.
showed that severe postoperative pain (score of 7/10 or greater) was more likely among Black (28%) and Hispanic (22%) women than among those who identified as White (20%) or Asian (15%). The study also showed that non-Hispanic White women were more likely to have their pain assessed and received more narcotic medications within the first 24 hours after cesarean delivery than Black, Asian, and Hispanic women.
A recent publication examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggested that racial concordance between the newborn and physician is associated with a significant reduction in mortality for Black infants. In the care of White physicians, Black newborns have a 3-fold higher in-hospital mortality rate when compared with White infants.
Interpregnancy, prepregnancy, and contraception care
Non-White race is a negative predictor of postpartum primary care follow-ups for people with pregnancy conditions that confer lifetime health risks, including diabetes or gestational diabetes and hypertensive disorders of pregnancy.
A California-based study of deliveries among 200,000 Medicaid recipients found that, compared with White women, Black women attended postpartum visits less often and were less likely to receive any contraception.
Self-reported rates of experiencing discrimination are negatively associated with contraception use and partially mitigated by eliminating financial and structural barriers to contraception access.
Regarding prepregnancy care, although Black women are more likely to have chronic conditions that might benefit from optimization and counseling before becoming pregnant,
Explaining the black-white disparity in preterm birth: a consensus statement from a multi-disciplinary scientific work group convened by the March of Dimes.
Preconception and interconception health status of women who recently gave birth to a live-born infant--Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
It is well established that SDOH and systemic racism have deleterious effects on reproductive health outcomes. To date, as cited in the previous sections, substantially more published evidence has been accrued for defining the problem and delineating the inequities than for resolving them. This lack of evidence is likely because of the multifactorial nature of any solutions, making the assessment of evidence and the development of concrete mitigation strategies difficult. In the next section, established strategies that can start to eliminate the disparities in obstetrical outcomes when possible, along with promising emerging strategies that will need to be continually evaluated for their efficacy over time, are presented. Suggestions for multilevel approaches to systems assessment and care delivery are summarized in Table 2 and can be considered when creating an “Equity Bundle.”
What can healthcare systems and institutions do?
Conduct internal assessments of the barriers against and facilitators of providing equitable care
Systematically conducting internal assessments will facilitate understandable and actionable comparisons between and within systems over time, which can be used to drive change.
Several frameworks have been proposed for healthcare system modification and healthcare worker training to reduce the risk for racism-based adverse outcomes. In 2018, Howell and colleagues
published the Reduction of Peripartum Racial and Ethnic Disparities Patient Safety Bundle, which includes several strategies related to conducting internal evaluations. Domains in which there are opportunities to improve include readiness, reporting and systems learning, recognition, and response. This information was reemphasized in 2019 with a proposed 8- step plan that healthcare systems can follow to reduce racial and ethnic disparities in care. Among these are strategies that should be adopted by health care institutions to assess how they are performing in terms of disparities in prenatal care utilization and in-hospital disparities, including:
Assessment of language needs and cultural barriers to receiving information
•
Implementation of a disparities dashboard
•
Performance of enhanced maternal mortality and SMM reviews
•
Evaluation of opportunities for standardization of care through checklists and bundles
•
Care utilization tracking
•
Evaluation of the institutional culture––is it a culture of equity and of safe reporting? This strategy must include an assessment of the engagement level of key stakeholders.
•
Evaluation of opportunities for new models of care that may eliminate disparities
•
Group prenatal care models; case management and patient navigation programs and virtual care pathways
Another framework that can be used to identify root causes and to eliminate disparities is an equity impact assessment tool. A Racial Equity Impact Assessment (REIA) is a systematic examination of how different racial and ethnic groups will likely be affected by a proposed action or decision.
REIAs are used to minimize unanticipated adverse consequences in a variety of contexts, including the analysis of proposed policies, institutional practices, programs, plans and budgetary decisions.
Create and support a culture of safety, centralized reporting, and institutional response to identify and address instances of racism or bias
It is incumbent on healthcare systems to create a reporting structure that prioritizes the identification of systemic and individual acts of racism or bias as potential root causes of adverse health outcomes. A fair and just culture supports robust reporting systems because well-intentioned employees can feel confident that the contents of the report will remain confidential and will lead to reflective system improvements instead of reflexive punishment.
As part of the quality and safety strategy proposed by the Institute for Perinatal Quality Improvement, another element of eliminating “strong but wrong routines” is to change a culture that may perpetuate disrespect and differences in care. The SPEAK UP for Black Women campaign (Box 1) encourages healthcare professionals to speak up against racism whenever they see racist behaviors or hear racial slurs.
Create a data infrastructure to improve health equity
Systems must prioritize the reporting of adverse outcomes with anonymized, multidisciplinary reviews that address the potential for racism or biases as a standard item. In 2016, the Institute for Healthcare Improvement (IHI) published “Achieving Health Equity: A Guide for Health Care Organizations,” which presents a 5-component framework to guide health systems in their efforts to improve health equity.
One of these strategies involves building an infrastructure to support health equity work. To improve health equity, organizations first need to understand where the disparities exist. Identifying disparities requires the accurate collection of race, ethnicity, and language (REaL) data, based on patient self-reporting, and the resources to analyze these data. Registration and admission staff are key to collecting accurate data. Research and field work have shown that registration staff and patients benefit when staff are partners in the process and when they receive training on the reasons for collecting this information and to develop the skills required to do so.
Establish a patient quality and safety infrastructure that monitors and evaluates for disparities in the outcomes
Once REaL data are being collected accurately, the next strategy for building data infrastructure to support health equity is to display the stratified data. The only way to make progress in reducing disparities is to measure them. For example, a disparities dashboard stratifies quality metrics by the social constructs of race and ethnicity. Implementation of this useful tool allows hospitals and healthcare systems to become aware of the disparities and to monitor their performance among groups with higher risks for poor outcomes by using quality metrics.
Another approach proposed by the IHI is to stratify REaL data for one strategic measure to build intention and interest among leaders and clinicians. Quickly deploying stratified data for one strategic measure instead of waiting for the development of an entire dashboard allows the organization to learn about and understand aspects of equity in practice. This approach supports the IHI’s current recommendation that organizations should gain experience in improving equity by first applying an “equity lens” to existing improvement projects aligned with strategic priorities rather than by chartering new projects with the specific focus to improve equity.
demonstrated the ability to eliminate disparities through quality improvement (QI) work by retrospectively looking at their outcomes after implementation of the hemorrhage patient safety bundle. The group performed a cross-sectional study among patients affected by obstetrical hemorrhage in 99 hospitals participating in a QI collaborative.
The group highlighted the “marked improvement” in the rates of SMM caused by hemorrhage among Black individuals and reducing Black-White disparities for this outcome. These important findings suggest that QI efforts can improve maternal outcomes and reduce inequities in care delivery for a specific medical condition. This group further concluded that the data demonstrated that there are opportunities for reducing Black-White disparities for the most common maternity complication, hemorrhage, by implementing national safety bundles for the prevention of and response to obstetrical hemorrhage. We propose approaching each QI effort with a health equity focus from the beginning of a project to allow for a more targeted approach by implementing interventions most likely to eliminate disparities.
In addition, as part of quality and safety case reviews and debriefs, SDOH and disparities should be evaluated routinely. Using a framework developed by the Council on Patient Safety in Women's Healthcare, the SMM review form can be used to conduct an enhanced review by a multidisciplinary team to identify potential system-, provider-, and patient-level factors that may have altered the outcome.
Patient-level factors include a focus on the influence of SDOH, such as how food and housing insecurity, lack of transportation, and lack of health insurance may have affected the outcome. Reviewing these potential contributing factors can assist with hospital QI plans that target upstream contributors to health outcomes, such as the use of social services to assist during prenatal care, so that adverse outcomes around the time of delivery may be averted.
Once disparities have been identified, use a systematic approach to eliminate them
The Institute for Perinatal Quality Improvement proposes the following 5 quality and safety strategies to guide national-, state-, and hospital-based efforts to eliminate disparities in perinatal outcomes and to ensure equity for all people and newborns:
1.
Apply a systems approach based on the socioecological model
2.
Identify root causes of disparities
3.
Identify and eliminate strong but wrong routines
4.
Use improvement and implementation science methods and tools
The key insight of the first strategy is that a person’s health is directly related to SDOH. Ishikawa cause-and-effect (fishbone) diagrams are used to understand the key components in a system that led to a failure or contributed to a poor outcome. The Institute for Perinatal Quality Improvement used the Ishikawa diagram format and the socioecological model to develop the Socio-Ecological Perinatal Disparities Ishikawa Diagram, which outlines numerous modifiable, system-level factors that can contribute to perinatal disparities (Figure 3).
This tool is recommended to support the second strategy, which aims to determine the root causes of disparities. The third strategy emphasizes scrutinizing and improving all routines to ensure that suboptimal processes are not propagated simply because they have become ingrained in clinical care. The fourth and fifth strategies stress the importance of sustaining QI efforts, even as new and competing initiatives are introduced. QI efforts can be sustained through continual surveillance of structure, process, and outcome data measures. The analysis should be done in a manner that easily identifies outcomes by race and ethnicity and allows comparison within a hospital and across hospitals, communities, regions, and nationally.
Socio-Ecological Perinatal Disparities Ishikawa Diagram. (Courtesy of Copyright owned by the Institute for Perinatal Quality Improvement, www.perinatalQI.org, 2018, All rights reserved. Reprinted with permission.)
Society for Maternal-Fetal Medicine. Best practices in equitable care delivery. Am J Obstet Gynecol 2022.
Develop and use innovative tools for care delivery that capitalize on opportunities for improvement
After performing an institutional assessment for opportunities to improve care delivery, changes should be implemented. Strategies to reduce the risk for adverse obstetrical outcomes can either be applied to an entire population, with the hope that improving outcomes for all will also improve outcomes for historically marginalized populations, or these can be targeted to marginalized populations, with the primary goal of improving health outcomes among those with the poorest outcomes. Selecting the most appropriate strategy to decrease health disparities likely depends on the clinical entity and population context. Given the dearth of evidence on care delivery models that directly diminish obstetrical health disparities, the development of care delivery strategies, assessment of their effect, and publication of findings are greatly needed.
Care delivery models that enhance cultural concordance and interweave with the experiences, beliefs, and needs of diverse community members may be more likely to improve care utilization, experience, and outcomes. In one survey study, group prenatal care improved food security by increasing confidence and skills in managing household food resources.
Although individual patient outcomes have shown improvement, group prenatal care has also been shown to affect clinicians and institutional systems by increasing the patient-clinician contact time, allowing deeper relationships to be formed, which help to eliminate clinician bias and racism and to improve patient care.
Patient navigation programs typically employ trained laypersons to assist patients in overcoming barriers to accessing care. This cost-effective intervention has been demonstrated to improve postpartum care receipt and retention among members from historically marginalized and low-income communities and should be considered a promising tool for improvement in care equity and outcomes in obstetrics.
US Department of Health & Human Services, Office of Minority Health. HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. 2016. Available at: https://www.minorityhealth.hhs.gov/assets/pdf/hhs/HHS_Plan_complete.pdf. Accessed May 6, 2022.
Telehealth as a care delivery model has become widely integrated into obstetrician-gynecologist and maternal-fetal medicine practices, although the remaining hurdles preventing implementation include confirmation of insurance and reimbursement and accessibility to internet or cellular services for all patients. Evidence related to the effect of virtual-care pathways on reducing disparities in care receipt and outcomes remains limited. As we learn more about whether virtual care is associated with a reduction in disparities, we also should keep in mind the concern outlined in a 2020 summary of telehealth in obstetrics that “low resources and poor health literacy can potentially predispose already disadvantaged women from participating successfully in telemedicine interventions.”
Implement unconscious bias and communication training
Antibias healthcare worker training is another systematic approach to promote equitable care delivery. However, despite data linking provider-level bias to disparities in care and outcomes,
multiple studies on the effect of cultural and bias training have been unable to provide evidence that this training improves patient adherence to therapy, health outcomes, or equity of services across racial and ethnic groups.
However, there is evidence linking this type of training to changes in attitude and knowledge regarding issues of racism and in the participants’ personal commitment to address them. Participants have also reported higher levels of confidence in developing strategies to improve the racial climate at their institutions and teaching learners to reduce racism in patient care.
Efforts to improve communication and reduce perceived discrimination constitute an important area of focus to improve patient-centered care in maternity services. In a 2015 SMFM survey about knowledge and attitudes regarding disparities with 79% of respondents identifying as White, 83% of respondents agreed that disparities have an effect on their practice; however, only 29% believed that personal biases affected how they care for patients.
Although these results showed the unconscious nature of some biases, pregnancy care providers need to be increasingly aware of their role in contributing to disparities in care during pregnancy and birth.
Advocate for patient voice in targeting interventions
Several resources and tools exist to enhance racial justice and equity by focusing on patient respect and giving the patient tools to be active decision-makers in their pregnancy and birthing experience. Ambulatory and hospital settings can work to create a safe and welcoming environment for patients that celebrate and acknowledge their identity and culture. Examples include displaying a Pride flag, Black Lives Matter poster, posters in patients’ preferred language, or a poster stating that people of all documentation statuses, races, gender identities, and religions are welcome. Trust and communication between patient and provider can be augmented by asking better questions about the patient’s identity, experiences in life and the healthcare system, asking relevant follow-up questions to make sure they feel heard, and clarifying a commitment to a partnership by addressing the patient’s goals and needs and jointly constructing a feasible care plan.
Some examples of initiatives at the national scale include the NYC Standards for Respectful Care at Birth, National Association to Advance Black Birth Black Birthing Bill of Rights (https://thenaabb.org/black-birthing-bill-of-rights/), the CDC’s “Hear Her” campaign (https://www.cdc.gov/hearher/index.html), and the Council on Patient Safety in Women’s Health Care Urgent Maternal Early Warning Signs.
Another opportunity to incorporate patient voice is by engaging patients’ participation in hospital committees addressing quality and safety along with the patient experience. By including a diverse group of patients in these discussions it can bring about a different perspective than that obtained from those leading healthcare institutions, which may help to minimize disparities.
Improve availability of race-concordant and language-concordant provider-patient relationships for patients who seek this concordance
A 2018 survey study of patients and providers showed that communication strategies and a patient-centered approach were linked to perceived care quality differences by race and ethnicity.
Other studies and expert reviews have confirmed a link between patient-provider language and race concordance and patient satisfaction by a variety of different measures but have not been able to identify specific strategies associated with improved quality.
Although several studies demonstrate that with patient-provider language concordance, increased healthcare engagement and satisfaction are present and some improved clinical outcomes are seen.
Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (Distance).
Nevertheless, some experts have concluded that a staple strategy to improve care quality for Black people is to increase the availability of race-concordant provider-patient relationships and develop a healthcare workforce that is representative of the US population.
For organizations seeking to offer services responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs, the enhanced National Standards for Culturally and Linguistically Appropriate Services (https://thinkculturalhealth.hhs.gov/clas) may be a useful framework.
Implement universal assessment of social determinants of health during pregnancy and the postpartum period and establish partnerships with social services and community-based organizations to address identified needs
Just as data on symptoms and obstetrical, medical, and family history are routinely collected to inform diagnosis and treatment, data on patients’ social circumstances need to be collected and tracked. Given the frequency of obstetrical visits, pregnancy is a unique time in a person’s life to collect and analyze data on SDOH. Although there is no standard for how often SDOH assessments should be performed during pregnancy, it is reasonable to consider screening on the first prenatal visit, in the third trimester, before hospital discharge after delivery, at the postpartum visit, and any time there is a noted change in the patient’s needs or circumstances.
Several validated screening tools are available to assess SDOH in clinical practice, and they do not have to be administered by a physician. If needs are identified through screening and a person wants assistance in addressing those needs, it is important to connect and navigate people to the appropriate community resources. In one study, performing universal screening for SDOH among patients with sickle cell disease in a pediatric hematology clinic using existing resources and staff was found to be feasible and positively received by patients. The authors noted that the universal screening approach mitigates the role of provider perception in deciding which families should be asked about SDOH in a population of patients with an already high burden of bias and stigma. In addition, universal screening captured needs that were not formerly recognized.
Institutions should familiarize themselves with community resources outside of their institutions, such as findhelp.org, a free online social services search engine that connects people in need to programs in their community, and make use of these.
Incorporate diversity, equity, and inclusion training into leadership training programs offered by national organizations
Leadership training programs are frequently offered by national organizations and should incorporate diversity, equity, and inclusion training with emphasis on how to mitigate biases and aggressions. This type of training should become a routine part of any leadership training as competency and awareness in this arena is critical to being a successful leader.
Engage in bias and racism training along with self-reflection
Establishing racism as an important public health problem can have a measurable effect on the health of non-Hispanic Black people and their infants and all marginalized groups that experience racism.
To eliminate racial inequities in birth outcomes, healthcare professionals, policymakers, and social and economic institutions need to understand, acknowledge, address, and prevent racism. Although Black people experience discrimination across a variety of settings, pregnancy is often viewed as a window of opportunity during which people have increased contact with the healthcare system. Therefore, this period offers the maternal and child healthcare professional an opportunity to learn from people about their personal experiences of racism throughout their life course and better understand its role in maternal and neonatal outcomes. Self-reflection on the part of professionals and institutional examination of policies and practices that may contribute to racism are necessary steps toward ensuring that all patients, regardless of race or ethnicity, achieve equitable health outcomes.
Recognize groups that are at higher risk for adverse outcomes as a consequence of racism instead of citing race as an independent risk factor for such outcomes
The use of healthcare strategies that use race as a modifier for risk assessment, counseling, and patient management is being reexamined. Citing race as an independent risk factor for adverse outcomes centers the blame for such outcomes on the pregnant individual rather than on the societal influence of racism and its downstream effects. For example, the inclusion of race in algorithm-based care may increase the risk for providing counseling or making management decisions that perpetuate the negative influences of racism on health outcomes for Black people. In obstetrical care, the original vaginal birth after cesarean (VBAC) calculator had negative race-based correction factors for Black and Hispanic women, leading to a systematically lower predicted probability of successful VBAC in these 2 groups than in White women.
The unintended effect of the race-based correction in this highly used calculator conferred negative consequences for Black and Hispanic women because obstetrical clinicians may have viewed the likelihood of a successful VBAC to be lower for Black and Hispanic pregnant individuals and therefore taken clinical actions that led to a higher rate of repeat cesarean deliveries. Several publications comparing the VBAC rates predicted by the calculator with actual success rates in diverse US populations indicated higher success rates for Black and Hispanic individuals in practice than the rates predicted by the calculator.
Since then, many other algorithms have validated the VBAC model’s efficacy without race-based correction, and the calculator has been updated to remove the race-based correction.
Race-based correction can be seen in multiple algorithms in other specialties, such as estimated glomerular filtration rate and pulmonary function tests.
Engage in antiracist activities to dismantle structural racism
Individuals involved in medical education and training should develop guidance for engagement with policies promoting racial justice. The Association of American Medical Colleges released a statement noting that “organized medicine must come together in solidarity to make ‘good trouble’ and fight collectively for racial justice so that every community we serve can achieve their full health potential and achieve racial equity—that is, giving people what they need to enjoy full, healthy lives regardless of race.”
This effort requires honest and open conversations about the presence of racism and the inequity among races in terms of healthcare outcomes in addition to the acknowledgment of the medical establishment’s involvement in racist activities. Understanding and acknowledging this racial history is paramount for all individuals and it provides the framework for engaging in antiracist activities.
Medical professionals have a voice in society that can be used to address the issue of racism in medicine, and this voice should be used to engage in advocacy within and outside one’s institution.
Individuals should also undertake antiracist activities in the same way they pursue clinical research. SMFM has written a special statement on addressing race in maternal-fetal medicine research that provides an antiracist research framework for guidance that addresses the following
Society for Maternal-Fetal Medicine Society for Maternal-Fetal Medicine Special Statement: Race in maternal-fetal medicine research- Dispelling myths and taking an accurate, antiracist approach.
How race should be conceptualized when developing a research question
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Advocating for diverse research teams
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Best practices for recruiting diverse research participants
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Engaging communities in research
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Defining research justice
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Evaluating research with an antiracist approach
Recognize your own cognitive biases
Cognitive biases are flaws or distortions in judgment and decision-making that can frequently lead to disparate patient outcomes. Cognitive biases have been associated with 28% of diagnostic errors.
Most of these cognitive biases are unconscious and are frequently referred to as implicit or unconscious biases. These biases are known to contribute to racial and ethnic disparities in healthcare. Using patient quotes to suggest that their words may be doubted or judgmental language such as “insists” or “claims” in their record convey a sense of doubt or negative judgment on the part of the physician and are more frequently seen in the records of Black patients and women.
This type of linguistic bias suggests that Black patients may be subject to systematic bias in physicians’ perceptions of their credibility, a form of testimonial injustice that can lead to delayed diagnosis, inappropriate treatments, unnecessary pain and suffering, and death.
Reading stigmatizing language in the medical record can also lead to more negative attitudes toward the patient by other healthcare providers and can affect care management.
As individuals, we should acknowledge our own biases and work toward eliminating the presence of these biases in our documentation and presentation of patients.
What can we do as a society?
Expand Medicaid and ensure access to the full spectrum of reproductive healthcare
A larger healthcare system modification that could influence care utilization is Medicaid expansion.
Dave DM, Decker SL, Kaestner R, Simon KI. The effect of Medicaid expansions on the health insurance coverage of pregnant women: an analysis using deliveries. Inquiry 2010–11;47:315–330.
This is one example of a demand-side intervention that has historically been shown to improve the uptake of prenatal care among low-income populations at risk for disparities.
Dave DM, Decker SL, Kaestner R, Simon KI. The effect of Medicaid expansions on the health insurance coverage of pregnant women: an analysis using deliveries. Inquiry 2010–11;47:315–330.
However, Medicaid expansion has not been shown specifically to improve birth outcomes, with the outcomes most frequently studied being low birthweight, prematurity, and infant mortality, and it has be proposed that maternal outcomes should be evaluated instead.
Access to and availability of publicly funded services, particularly family planning services and prenatal care, have been shown to reduce Black-White mortality disparities locally.
Local public health delivery of maternal child health services: are specific activities associated with reductions in black-white mortality disparities?.
Based on data from 2011 to 2016, state Medicaid expansion was not significantly associated with differences in the rates of low birthweight or preterm birth outcomes overall. However, there were significant improvements in the relative disparities for Black infants when compared with White infants in states that expanded Medicaid when compared with those that did not.
SMFM supports federal and state policies that expand Medicaid eligibility and continue Medicaid coverage through 12 months postpartum as a key strategy to address the maternal morbidity and mortality crisis and to improve health equity.
Create and incentivize the use of standardized tools for assessing healthcare systems and adverse outcomes on a national level
Maternal mortality reviews exemplify how systematic assessment of an adverse outcome can be improved by a structured approach. However, this systematic approach at the national level is still lacking in the United States. Individual states routinely perform standardized maternal mortality reviews, but addressing such reviews at the national level with a centralized approach does not exist. The United Kingdom’s national system, which has been in place for more than 60 years, has been credited with decreasing the already low maternal mortality rate and the differences in pregnancy outcomes related to racial disparities. The result is a significantly decreased maternal mortality rate among Black individuals, despite having similar population trends as the United States.
Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.
Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14.
National Perinatal Epidemiology Unit, University of Oxford,
Oxford2016
The specific methods used by the United Kingdom include centralized reporting, case review by multiple experts after full anonymized data are acquired, and case examination by a multidisciplinary writing group to elucidate the main themes for learning, which are reported as recommended clinical guidelines.
Support community-based strategies as a complement to traditional medical care for specific historically marginalized populations
It is worthwhile to consider societal and community-based strategies that can complement traditional medical care if they facilitate improved outcomes in marginalized populations. In addition to Medicaid expansion, these strategies include accountable care organizations, community health worker engagement, and home visits. Additional support should be provided for hospitals that specifically serve marginalized populations. The delivery of most Black infants occurs in a concentrated set of hospitals, and these hospitals tend to have higher SMM rates. Targeting QI efforts at these hospitals may specifically improve care for Black people.
The Black Mamas Matter Alliance (BMMA) is a Black women–led, cross-sectoral alliance that provides resources for the advocation of policy changes at the state and national levels. The BMMA emphasizes that “in addition to improving health care access and quality, government actors need to address the root causes of Black maternal mortality and morbidity—including socioeconomic inequalities and racial discrimination in the healthcare system and beyond.” The BMMA proposed and detailed actionable items at a national level for each policy proposal and these are presented in Box 2.
Advocate for environmental and neighborhood improvements
Many toxic chemicals and psychosocial stress contribute to the risk for adverse birth outcomes, and Black individuals often experience greater levels of exposure than White individuals.
The extent to which environmental exposures combine with stress and culminate in racial disparities in birth outcomes has not been quantified but it may be substantial. Primary prevention of adverse birth outcomes and elimination of disparities will require a societal approach to improve education quality, income equity, and neighborhoods. An even higher-impact approach is to co-locate health and social services. Some healthcare settings have co-located on-site emergency food boxes, farmers’ markets, and Special Supplementation Nutrition Program for Women, Infants, and Children offices. Others offer health and legal services through medical-legal partnerships that address health-related legal needs, such as unsafe housing or denial of insurance. Health and social service co-location can provide increased consumer utilization and program efficiencies.
SDOH and systemic racism are key factors affecting reproductive and sexual health outcomes. To mitigate their effects, a systematic approach at the individual, institutional, and societal level is necessary. Frequent and transparent acknowledgment of the role of these factors in health outcomes and the incorporation of them into our quality and safety initiatives are required. We have an opportunity to reduce the disparities in reproductive health outcomes and improve maternal health by implementing the initiatives described thus far. It remains our responsibility to continually improve and add to these initiatives as further research determines the most effective ways to overcome systemic racism as a cause of obstetrical health disparities.
References
Carter E.B.
EleVATE Women Collaborative
Mazzoni S.E.
A paradigm shift to address racial inequities in perinatal healthcare.
Explaining the black-white disparity in preterm birth: a consensus statement from a multi-disciplinary scientific work group convened by the March of Dimes.
Racism, African American women, and their sexual and reproductive health: a review of historical and contemporary evidence and implications for health equity.
Community-informed models of perinatal and reproductive health services provision: a justice-centered paradigm toward equity among Black birthing communities.
Do US Black women experience stress-related accelerated biological aging?: a novel theory and first population-based test of black-white differences in telomere length.
Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility.
Preconception and interconception health status of women who recently gave birth to a live-born infant--Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
US Department of Health & Human Services, Office of Minority Health. HHS action plan to reduce racial and ethnic health disparities: A nation free of disparities in health and health care. 2016. Available at: https://www.minorityhealth.hhs.gov/assets/pdf/hhs/HHS_Plan_complete.pdf. Accessed May 6, 2022.
Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (Distance).
Society for Maternal-Fetal Medicine Special Statement: Race in maternal-fetal medicine research- Dispelling myths and taking an accurate, antiracist approach.
Dave DM, Decker SL, Kaestner R, Simon KI. The effect of Medicaid expansions on the health insurance coverage of pregnant women: an analysis using deliveries. Inquiry 2010–11;47:315–330.
Local public health delivery of maternal child health services: are specific activities associated with reductions in black-white mortality disparities?.
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