Q&A: Maternal health care disparities, distrust disproportionately affect Black women

Key takeaways :

• Black women experience substantially higher maternal mortality compared with their white counterparts.
• It is important to provide the same quality of care to all patients.

A CDC report released in March identified a 40% increase in maternal mortality in the U.S. in 2021 compared with 2020 and a mortality rate 2.6 times higher among Black women compared with white women.

Black Maternal Health Week is April 11 to 17. Healio spoke with Veronica Gillispie-Bell, MD, MAS, head of women’s services at Ochsner Medical Center in Kenner, Louisiana, about social factors and barriers that influence the increasing mortality among Black pregnant women in the U.S.

Healio: Have disparities in maternal mortality always been substantially higher for Black women vs. other racial and ethnic groups? Why or why not?

Gillispie-Bell: From the time we started looking at the maternal mortality data disaggregated by race and ethnicity, we have seen that this disparity exists. In the latest report, we see that the maternal mortality rate worsened during the pandemic, but also that the disparity gap got even wider. Black women experienced maternal mortality at a rate higher than that of their white counterparts. Some of us in health care and in public health are not surprised by the findings. During the pandemic, there were disruptions in the health care system that impacted access. We know that anytime there are disruptions in the health care system, Black and brown individuals are going to suffer the most.

Healio: Do these disparities affect just the mother or also their infants?

Gillispie-Bell: This particular set of data is only looking at maternal mortality, so the numbers here represent only maternal outcomes. But, yes, we know that infants are affected as well. We know there are disparities in infant outcomes. For example, the mortality rate for Black infants is higher than that of white infants. We know the preterm birth rate for Black mothers is higher than that of white mothers, which means infants are born early. Infants that are born early also have issues with respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage — all complications associated with prematurity. We also know babies that are breastfed have better infant and childhood outcomes, and if there is no mom to breastfeed, those infants don’t get that benefit.

Healio: What are some social factors or barriers specific to the health care system that can influence this rising maternal mortality rate among Black women?

Gillispie-Bell: We know that the social determinants of health affect our health outcomes. Eighty percent of our outcomes are due to social determinants of health. As a physician, I like to think that clinical care is the most impactful, but quite honestly, what happens in the clinical care setting is only about 20% responsible in determining health outcomes. Social factors are really the biggest predictor of one’s health outcomes. We know that for Black and brown individuals, because of systemic racism and policies that have historically been in place, our social determinants of health have been impacted in a negative way, and that is why we see all health disparities, not just maternal mortality. The social factors impacting social determinants of health are the reason Black individuals died from COVID-19 at a rate higher than that of their white counterparts. We are just now starting to talk about social determinants of health and how impactful they are on health outcomes and the disparities that we see.

Healio: Can individual physicians lessen the influence of these social factors? Is there a role for patient or physician education?

Gillispie-Bell: A resounding yes! I do think when you as a provider hear that the social factors are so impactful, then you say, “I’m not in that individual’s community and I’m not in their social environment, what can I do?”

The first thing is that, as providers, it is our responsibility and the recommendation from our professional societies to screen for social determinants of health. That’s the first thing that we can do. When we screen for those social determinants of health, we can uncover where there are barriers in the social environment that are impacting health and then we can help connect our patients to resources. We definitely have a role to play.

We have a duty to screen so that we can connect patients to resources.

Healio: Is there any research out there that supports diversifying health care work forces and systems to decrease such disparities?

Gillispie-Bell: Yes. There is research that was conducted by Dr. Rachel Hardeman and her colleagues that when there is concordance of race between a patient and their physician, there is a decrease in infant mortality for Black infants. With that said, only about 5% of practicing physicians identify as Black and about 6% identify as Hispanic or Latinx. We must diversify the health care workforce to improve disparities.

At Ochsner, we have partnered with Xavier University of Louisiana, here in New Orleans, to tackle this issue. Our partnership began with creating a physician assistant program. This program helps to create pathways for students to see there are other careers in medicine, not just being a physician, and as Xavier is a historically Black college and university, the majority of students matriculating are Black and brown. Also, it was recently announced that, through our partnership, we are starting a medical school with Xavier. This is going to help to create racial diversity in the physician workforce.

Healio: In your own personal experience, how has inequitable health care access impacted patients you’ve treated?

Gillispie-Bell: The biggest thing that I see is the lack of respectful care and lack of culturally sensitive care. That lack then leads to distrust of the health care system, and then that leads to individuals not wanting to interact with the health care system at all.

We know that when there’s concordance of race between the patient and the physician, there are better outcomes. Part of that is that there is automatically a level of trust. When you walk in and see somebody that looks like you, that at least starts to bring your guard down as a patient, and you start to develop that level of trust. For Black and brown patients, they are coming into a health care system that they may not trust for very good reasons, and then there’s no one that looks like them. It is up to us, as providers and health care systems, to earn the trust back from our patients, and we do that by giving them respectful care, making sure that they’re heard, making sure that they’re acknowledged and making sure we’re centering them in the decisions that we’re making about their care. LaToshia Rouse is a patient and family engagement expert, and she always says care should be something we do with a patient, not to a patient and not for a patient.

Healio: We know that there is distrust in general for women presenting to women’s health physicians. Will earning trust from Black patients also strengthen trust in women’s health overall?

Gillispie-Bell: Absolutely, it’s what I see in my practice and it’s what I hear from other providers. I have a lot of patients who seek me out because they are Black women, and I am a Black woman. There is a cultural shared experience that creates a level of trust. And for the same reason, there are many women that seek out other female providers because there’s automatically a feeling of camaraderie. However, as male physicians or when there is not concordance of race, by providing care that is patient-centered and respectful, you can gain the same level of trust from your patients. Understanding how to practice in this way benefits everyone.

Healio: Do you know of any current research related to investigating how to close the disparity gap between Black and white pregnant women in the U.S.?

Gillispie-Bell: There are a lot of activities and research being conducted to understand how to close the disparity gap. Many U.S. states have CDC funding for maternal mortality review committees. In these committees, we review pregnancy-associated deaths, which is a death that occurs at the time of pregnancy or up to 1 year at the end of pregnancy. We review the deaths to determine the cause of death and identify areas of prevention. We disaggregate the data by race to determine if there are disparities. Also, when we review the deaths, we use a tool provided by the CDC called “MMRIA,” which stands for Maternal Mortality Review Information Application, to standardize the review. In 2021, the CDC added a “bias and discrimination” checkbox to encourage us to consider that as a contributor to the decedents’ death. So, as we’re reviewing these deaths, if we feel like bias or discrimination may have occurred and may have impacted the outcome, we’re able to indicate that. That allows us to better identify when bias and discrimination is impacting outcomes.

For state perinatal quality collaboratives, which are also funded by the CDC, many of us are focused on improving readiness, recognition and response in birthing facilities to improve maternal outcomes by implementing the Alliance for Innovation on Maternal Health (AIM) patient safety bundles. These evidence-based bundles are designed to address these drivers of maternal morbidity and mortality. In these bundles, respectful care is woven into each aspect to ensure we are implementing the bundles in an equitable way. In Louisiana, we launched our perinatal quality collaborative in 2018 and did so with a focus on equity when it wasn’t very popular, even before it was incorporated in the AIM bundles. Since then and now, we have worked with our birthing facilities to understand the drivers of disparities in maternal outcomes which includes acknowledging and addressing implicit bias that impacts health care delivery. There is a lot of research being done on better ways to determine if respectful care is happening. There are validated survey tools for assessing respect and autonomy in care and more research being done on how to use these tools to improve care.

Healio: Is there anything else that you would like to add?

Gillispie-Bell: The other thing that I try to make clear is that race is a social construct, not a biological condition. There is no biological reason for Black women to experience maternal mortality at a rate higher than that of their white counterparts. It’s the social conditions that have affected social determinants of health that are leading to these outcomes. We also need to acknowledge and understand our implicit biases that serve as a barrier to providing patient-centered, respectful care.

We, as physicians, have a duty to establish respectful care and have a role in addressing social determinants of health. Our treatment can’t be a one-size-fits-all. It’s about giving the same quality of care, not the same care, and understanding our role in that.

Reference:

• CDC. Maternal Mortality Rates in the United States, 2021. www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm. Published March 2023. Accessed March 31, 2023.