Pregnancy-Related Deaths Reflect How Implicit Bias Harms Women. We Need To Fix That.
Laurie Zephyrin, MD, MPH, MBA
This article originally appeared on STAT News: reporting from the frontiers of health and medicine.
I have had babies, delivered other women’s babies, and worked in a bustling, diverse maternity ward. I know from my experience in all of these roles that we have created a health care system that too often fails women. So I now spend my days figuring out how we can fix it.
Health care encounters can be intimidating and scary, especially for women who are pregnant — a time when they are at their most vulnerable, worried not only about their own health and safety but also about their baby’s. There’s a power gap between doctor and patient: The clinician seems to have so much knowledge, and daunting decisions must be made. Now imagine having that fear and vulnerability compounded by feeling disregarded and not listened to.
That happens to women, especially women of color, every day. The American College of Obstetricians and Gynecologists acknowledges that racial bias within the health care system is contributing to the disproportionate number of pregnancy-related deaths among women of color. Providers spend less time with black patients, ignore their symptoms, dismiss their complaints, and undertreat their pain.
This is especially dangerous because quick assumptions about an individual can make all the difference between empathy and apathy, which can then translate into life and death decisions. Pregnancy-related deaths occur 3.3 times more often among black women, and 2.5 times more often among Native Americans and Alaska Native women, than they do among white women.
To right this wrong, we need to do three things: prioritize women’s health throughout their lives; take concrete steps to address racism and implicit bias in health care, and spread information about what we know works to keep all women safe and healthy.
What does it mean to make women’s health a lifelong priority? For starters, women need health insurance coverage and access to primary and behavioral health care from the cradle to the grave. Whether a woman becomes sick, disabled, or dies following childbirth is influenced by her health and well-being before and after pregnancy.
The majority of pregnancy-related deaths occur after birth. The so-called fourth trimester is an important transition period for women; access to care that meets their needs during this time is essential. Medicaid covers half of all U.S. births. But in states that have not expanded this program, maternity coverage typically ends at 60 days after birth, leaving women uninsured at a time of risk. One way to ensure better lifetime health for women is to expand Medicaid.
We must also build primary health care models that make it possible for women to have their medical, behavioral health, and social needs met in one place. Group prenatal care, which provides women with medical care and community support, holds promise. In North Carolina, the maternal medical home model has been improving outcomes for pregnant women. In addition to providing medical care, maternal medical homes address nonmedical issues that can put mother and child at risk, such as addiction, domestic abuse, and lack of secure housing and healthy food.
It is a societal failure if any of part of a woman’s identity puts her at risk during pregnancy, childbirth, and beyond. We know this is happening in the U.S., but we need to understand it better by tracking health quality indicators by race and ethnicity at the local health system level. When we see it happening, we must intervene with proven approaches.
One of those approaches is requiring implicit bias training, during which people are taught to recognize and interrupt the unconscious stereotypes and assumptions that influence their actions, for the entire health care team. This training needs to happen regularly, and providers must be given time to complete it. In addition, after a woman has died as a result of pregnancy or childbirth, or has had a poor pregnancy-related health outcome, her care team needs to address the role implicit bias may have played. Quality and safety reviews must also take equity into account. Although these discussions are uncomfortable, they need to happen.
Last but not least, federal, state, and local governments, payers, and health systems must work together to support proven efforts that are already making a difference. For example, doulas are familiar with the language of the health care system and the needs of patients, making them uniquely positioned to help women navigate a complex and overwhelming system and advocate on their behalf in their time of need. In the U.S., as around the world, using these types of community health workers has been shown to improve health care outcomes, especially for people who have traditionally been marginalized. These kinds of providers should be a regular part of maternal care delivery and insurers should pay for their services.
The bottom line? Women going through pregnancy and childbirth deserve a health care system that supports them, not one that scares them or puts them on defense. If we are going to create that kind of system and eliminate racial disparities in pregnancy-related deaths, we must confront the biases that got us here in the first place, prioritize women’s health, and start implementing what we know works.