Black Maternal Health Disparities - Working to Improve Equity

About 700 people in the United States die each year during pregnancy, and about 50,000 experience serious health complications. These numbers are also known to be increasing. In addition, Black birthers are 3-4 times more likely to die or have complications during pregnancy, birth and the postpartum period than white birthers.

Black maternal and infant mortality has increased nationally as well as locally. Baystate Health, like much of the healthcare industry, is working to combat this disturbing trend. Black women die at a higher rate in large part because of racial biases that many times result in substandard care, according to Tonja Santos, CNM (Certified Nurse Midwife) with Baystate Health.

Enacting Change

“I felt like someone needed to start asking the questions about potential inequities within our system,” Tonja says. “I approached Dr. (Heather) Sankey (department chair OB/GYN) and told her I wanted to pull together a group to work on this. She was very invested from the start and has even funded part of my time to do so.”

Since her talk with Dr. Sankey, a group of interested and invested people—including inpatient and outpatient nurses, social workers, midwives, and physicians—have formed a committee to look at racial disparities in maternal health. The Racial Disparities and Health Equity Steering Committee, Department of OB/GYN, enacts change at Baystate to improve outcomes and ensure patients feel respected and heard.

“It’s pretty unique to the system,” she says. “We’re looking at these issues on a global level, as well as nationally, statewide, regionally, and of course, at Baystate Health.”

Why Do Black Birthers Have Higher Mortality Rates?

Study after study has shown that Black birthers have a greater chance of dying during childbirth or postpartum than their white counterparts. There are many determinants, including economics, according to Tonja. Black birthers also experience higher rates of early births, unsuccessful breastfeeding, and infant and neonatal deaths. They may be less likely to have access to good healthcare, particularly impactful if they have underlying health conditions, and they have to contend with structural racism and implicit bias.

“Studies and lived experiences show us that many birthers feel they aren’t listened to or heard,” she explains. “Black birthers feel like some in the healthcare system are not paying attention. They speak to their providers and are dismissed. Much of our work is around patient experience and satisfaction. Patient experience in many ways drives clinical outcome.”

She says that since much of the morbidity and mortality occurs during the postpartum period, it is a particularly important time.

“People are busy or distracted by their newborn and may be more likely to dismiss symptoms. And if they have a history of being dismissed by the system, they are less likely to seek care, which increases the risk of this timeframe.”

She explains that patient experience drives willingness to seek care or partner with a healthcare provider to follow through with a plan of care.

Racism and Implicit Biases in Healthcare

Tonja says the cause of disparities is racism and bias, not race.

“We have a long history of treating race and ethnicity like they are immutable,” she says. “The disparities, inequities have little to do with physical similarities or differences between human beings. After we weed out other potential causes: obesity, smoking, decreased physical activity, housing, education, insurance, people are still treated differently. Healthcare is not exempt from the racism and bias that exist in the United States.”

She says when a person walks into a clinical interaction with implicit biases that they are either aware or unaware of, it has an impact on the interaction. It can impact how providers talk to patients, how much they talk versus listen, how they perceive patients’ reactions/behaviors, and the words used in medical records.

“When looking at inequities we have to look at things like how many diagnostic tests are ordered for different people with the same condition,” she explains. “How far down the road do we explore people’s symptoms? Are there implicit biases that exist? Can the resulting treatment decrease patient satisfaction? Will there be different clinical outcomes? We are exploring all of these questions.”

She provides an example of a provider that has an implicit bias. They see a white patient and a Black patient with similar issues. The provider is either aware or unaware that they believe Black people experience pain differently, so one patient gets an X-ray and the other does not.

“A clinical scenario like this can lead to different patient experiences and potentially different clinical outcomes,” she says. “Those are the things we need to examine. We need to examine our own individual implicit biases in order to be able to come to terms with and mitigate them.”

Tonja explains that implicit bias can be “baked in” to an institution to the point where people experience access differently, and can even impact how appointments are scheduled.

“The good news is Baystate Health is working on this all the time and will continue to do so,” she says. “I also have great hope that we can and will do better, for all our patients. There is usually great joy in expanding a family. We are striving to be in a place where all families can have that joy, rather than fear of death and sickness and the impact of bias in healthcare, as their focus.”

Committee Focused on Disparities in Healthcare

Clinically, the Racial Disparities and Health Equity Steering Committee, Department of OB/GYN group is focusing on known disparities and what national research is telling them. They are working to reduce primary C-sections and addressing hypertension (high blood pressure) in pregnancy. The department is also operationalizing evidence-based guidelines around risk assessment and management of postpartum hemorrhage, for instance, as well as ways to decrease disparities in outcomes and decrease risk for all birthers.

Structurally, the group is looking at ways systems in the institution and the department may unintentionally contribute to inequities, and how to counteract these biases. The committee is looking at ways bias plays a role in suboptimal outcomes and incorporating this analysis into case reviews at all levels within the labor & delivery department, for example.

“We’re looking at ways biases might play a role in outcomes,” Tonja says.

“The third pillar of our approach is culture – it’s possibly the most important and hardest to tackle,” she says. “We can chip away at particular clinical or systemic disparities, but we have to address the underlying cause – bias in healthcare. It’s all for naught if we don’t because other disparities and inequities will crop up in place of the ones we eliminate.”

How is Baystate Health Addressing the Problem?

One of the cultural ways Baystate Health is working on the issue is by providing the department with cultural humility training.

“Almost everyone in the department who has a clinical role has undergone the training,” she says. “It is geared toward healthcare workers. The Women of Color Health Equity Collective did the training.”

Tonja said there is ongoing education for employees. Examples include creating trans-inclusive spaces, improving healthcare for immigrants, and developing improved care for women of size. There is also work being done on making trauma-informed care more universal.

“We want to advance and expand people’s understanding of the impact of implicit bias in healthcare,” she explains. “One of the ways we’re working on decreasing these disparities is trying to make doulas accessible to all,” she says. “The department currently has a grant, called BeSide, to offer free doula services to a small number of birthers who identify as Black. Our hope is that with new efforts at MassHealth to cover doula services, doulas will be available to more people who deliver in the State.”

The committee has joined with a state collaborative called PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts). “This organization helps institutions like Baystate initiate AIM (Alliance for Innovation on Maternal Health) bundles. The national effort promotes the development and uptake of “maternal safety bundles” to improve patient outcomes and reduce severe illness and death.

“This maternal-infant health quality initiative focuses on five or six areas of evidence-based practice,” she says. “We’ve already done some of them, so we’re focusing on the ones we haven’t yet. Right now, one of our areas of focus is visibility – bulletin boards in four different areas in our OB/GYN department. These shine a light on racial disparities and health equity in infant and maternal health, as well as ways people can learn more and what they can do to help make much-needed change.” The initiative includes both basic and concrete information and provides resource flyers, website links, and reading materials.

“I’m really excited, because really soon it will contain outcomes data stratified by race and ethnicity, and eventually, language,” she shares. “Our goal is to have any data we think is important enough to look at (like C-section induction and hemorrhage rates for example) stratified by race, ethnicity and language so that we can keep tabs on how we are doing overall and be able to ask ourselves: are there inequities in the care we are providing?”

In May, all Baystate Health employees will be invited to watch “Aftershock,” a film about racial disparities in maternal health. There will also be a panel discussion after the showing.

“We want to keep the issues of inequities in maternal and infant health – and all health – at the forefront of people’s minds as they go about their daily work,” Tonja says.

The Committee is Recognized for its Work

The committee was one of three recognized at Baystate Health recently, receiving the President’s Excellence Award for its work.

“It’s the first time for a clinical health equity category,” she says.

What Can Providers Do to Reduce Implicit Bias?

• Use evidence-based screening and treatment tools
• Ask questions to better understand the patient and their needs
• Help patients understand urgent maternal warning signs
• Help patients articulate their needs and wants, and advocate for them
• Recognize unconscious biases in self and others
• Provide all patients with respectful care, including shared decision-making
• Address systems-level sources of inequities

What Symptoms Should Pregnant or Post-partum People Consider Urgent and Seek Medical Care Immediately?

According to the Alliance for Innovation on Maternal Health, you should call your provider or go to the emergency room immediately if you experience any of the following symptoms during or after pregnancy.

• Headache that won’t go away or gets worse over time
• Dizziness or fainting
• Thoughts about hurting yourself or your baby
• Changes in your vision
• Fever
• Trouble breathing
• Chest pain or fast-beating heart
• Severe belly pain that doesn’t go away
• Severe nausea and throwing up (not like morning sickness)
• Baby’s movements stopping or slowing during pregnancy
• Vaginal bleeding or fluid leaking during pregnancy
• Vaginal bleeding or fluid leaking after pregnancy
• Swelling, redness, or pain of your leg
• Extreme swelling of your hands or face
• Overwhelming tiredness

April 11-17 is Black Maternal Health Week, an annual week-long public health campaign founded and led by the Black Mamas Matter Alliance to build awareness, activism, and community-building to amplify the voices, perspectives and lived experiences of Black Mamas and birthing people.

If you’re pregnant or planning to become pregnant, meet our team and consider having your baby at Baystate Health.