Why prenatal care providers should care about racial equity
In Hamilton County, Black infants are nearly three times as likelyto die when compared to their White counterparts – and this disparity has beengrowing for decades. At Cradle Cincinnati, we believe we will not be successfulin lowering our community’s infant mortality rate without a broader fight forracial equity. This starts with the care Mom receives during pregnancy.
Time and again, women in our community tell us that they feel mistreated during their prenatal care experience due to their race. That’s why we recently launched implicit bias training with several of our prenatal care partners, with the goals of strengthening relationships between clinical staff and patients and investigating the root causes of the biases buried deep within our healthcare systems.
Cradle Cincinnati is currently partnering with Avant Consulting Group to lead this work. Nicole Avant, president of Avant Consulting Group, recently shared why someone working in maternal and infant health should be concerned with racial inequities, the steps a person can take to mitigate his or her own implicit biases and more. Read on below.
Why should someone working in maternal and infant health be concerned with racial inequities?
Individuals working in maternal and infant health should understand that racial inequities and biases impact the care, health outcomes, and psychological well-being of moms of color. Racial inequities lead to increased morbidity (e.g., anxiety, depression, cardiovascular conditions, pain conditions, respiratory conditions) and mortality.
As clinicians, we are trained very well in gathering subjective and objective information to make clinical assessments and plans for our patients. However, we should consider creating assessments and plans that include structural interventions to address the social determinants of health such as education, employment, income, housing, transportation, criminal justice, and food access among others. We should expand care from delivering culturally competent care, which focuses on values and beliefs, to structurally competent care, which focuses on structures that more significantly impact care.
Structural competency requires knowledge and mitigation of structural inequities to prevent patients from “falling off the cliff of good health”. It requires us to assess differential access among groups (e.g., racial/ethnic) to ensure we are not crafting solutions that benefit dominant groups while pushing other groups further to the margins or off the cliff of good health.
Ultimately, we should be concerned about inequities because it’s not only our duty to care for all patients but also we want patients to live full healthy lives.
How does implicit bias present itself in the prenatal care setting?
Implicit bias manifests in many ways from non-verbal to verbal cues such as not believing, valuing, and respecting patients. It also includes making assumptions and value judgments about patients based on their identities. For example regarding pain, patients of size are routinely told that their pain or discomfort is solely based on their weight. They may not receive the same thorough patient workup as thinner patients. Clinicians may also assume that working class patients are drug seeking when they describe pain. Additionally, research shows that clinicians undertreat pain in Black patients based solely on the biased belief that Black people feel less pain than their white counterparts.
These instances occur in health systems across Cincinnati and the US. One story I will never forget involves a Black woman presenting with a past medical history consisting of a recent HIV diagnosis and a substance use disorder. Clinicians argued over who would care for her. She was dehumanized and treated as an object to be feared; assumptions were made regarding her life circumstances.
Implicit bias disrupts clinician-patient relationships. It cultivates an environment of devaluing, disrespecting, and decentering patient care based on social identities.
What steps can a person take to mitigate his or her own implicit biases?
The first step is to recognize that we all have implicit biases. It can be challenging to accept; consequently when confronted with bias, individuals may become defensive. But admitting to our biases is necessary in fostering robust clinician-patient relationships.
The next step involves identifying the types of biases we hold. This step may involve taking Harvard Implicit Association tests to measure unconscious attitudes related to race, gender, body type, religion, hair type, and many others.
After identifying biases, mitigating bias requires several ongoing, overlapping steps. It includes critically evaluating media content and verbally rejecting messages that run counter to humanizing individuals. Clinicians need to see patients as whole individuals, separating the patient from stereotypes. Clinicians should value differences instead of engaging in a colorblind mentality, which is another form of erasure, but work towards a real engagement in connecting difference and humanity within their patients and colleagues of color. Additionally, mitigating bias requires reflecting on how it impacts others, continuously watching first thoughts to identify biases, engaging in perspective taking and intergroup dialogue with others to build empathy, as well as building authentic relationships with diverse others.
Although mitigating biases is a lifelong process, clinicians should develop strategies to prevent biases from surfacing in clinical encounters. For example, if they have a “pro-white” bias, then the clinician needs to be explicitly friendly, see, and acknowledge the humanity of their patients of color.
Why is racial equity important to you? i.e. Why have you dedicated your career to addressing inequities in health?
This question is complicated because it takes me back to my own personal story. This work has been important to me since I recognized I was a diverse “other” at a very young age. In undergrad, I developed a personal mission statement to increase the upward mobility of diverse “others” through health, academics, and economics. Every decision I have made since then centers that mission.
I grew up in financially disinvested neighborhoods. I think it's important to utilize financially because people often place blame on the poor or Black and brown people in those environments. Even so, I knew at a very young age that education was a way to gain access to resources I didn’t have growing up.
I graduated top of my high school class with a GPA above 4.0. I then enrolled at the University of Illinois-Urbana Champaign (UIUC), a historically white college and university (HWCU). Due to many factors, I felt incredibly insecure. I was an urban, young Black woman at a HWCU, often the only Black woman or one of few Black people in many of my business courses. Also, I was a non-traditional student parent who had to enroll in remedial math and French 101 even though I’d been in advanced and AP courses in high school. I quickly realized my high school did not pour into me or fully educate me but had overlooked and shortchanged me and many other people who looked like me.
Consequently, I spent my undergraduate career studying more than four hours a night with my infant son nearby. I was disengaged from the typical undergraduate experience because I had to play significant academic catch up to my white peers. Although I was academically successful, I still lived in constant fear that UIUC admissions made a mistake and they were going to rescind my admission.
I ended up graduating with honors despite experiencing interpersonal and environmental microaggressions as well as structural inequities. I wish I could say those barriers were limited to one or two experiences I had in undergrad but I continued to be exposed to these inequities. There were not many Black students in pursuit of my Doctor of Pharmacy. I was the only Black resident in both of my residency classes. In 2015, I was hired as the Chief Diversity Officer and assistant professor for a college of pharmacy housed in a large, research one intensive predominantly white academic university. I was hired as their first Black woman faculty in ~150 years and the only Black faculty member at the College.
I have not always owned the language to describe my experiences with bias and structural inequities or fully understood the impact. For a long time, I unfortunately normalized and internalized my experiences. Now that I have access to privilege related to a higher socioeconomic status and increased social capital, I can more easily identify the differences in access and treatment (e.g., policing, housing, food access) among groups.
I now externalize challenges to the system level instead of placing blame on individuals. Society would have me and others to believe that Black people in communities similar to communities I grew up in are responsible for their environment. However, I am where I am today because of my community (not despite of my community). My grandmother, who survived as a sharecropper in Mississippi and a maid in Chicago, taught me the value of hard work.
And just as importantly, my family and community taught me the value of community building. I grew up in a 2-bedroom apartment with my cousins, aunts, mom, and grandmother; we pooled resources. My community shared with one another for essentials and supported one another during difficult times.
Despite boiling water at times to take baths due to limited financial resources as well as navigating rodents and pests in our large apartment complex because our landlord did not find value in eradicating, I had a fond childhood. I remember playing games (e.g., Double Dutch, rock teacher on the porch steps, Hide-n-Seek), gazing at stars, getting my hair braided, talking to my elders, and listening to insects chirp at night.
Ultimately, I do this work to educate others and liberate those from internalizing inequities, as others have done for me. But more importantly, I do this work to disrupt narratives regarding all people at the margins but especially the negative narratives concerning Black women.