By Efua Erbynn, MD, Facility Medical Director, OB/GYN Hospitalist, Inova Loudoun Hospital
Black Maternal Health Week occurring April 11 – 17, 2022, is a time of celebration, awareness, activism, amplification and visibility for Black maternity. In recognition of the week, Dr. Efua Erbynn participated in a question and answer session to discuss the persistent racial and gendered biases in medicine and what more needs to be done to combat these pervasive issues.
What does it mean to have Black Maternal Health Week officially recognized?
Black Maternal Health Week was formally recognized by the White House in 2021, but has been acknowledged by congress for the past five years. It is not well known or celebrated, even in the medical community. Considering that women have been giving birth for thousands of years, and it is well known that Black women have more pregnancy-related morbidity and mortality, it is startling that it has taken so long to acknowledge and specifically address Black maternal health disparities.
One of the greatest public health achievements over the last century, has been the dramatic lowering of the maternal mortality rate from 600 per 100,000 deliveries in 1915, to 23.8 per 100,000 births in 2020. However, even with these achievements, Black women are still three times as likely to die due to pregnancy-related causes as non-Hispanic white women (55 vs 19 per 100,000 births). Even though the U.S. has been keeping track of morbidity and mortality rates for hundreds of years, little has been done to improve Black maternal health. The problems have been largely ignored, or lumped together with other comorbidities related to socioeconomic status. This feeds into the overall distrust in the African American community for medical professionals and the healthcare system in general – reinforcing the idea that nobody listens, or cares about things that are affecting them.
Anytime you have something acknowledged by the White House, you get a lot of attention and people start rallying around it. It allows people to have a focus, and to make sure that they are continuing to improve. As with any type of process improvement, having a date when we can review our progress annually, allows us to look back on how we’ve done, and make plans for the next year. We can specifically ask, “How have we done in reducing implicit bias, maternal mortality rates, etc.?”
What more needs to be done in the medical community to promote better health outcomes for Black women?
I think the best way to acknowledge that implicit bias is occurring and to work towards decreasing it, is for people to be more aware of how pervasive it is in the community. In addition, both patients and healthcare workers need to feel comfortable raising the issue, when it arises, and work towards improvement. This would be enhanced further, with a more diverse healthcare workforce, especially at the Physician level or higher (C-suite). Patients have greater satisfaction, improved access to care, and better outcomes, when the workforce is more diverse and inclusive.
As an example, a White woman who was 35 weeks pregnant presented to the emergency department reporting intermittent high blood pressures on her home BP machine, and some chest pain and shortness of breath. The White patient was immediately worked up for preeclampsia, and admitted to Labor and Delivery. Preeclampsia is a pregnancy-related condition that involves high blood pressure and protein in the urine. It is common towards the end of pregnancy, and can have symptoms such as headache, chest pain, shortness of breath, visual changes, or abdominal pain. If not treated appropriately, it can rapidly progress from mild disease to severe complications, including seizures, stroke, and permanent disability. A few days later, a Black woman who was 36 weeks pregnant presented to the ED reporting headache, chest pain and shortness of breath. She was noted to have very elevated blood pressures in the ED. She did not have a full work up for either preeclampsia, or other potential causes of chest pain and shortness of breath such as a blood clot in the lungs. Instead, the symptoms were attributed to a panic attack. She was given a sedative to treat a panic attack, rather anti-hypertensive medication. After the staff thought her panic attack passed, she was discharged despite still being hypertensive.
On her way home, she started experiencing chest pain again, as well as severe abdominal pain. She was transported back to the hospital by ambulance. On arrival, her blood pressures were in stroke range, and she had developed a severe form of preeclampsia called HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelets), which can be life-threatening. She was quickly delivered via Cesarean, and fortunately had no further complications, but it could have been much worse.
Black women are often dismissed or marginalized in the healthcare system, and do not feel comfortable voicing their concerns. The Physician who initially saw her was White, and assumed she was having a panic attack because she had one in the past. The patient did not feel comfortable questioning the diagnosis, or speaking to anyone else, because she could not identify with any of the staff. Though bias cannot be easily proved in this case, it is clear that the symptoms of the Black patient were minimized, and she did not get the full work up a White woman with similar symptoms received a few days prior. This oversight led to increased morbidity (HELLP), and she could have died and become yet another grim statistic.
What can help prevent other scenarios like this?
We need to be more cognizant about situations like this, and actively work towards eradicating them. It’s well-documented that there is institutional, structural, and systemic racism throughout our society that have contributed to marginalization of Black people. The healthcare system must invest in more educational and training programs aimed at recognizing our implicit biases and eliminating them.
We also must allow patients to feel safe enough to tell us what they’re feeling, even if they’re feeling discrimination or bias. Black women are often stereotyped as “difficult”, “non-compliant,” “drug seeking” or “angry,” and this can play a role in our perception of them as patients. In the example above, the patient felt that the doctors were telling her she was anxious, so then maybe it was true. She didn’t feel that was what was wrong, but did not feel empowered to advocate for herself in that environment.
Having more healthcare workers of color, will also help patients feel more comfortable within the healthcare system. Despite the changing demographics of the US, with increasing numbers of minority patients, the healthcare workforce remains predominantly White. Programs aimed at recruiting minority workers will help improve patient experience/satisfaction by increasing the overall cultural competency of the workforce. This would improve the overall quality of care and patient outcomes.
How has this impacted you personally?
I’m originally from Ghana, in West Africa. Having grown up in a country where everybody is Black, it was a big change to move to the U.S. There are definitely problems in healthcare systems in other countries, but they are usually not related to color. When I moved to the U.S, the disparities in diversity, equity, and inclusion were quite obvious to me, but not to the White physicians I worked with. Being a member of the group experiencing the bias, you are more aware of what is going on. However, the people who are doing it (hopefully unconsciously), may not be aware of the problem. There have been numerous occasions when I entered a room with a white nurse, and introduced myself to the patient as Dr. Erbynn, only to have the patient conclude that I was the nurse, and the white person was the physician.
Another example occurred several years ago when I worked as an Ob/Gyn in a private practice located in a small town. The town had an approximately 40% Black population, however, only 5-10% of the prenatal clinic patients were Black. We had a lot of minority women presenting in active labor, having had no prenatal care. This led to increased complications for both the mothers and infants. After I joined (with an advertising campaign to showcase the new providers), our Black and minority patient population rose dramatically. Patients expressed that they felt more accepted and comfortable coming to a practice/physician that was more racially and culturally diverse. I noticed some disparities in how the staff referred to the partners who came in with the patients, and worked to change our verbiage. All the partners were now referred to as the “father of the baby,” where previously Black partners were usually the “baby daddy” vs the white partners who were “husband.” This had a small, but positive impact on patient satisfaction, and increased the number of Black patients seeking prenatal care, which in turn, improved patient outcomes.
Black Maternal Health Week 2022
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