Promoting Birth Equity

Narrator: Birth equity is the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort.

Narrator: What are the odds of this newborn baby surviving to her first birthday?

Narrator: Will this mother avoid childbirth-related complications or even death?

Statistical data may help answer these questions.

Narrator: According to the National Center for Health Statistics, in 2017 and 2018, infants of non-Hispanic Black women had the highest mortality rate and the highest neonatal mortality rate compared with infants of other race and Hispanic-origin groups.

Narrator: And, CDC data confirms significantly higher pregnancy-related mortality ratios among Black women, and these inequities increase with age.

Narrator: When women of color tell their maternal healthcare provider that they are having pain or some other kind of physical or emotional complaint, their complaints are frequently dismissed.

When a woman's headache, pain, or bleeding is not taken seriously, it can lead to deadly consequences.

Narrator: In a 2019 study, W-H-O researchers found that women of color reported far higher rates of mistreatment than the broader population, causing them to feel as if their provider was not listening to them, leaving them out of decision making, or refusing their requests for help.

Narrator: What can you do to improve birth equity in your own medical practice?

Narrator: A Committee Opinion written by The American College of Obstetricians and Gynecologists states there is evidence to suggest that factors such as stereotyping and unconcious bias on the part of healthcare providers may contribute to racial and ethnic disparities in health.

Narrator: What's your bias IQ?

Narrator: Biases can lead to differential treatment of patients by race, gender, weight, age, language, income, disability, sexual orientation, and insurance status.

Narrator: Biases can interfere with clinical assessment, decision making, and provider-patient relationships.

Narrator: Biases can lead healthcare professionals to treat patients differenlty merely based on certain patient characteristics. This is known as "differential treatment."

This happens because biases can interfere with clinical assessment, decision making, and provider-patient relationships.

As a result, health goals may be compromised.

Narrator: Bias occurs when patients are judged and/or treated differently based on all of these and more!

Narrator: Both medical and administrative staff may judge patients and/or treat them differently based on a variety of characteristics.

Dr. Roberts (speaking rapidly, looking at a tablet or comupter screen, not engaging with patient): So, Mrs. Abdi, I see you are over due for this follow-up. Why did you wait so long to come in? It says here that we sent you home with some prenatal care instructions about two months ago. Didn't you read them? (Dismissive) A woman like you should be doing all she can to take better care of herself.

Mrs. Abdi (hesitatantly, with embarassment): I'm sorry, Doctor. Um, could you slow down, I don't speak English very well.

Dr. Roberts (facing patient, frustrated, speaks a little louder, but does not pause between questions): Oh, I see. [Sighs] How are you feeling? Do you have any complaints? Are you at least following the nutritional guidelines we provided?

Mrs. Abdi (speaking quietly, sheepish smile, shrugs): I'm okay.

Narrator: Unfortunately, dominant communication styles, fewer demonstrated positive emotions, infrequent requests for input about treatment decisions, and less patient-centered care seem to characterize patient–provider interactions involving people of color.

Narrator: Dr. Roberts may have biases that impact his ability to provide the best possible care ― and he may not even realize it.

Narrator: In the maternal healthcare setting, biases can reveal themselves in many ways and can come from any member of the staff ― both medical and administrative.

Narrator: Bias may be in play when you fail to use a trained interpreter to communicate important medical information or determine whether a patient can read or read in the written language provided.

Narrator: Verbal and nonverbal communications that subtly convey rudeness and insensitivity or demean a person's heritage or identity may also stem from bias.

Narrator: So, what are some of the consequences?

Patients who feel minimized may not respond openly to questions. They may choose to visit the hospital emergency room instead of returning to the provider's office.

Narrator: When providers fail to use interpretive services, patients may be unable to report symptoms that can cause complications, and they may not understand a treatment plan, diagnosis, prognosis, or medication side effects.

Narrator: When communication breaks down and patients don't feel they can share openly, other serious concerns around housing, transportation, food, and interpersonal safety may be left out as well.

Narrator: It takes a long-term commitment and constant discipline and effort to overcome unconscious bias, but the benefits are worth it!

Narrator: According to the CDC, healthcare providers who identify and address unconscious bias would likely improve all of these!

Jada (smiles and greets patient Billie when she reaches the front desk): Good morning. Have a seat and we'll call you up in a few minutes.

Front Office Staff 1, Adriana, (speaking to Jada, incredulous): Did you see that girl's purse? And those clothes?

Front Office Staff 2, Jada, (speaking to Adriana, finger to lips): Shhh, she can hear you.

Front Office Staff 1, Adriana, (speaking to Jada, animated): No she can't; she's wearing those $200 headphones! Girls like that get themselves pregnant just to play the system!

Front Office Staff 2, Jada, (speaking to Adriana, calmly, sincere): Look Adriana, I'm sure you don't really believe that, but that comment you made just reinforces a negative stereotype.

Front Office Staff 1, Adriana, (looks embarassed, regretful): Oh, I didn't think about it that way.

Narrator: One of the best ways to defeat your own biases is to avoid stereotyping.

Narrator: Stereotyping limits your ability to deal with people and situations effectively.

So, treat each person as an individual rather than as part of a group, and don't assume that people have certain traits or behavior simply because they belong to certain groups or nationalities.

Narrator: Another way to defeat your own biases is to always demonstrate empathy.

When you demonstrate empathy, you make a positive impact on a patient's satisfaction, confidence, emotions, medical adherence, and health outcomes!

Narrator: By practicing evidence-based medicine with great care, physicians and medical staff can defeat biases.

Narrator: And remember, you are treating more than just a symptom or a physical condition.

Treat the whole patient ― physical, emotional, spiritual, and psychological.

Narrator: Fighting your own biases is not as simple as doing a few activities and then moving on.

It takes a long-term commitment and constant discipline and effort to overcome unconscious bias.

You learned racial associations over the course of your lifetime. It will take just as long to reject them and retrain your mind.

CNP, Liz, (leaning forward, looking at Billie): How can I help you today? What would you like to talk about?

Patient, Billie, (hand to her head): I get these sharp pains in my head. It's making me scared there's something really wrong.

Narrator: Communication is a fundamental component of each healthcare interaction, and it impacts the patient's health outcomes, safety, and healthcare experience.

Narrator: Being a good listener is a basic sign of respect. These simple things can help make you a better listener.

Narrator: Avoid jumping in and assuming you know what each mother needs to hear. Passive listening can lead to trust and genuine engagement.

Narrator: Eye contact shows that you are interested in what your patient is saying. Avoid staring at a computer screen and entering information while your patient is speaking.

Narrator: Resist interruptions, such as taking calls or texts, interrupting the patient while she is speaking, allowing staff members to interrupt the appointment, or multi-tasking.

Narrator: Health professionals may make assumptions based on race, ethnicity, or socioeconomic status. And, intentionally or not, this results in alienating advice.

CNP, Liz, (leaning forward, looking at Billie, reaches for her hand): I'm very sorry to hear you have not been feeling well. And, I understand that it can be scary. Before we discuss your headache, is anything else bothering you?

Patient, Billie, (voice cracks, holds head): Well … there's just so much going on … I have all this homework … (sighs). It's all just really stressful.

Narrator: Check out these ways to improve your responses and communiction style.

Narrator: Mothers and caregivers are under significant emotional stress, often worried and exhausted.

Validating the feelings you hear shows that you are on their team. This makes the conversations authentic and, in turn, more impactful.

Narrator: By demonstrating that you really hear a patient's concerns and the feelings behind them, you will be viewed as more caring.

Narrator: Clarify your understanding by inviting your patient to share more information and by asking questions that cannot be answered with a "yes" or "no" response.

These "open-ended questions" bring out information, as well as gauge the patient's understanding, emotions, attitudes, and beliefs about their situation.

Narrator: Confirm and summarize what you have heard. This lets your patient know that she has been heard and gives her a chance to correct any misunderstandings.

Many patients want to be partners in the decision making about their healthcare, so it's important to reach agreement on goals, treatments, and next steps.

Narrator: Good communication skills are only effective if the patient can understand you.

So, use appropriate and qualified Language Interpretation Services, when needed.

Narrator: And, provide information that meets the patient's health literacy, language, and cultural needs.

Narrator: Don't let your patient-provider rapport suffer because of mask-wearing requirements.

During any situation when you are required to wear a mask that covers your nose and mouth, reinforce normal communication skills.

Nurse, Lucy (friendly tone, speaking deliberately, but not loudly, gives a little wave): Good morining, Mrs. Abdi. It's nice to see you again.

Patient, Mrs. Abdi: Hello.

Nurse, Lucy (friendly tone, speaking deliberately, but not loudly, good enunciation, using hand gestures): I'm Lucy, and I'm going to be taking your vitals today. I know these masks make it really hard to talk, so please tell me if you can't understand me, okay?

Patient, Mrs. Abdi (nods): Yes, thank you, but my English is not very good,

Nurse, Lucy (friendly tone, speaking deliberately, but not loudly, good enunciation,nods): Oh, I understand. Tell me your preferred language, Mrs. Abdi, and I'll see if I can get an interpreter to help us today.

Narrator: Handshakes are out and smiles hidden, so when greeting patients, make eye contact, smile with your eyes, clearly extend a verbal greeting, and even give a little wave.

Narrator: Acknowledge to your patient that communication while wearing masks is not ideal, and encourage her to let you know if she cannot understand you.

Narrator: During the appointment, use good eye contact, lean forward toward the patient, use an expressive tone of voice, and use appropriate gestures.

CNP, Liz (speak more slowly than normal, enunciate): While wearing a mask and speaking, it's important to slow down your speech, to enunciate each syllable, and not to mumble.

Physician, Dr. Miller (speak more slowly than normal, enunciate): Speaking louder may not be necessary. If someone is not understanding you, try repeating the sentence in a normal voice or say it in a different way with more context.

CNP, Liz: When a patient is speaking, use nonverbal encouragement and maintain eye contact. While wearing a mask, the message your eyes and body language are sending becomes amplified.

Physician, Dr. Miller: You may feel confident that you can look at a patient's chart and listen at the same time, but not all patients share that perspective. A lack of eye contact can contradict a verbal invitation for patient participation.

CNP, Liz: And, you might want to find out if "clear-window" surgical masks are available in your area.

Dr. Roberts: In my practice, we've been working to build and encourage a culture of equity.

Dr. Roberts: We've provided staff-wide education on unconcious bias and peripartum racial and ethnic disparities and their root causes.

Dr. Roberts: Our medical staff is aware of the qualified interpreter services available within the healthcare system.

Dr. Roberts: And, we encourage patients, families, and staff to report inequitable care and episodes of miscommunication or disrespect in order to build a culture of accountability.

Narrator: Check out three more ways to build and encourage a culture of equity in your practice.

Narrator: Educate patients in a culturally sensitive manner about steps they can take to prevent disease conditions that are prevalent in their racial and ethnic groups.

Narrator: All staff working with patients should be skilled in culturally competent communication and patient education.

All staff should know and work within their scope of practice.

Narrator: If most of the patient population you serve is of color, it's important that your staff reflects that. Altering hiring practices and policies to increase diversity can be an important step toward achieving equity.

Narrator: All mothers and babies — regardless of race or ethnicity — must have every opportunity to receive optimal maternal and birth outcomes. It is the responsibility of every medical professional to affect change and avoid preventable deaths from pregnancy or its complications.