Addressing equity to enact change
The efforts in Louisiana also set the stage for better maternal outcomes. At the 2019 ACOG meeting where she spoke as part of the President’s Panel, Dr. Gee said Louisiana had the highest maternal mortality rates in the nation. The NCHC data released in January, however, suggest that may no longer be the case.
Inconsistencies in how the latest and prior data were reported, including in how maternal mortality was defined, make direct comparison impossible. But in the latest report, Louisiana ranked seventh among states with available data.
“Ninety percent of the deliveries in the state happen at hospitals that we worked with,” Dr. Gee said, highlighting the reach of the efforts to improve outcomes there.
She also described a recent case involving an anemic patient whose bleeding risk was identified early thanks to the programs put in place. That enabled early preparation in the event of complications.
The patient experienced a massive hemorrhage, but the preparation, including having units of blood on hand in case of such an emergency, saved her life.
“So we clearly have not just data, but individual stories of people whose lives have been saved by this work,” she said.
More tangible data on maternal morbidity further show that the efforts in the state are making a difference, Dr. Gillispie said, citing preliminary outcomes data from the Pregnancy-Associated Mortality Review launched in 2018.
“We started with an initial goal of reducing severe maternal morbidity related to hypertension and hemorrhage by 20%, as well as reducing the black/white disparity gap by Mother’s Day 2020,” she said.
Final analyses have been delayed because of COVID-19, but early assessments showed a reduction in the disparity gap, she said, again highlighting the importance of focusing on equity.
“Definitely from the standpoint of the Quality Collaborative side ... we’ve been working with our facilities to make them aware of what implicit bias is, helping them to also do the Harvard Implicit Bias Test so they can figure out what their own biases are, start working to acknowledge them and address them, and start working to fight against letting that bias change how they treat individuals,” Dr. Gillispie said.
The work started through these initiatives will continue because there is much left to be done, she said.
Indeed, the surprised reactions in recent weeks to the reports of disparities in COVID-19 outcomes further underscore that reality, and the maternal mortality statistics – with use of the voices of those directly affected by structural and overt racism and bias in maternal care as a megaphone – speak for themselves.
Hearing implicit bias from patients’ perspective
Just ask Timoria McQueen Saba, a black woman who nearly died from a postpartum hemorrhage in 2010. At ACOG 2019, she spoke about how she had to switch ob.gyns. three times during her first pregnancy because she felt she had not received quality care – one doctor neglected to tell her she had placenta previa. She also experienced excessive wait times at prenatal appointments and had been on the receiving end of microaggressions and degrading questions such as “Are you still married?” and “Is your husband your baby’s father?” – and these are all things her white friends who recommended those physicians never experienced, she said.
Timoria McQueen Saba
“The health care system has just sometimes beaten people down so much, just like the world has – people of color, especially – to where you’re dismissed, your concerns are invalidated,” she said. “Some doctors don’t even think black people feel pain [or that] our pain is less.”
Mrs. Saba also spoke about how her health care “improved a billion percent” when her white husband accompanied her to appointments.
Just ask Charles S. Johnson IV, whose wife Kira Dixon Johnson died in 2016 during surgery for postpartum bleeding complications – after he and other family members spent 10 hours pleading for help for her.
Speaking at the ACOG panel discussion with Mrs. Saba, Mr. Johnson described “a clear disconnect” between the medical staff at the hospital and the way they viewed and valued Kira. He shared his frustration in wanting to advocate for his wife, but knowing that, as an African American male, he risked being seen as a threat and removed from the hospital if he didn’t stay calm, if he “tapped into those natural instincts as a man and a husband who wants to just protect his family.”
He fought back emotions, struggling to get the words out, saying that’s what haunts him and keeps him up at night – wondering if he should have “fought harder, grabbed the doctor by the collar, raised his voice, slammed on the counter.
“Maybe they would have done something,” he said.
Such experiences cross all socioeconomic boundaries. Ask U.S. Track and Field Olympic gold medalist Allyson Felix, who testified at a U.S. House Ways and Means Committee hearing on May 16, 2019 after developing severe preeclampsia that threatened her life and that of her baby. Ask tennis champion Serena Williams, who demanded assessment for pulmonary embolism following the birth of her child; she knew the signs, but her health care providers initially dismissed her concerns.
Their experiences aren’t just anecdotal. Data consistently show how racism and bias affect patient treatment and outcomes. Dr. Gee, for example, shared findings from a retrospective assessment of 47 confirmed pregnancy-related deaths in Louisiana between 2011 and 2016 that looked specifically at whether the deaths could potentially have been prevented if blood was given sooner, cardiomyopathy was recognized sooner, hypertension was treated on time, or other changes were made to care.
The answer was “Yes” in 9% of cases involving white patients – and in 59% of cases involving black patients (odds ratio, 14.6).
The study, reported in February in Obstetrics & Gynecology, showed that 27 of the deaths (58%) occurred at level III or IV birth facilities and that those deaths were not less likely than those at level I or II facilities to be categorized as preventable (OR, 2.0).
Findings from the Giving Voice to Mothers study, published in Reproductive Health in 2019, showed how mistreatment during childbirth might contribute to such outcomes.
In an online cross-sectional survey of more than 2,100 U.S. women, one in six reported at least one type of mistreatment, such as loss of autonomy, being yelled at or threatened, being ignored or having requests for help ignored, Saraswathi Vedam, SciD, of the Birth Place Lab at the University of British Columbia, Vancouver, and colleagues reported.
Race was among the factors associated with likelihood of mistreatment, and the rates of mistreatment for women of color were consistently higher – even when looking at interactions between race and other characteristics, such as socioeconomic status (SES). For example, 27.2% of women of color with low SES, compared with 18.7% of white women with low SES, reported mistreatment. Having a partner who was black, regardless of maternal race, was also associated with an increased rate of mistreatment, the authors found.
“I often get the question, ‘Do you think Kira would be alive if she was white,’ ” Mr. Johnson said. “The first way I respond to that question is [by saying that] the simple fact that you have to ask me is a problem.
“When this first happened, I was in so much pain that I couldn’t process the fact that something so egregious and outrageous happened to my wife because of the color of her skin, but as I began to process and really think about it and unpack this scenario, I have to be really frank ... do I think that she would have sat there for 10 hours while we begged and pleaded? Absolutely not.”
He stressed that his words aren’t “an indictment of the profession.”
“This is not an indictment saying that all people are racist or prejudiced,” he said. “But here’s the reality: If you are in this profession, if you are responsible for the well-being of patients and their families, and you are not able to see them in the same way that you see your mother, your wife, your sister, you have two options – you need to find something else to do or you need to take steps to get better.”