Health care providers play a unique, and intimate, role in the health and future of San Diego’s Black Legacy. Even with good intentions, providers may unknowingly contribute to health inequities. Implicit bias, when individuals act on the basis of prejudice and stereotypes without intending to do so, occurs among health care providers just as much as the wider population. 1 However, implicit bias in health care settings, and larger issues of structural racism, lead to poor birth outcomes such as preterm and low birthweight babies, and even maternal and infant death.

Key Facts and Data

The American College of Obstetricians and Gynecologists acknowledges that racial bias within the health care system is contributing to the disproportionate number of pregnancy-related deaths among women of color. Providers spend less time with Black patients, ignore their symptoms, dismiss their complaints, and undertreat their pain.  www.statnews.com/2019/07/10/pregnancy-related-deaths-implicit-bias/

Studies have noted that implicit bias influences patient-provider interaction and indicates that biases are likely to influence diagnosis and treatment decisions. This contributes to a higher allostatic load and adversely affects the health of the mother and fetus. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC medical ethics, 18(1), 19. doi:10.1186/s12910-017-0179-8

In a community meeting of Black mothers in San Diego in 2018, women noted implicit biases and racism during provider-patient interactions, feeling disrespected and judged by clinic and medical providers, with 80% of women feeling their provider did not care about them.  Statistics prepared by the County of San Diego, Health and Human Services Agency, Public Health Services.

In San Diego County, Black infants are over 5 times more likely to die, about 50% more likely to be born premature, and twice as likely to be born with low birthweight than White infants. Based on comparison of African-American/Black and White: 2019-2021 average infant mortality rates (8.6 vs. 1.6 deaths per 1,000 live births, respectively); 2020-2022 average preterm birth rates (10.9% vs. 7.2%, respectively); and 2020-2022 average low birthweight rates (10.2% vs. 5.2%, respectively). Data from State of California, Department of Public Health, Center for Health Statistics and Informatics, Birth Cohort Statistical Master Files and California Comprehensive Birth Files. Statistics prepared by County of San Diego, Health and Human Services Agency, Public Health Services

California’s Black women are over 3 times more likely to die from pregnancy-related causes than White women. Based on comparison of African-American/Black and White 2019-2021 average pregnancy-related mortality ratios (49.7 vs. 14.0 deaths per 100,000 live births, respectively). Data from California Department of Public Health, California Pregnancy Mortality Surveillance System. Accessed at https://www.cdph.ca.gov/Programs/CFH/DMCAH/surveillance/Pages/Pregnancy-Related-Mortality.aspx.

During 2017-2021, preterm African-American infants were more than twice (2.6 times) as likely to die as preterm White infants (44.1 vs. 16.9 deaths per 1,000 live births, respectively). Data from State of California, Department of Public Health, Center for Health Statistics and Informatics, Birth Cohort Statistical Master Files. Statistics prepared by County of San Diego, Health and Human Services Agency, Public Health Services.

Inequities in maternal and infant health outcomes frequently persist irrespective of income or education. An infant of an African-American woman with a college degree is more likely to die than one of a White woman who graduated high school. Much research has shown that structural racism drives the inequities.  For example, averaging 2017-2018, California’s Black-White disparity in infant mortality was greater among college-educated women than among women with less than a high school education (college-educated rates were 5.0 vs. 2.0 deaths per 1,000 live births, respectively, a 1.6-fold difference, while rates for less than high school were 10.7 vs. 6.7 deaths per 1,000 live births, respectively, a 2.5-fold difference). Source: Centering Black Mothers in California: Insights into Racism, Health, and Well-being for Black Women and Infants. Sacramento, CA: California Department of Public Health, Maternal, Child and Adolescent Health Division; 2023.

Nationally, averaging 2018-2022, infants of African-American mothers with a college degree were more likely to die than those of white mothers who graduated high school (7.3 vs. 6.4 deaths per 1,000 live births). Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Period Linked Birth/Infant Deaths on CDC WONDER Online Database.
 

Below are some of the factors that negatively impact patient-provider relationships, including:
 

  • Poor, unequal care
  • Limited time with providers and not explaining terms or concepts in ways that patients can understand
  • Delays in accessing prenatal care
  • Distrust of the medical system
  • Lack of accurate patient information due to the constant rotation of OB-GYN providers
  • Lack of diverse medical teams
  • Lack of awareness of resources and services available to new and current moms
  • Limited knowledge of how to utilize health care services and navigate options (e.g., C-section, midwives, and freestanding birth centers)
DeJon and Myke, North Park

What does this mean for health care providers and their role in reducing these disparities? As health care professionals, you have the responsibility to provide all patients with…

  • Respect, dignity, and nondiscrimination throughout their care
  • Education, information about their pregnancy, childbirth, and decisions made throughout their care
  • The ability to ask questions, participate in decisions, and provide informed consent for anything related to their well-being and that of their child
  • Quality, respectful care that honors patient’s choices, preferences, preferred language, culture, religion, or traditions
  • Personal support before, during, and after their pregnancy and childbirth from you and the health care team.

Download and share the Know Your Rights document with patients and your team.

DeJon and Myke, North Park

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Professional Statements

Know Your Patient’s Rights

  • Download and share our “Know Your Rights” document with your entire team or staff to ensure you and your team are providing the highest standards of quality, respectful care to all patients.
  • Become familiar with resources and local supports for African-American mothers and families such as the Black Infant Health Program, and other programs in the County.

Take Action

The best way to understand the role of implicit bias in health care is to examine our own biases. It is well documented that providers treat Black patients differently often with a lesser quality of care. Implicit bias training for providers shifts the burden of change from the individual to the systems level.

Senate Bill 464, also known as the California Dignity in Pregnancy and Childbirth Act, requires implicit bias training for all health care professionals working in perinatal services. The trainings should include:

  • Identification of previous or current unconscious biases and misinformation.
  • Identification of personal, interpersonal, institutional, structural, and cultural barriers to inclusion.
  • Corrective measures to decrease implicit bias at the interpersonal and institutional levels, including ongoing policies and practices for that purpose.
  • Information on the effects, including, but not limited to, ongoing personal effects, of historical and contemporary exclusion and oppression of minority communities.
  • Information about cultural identity across racial or ethnic groups.
  • Information about communicating more effectively across identities, including racial, ethnic, religious, and gender identities.
  • Discussion on power dynamics and organizational decision-making.
  • Discussion on health inequities within the perinatal care field, including information on how implicit bias impacts maternal and infant health outcomes.
  • Perspectives of diverse, local constituency groups and experts on particular racial, identity, cultural, and provider-community relations issues in the community.
  • Information on reproductive justice.

The following are some resources to learn more about implicit biases in health care.

In addition, health care providers can play a role in being actively anti-racist and raising awareness of this issue by joining the Perinatal Equity Initiative’s Community Advisory Board or attending a meeting, and sharing information with your colleagues. You can also share and post the Black Legacy Now campaign resources in your office, clinic or colleagues.

Posters and Printouts

“Doctors, like all other people, are subject to prejudice and discrimination. While bias can be a problem in any profession, in medicine, the stakes are much higher.”
 

Damon Tweedy, M.D, Black Man in a White Coat: A Doctor's Reflections on Race and Medicine

 

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