__________________________________________________________________ Maternal Health Disparities
STRATEGIES TO PROMOTE AWARENESS It is important to promote awareness of bias—both explicit and implicit biases and at personal, organizational, and pro- fessional levels. Education and training are powerful tools to identify and address issues related to bias. Reflection exercises and role play can be used, as hands-on skills are necessary in order to apply theories to practice. Creating safe environ- ments and using skill-building exercises are key components of any program designed to reduce biases and related health disparities [31]. Harvard University sponsors Project Implicit, a research project which monitors implicit biases. Project Implicit houses the Implicit Association Test (IAT), which can be used as a metric to assess professionals’ level of implicit bias on a variety of subjects, and this presupposes that implicit bias is a discrete phenomenon that can be measured quantitatively [32]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact. The IAT is available at https://implicit.harvard. edu/implicit, and anyone may complete an assessment. Another way of facilitating awareness of providers’ implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (or subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [33]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction: • Did I think about any socioeconomic and/or environ- mental factors that may contribute to the health and access of this patient? • How was my communication and interaction with this patient? Did it change from my customary pattern? • How could my implicit biases influence care for this patient? When reviewing the SOAP notes, providers can look for recurring themes of stereotypical perceptions, biased com- munication patterns, and/or types of treatment/interventions proposed and assess whether these themes could be influenced by biases related to race, ethnicity, age, gender, sexuality, or other social characteristics. A review of empirical studies conducted on the effectiveness of interventions promoting implicit bias awareness found mixed results. At times, after a peer discussion of IAT scores, participants appeared less interested in learning and employing implicit bias reduction interventions. However, other studies have found that receiv- ing feedback along with IAT scores resulted in a reduction in implicit bias. Any feedback, education, and discussions should be structured to minimize participant defensiveness [34].
IMPACT OF BIAS ON THE DELIVERY OF PERINATAL CARE
Worldwide, the maternal mortality has decreased 43% since 1993. However, the United States is the only developed country in which maternal mortality has increased [35]. As of 2023, the United States reports the highest maternal mortality of all developed countries. The rate in New Jersey (25.7 maternal deaths per 100,000 live births) is higher than the national average (23.5 deaths per 100,000 live births). The greatest rates tend to occur in the South [36]. What is further troubling is that most maternal deaths and cases of severe morbidity are preventable [35]. This then leads to the necessary question: Why are these deaths occurring? A review of maternal deaths across nine states found that the deaths were most commonly related to “clinician, facility, and system factors, such as inadequate training, missed or delayed diagnosis of complications, poor communication, and lack of coordination between clinicians” [37]. Improvements in clinician knowledge, skill, interprofessional collaboration, and bias could make inroads to improving maternal health care in the United States. In a survey of 2,402 women regarding their maternal care, the following mistreatments were most commonly reported [2]: • Receiving no response to requests for help • Being shouted at or scolded • Not having their physical privacy protected • Being threatened with withholding treatment or made to accept unwanted treatment About 30% of Black, Hispanic, and multiracial women reported mistreatment, with lower rates or reported mistreat- ment among White (19%), Native American/Alaska Native/ Native Hawaiian/Pacific Islander (18%), and Asian (15%) patients. Mistreatment was most commonly reported by those with no insurance (28%) or public insurance (26%); only 16% of those with private insurance reported mistreatment. Patients most commonly reported discrimination and/or mistreatment during prenatal care related to age, weight, income, and race/ ethnicity [2]. About 29% of women experienced discrimina- tion, with the highest rates among Black (40%), multiracial (39%), and Hispanic (37%) women [2]. While satisfaction with maternity care overall was high (90%), satisfaction among those who reported mistreatment was considerably lower (75%). Mistreatment and discrimination impact experiences of care. Social determinants of health are the conditions in the environ- ments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.
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MDNJ1525
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