Khadeja Haye, MD, MBA, FACOG, National Medical Director, Acute Hospitalist Medicine, OB/GYN Hospitalist
Medicine never stops improving. As medical professionals, we push to develop new techniques, treatments and methods that will have a long-lasting benefit for the health of our patients. This impact speaks for itself. Between 1990 and 2018, U.S. life expectancy increased by three years, infant mortality rates dropped by 40 percent and the number of heart disease-related deaths was cut in half. Many of the improvements made in healthcare benchmarks directly result from medical advancement, ranging from new technologies to updated policies and systems.
We see these improvements across the board, from the impact of regular screenings on cancer rates to better technology that provides earlier diagnoses for other life-threatening conditions. Despite the enormous progress that has been made in the medical community, there is a critical area that demands our collective attention – implicit bias in healthcare.
A Rising Maternal Mortality Rate
Last year, the Centers for Disease Control and Prevention released the 2018 national maternal mortality rate, reporting 17.4 maternal deaths per 100,000 live births. In other words, 658 U.S. women died due to pregnancy or birth-related complications in one year. This places the U.S. 55th among developed nations. In 1990, the national rate was 8.2 deaths per 100,000 live births – half the number reported in 2018. This is indicative of the importance of this topic and the potential impact on women’s health.
Maternal mortality does not impact all women equally. There are significant racial disparities, as the maternal mortality rate among Black women is three times higher than among white women. Black women suffer greater mortality from potentially fatal complications of pregnancy including maternal hemorrhage, hypertensive disorders and cardiomyopathies. A national study published in 2007 evaluated pregnancy-related mortality among Black women and white women. They determined that while Black women do not have a significantly higher prevalence of these pregnancy complications, they still had a case fatality rate two to three times higher than white women.
During the COVID-19 pandemic we have noticed an additional impact on maternal mortality rates among Black women. Black women made up 14.1% of women included in the analysis group but represented 26.5% of COVID-19 related deaths among pregnant women. Non-Hispanic Black women experienced a disproportionate number of deaths relative to their distribution among reported cases. As a healthcare provider and OB/GYN physician, I am concerned about the numerous examples of healthcare disparities even within my specialty.
The Impacts of Implicit Bias in Healthcare Treatment
The disparity in maternal mortality rates is part of a broader, fundamental problem of racial inequity within healthcare. We see this inequity across the system, rooted in our policies and prevalent in our beliefs.
Research on implicit bias has revealed startling insights into how people of color face disparity when seeking medical care. A 2019 study found that white participants more easily recognized expressions of pain on white faces than they did on Black faces. Another study indicated that Hispanic and non-Hispanic Black women experience disparities in postpartum pain management not explained by less perceived pain. In fact, those Hispanic and non-Hispanic Black patients received less opioid treatment than non-Hispanic white individuals for similar pain levels and conditions. Implicit bias has a tangible impact on how we treat our patients, which in some cases can result in poor outcomes.
Early Education Can Save Lives
We cannot begin to address a rising maternal mortality rate without first looking at the implicit bias that underlies it. While implicit bias can be challenging to correct, early action in educating clinicians is vital to ensuring their future patients receive appropriate medical care.
Our clinicians learn valuable lessons during their medical training that they will carry with them throughout their careers. There should be an emphasis on training future providers regarding the impact of implicit bias on patient experience and clinical outcomes. We must also train providers on how to identify their own biases that may impact the care they provide. Historically, there is very little emphasis placed on bringing awareness to implicit bias in medical training in the U.S. In recent years, diversity and inclusion training has increased but it still remains a very brief part of the curriculum. We must go even further and make it a part of the core medical curriculum. It should be taught by those with expertise in this area. I submit it is just as important as learning how to diagnose and treat common ailments or developing good surgical skills.
Education and Training at TeamHealth
At TeamHealth, we have developed an in-depth training course to educate clinicians on healthcare disparities in obstetrical care. The course explores the historical factors contributing to current healthcare inequity, bringing awareness to the issue that some may not have appreciated. The module also highlights the current obstetrical disparities and how social constructs and individual practice can impact the care received by underrepresented populations. The goal of this required module is to help our clinicians identify their own biases with the ultimate goal of improving patient outcomes while continuing to deliver higher-quality care to all patients.
Early exposure to the topic of implicit bias in medical education and a focus on diversity and inclusion in our provider recruitment are required if we want to address healthcare disparities. Ongoing training is equally important to ensure we remain mindful of how our biases can shape our patient interactions. As clinicians, it is our responsibility to ensure that patients, no matter their race, ethnicity or socioeconomic status receive the best care we can provide. We must commit to educating ourselves and educating future healthcare providers on how they can best serve their communities.