Anti-Racism Reading Group #3: Perinatal Mortality

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here and part two here.

For the third meeting of the anti-racism reading group, we focused on increased rates of perinatal death (i.e. death around the time of birth) for black women with this excellent piece of reporting by NPR and Propublica. NPR’s Code Switch team produced an excellent podcast on this same story which you can listen to here or read the write-up here.

This is an especially timely reading given Erica Garner’s recent death at age 27 from a heart attack just three months after giving birth. Erica was the daughter of Eric Garner who was murdered by the New York City Police. Since his death, she had risen up to be a prominent and effective activist against police violence.  

When I sent out the reading, I asked participants to consider the following questions:

  1. What factors contribute to perinatal mortality for black women?
  2. Which of these factors can be improved by better prenatal, obstetric, and postpartum medical care? How?
  3. Which of these factors require public health, social welfare, and anti-racism work? How that that be implemented?
  4. How have you seen these factors play out in your personal and professional experiences?

The central fact which the article explores through Shalon Irving’s story is that Black women are 3.4 times more likely than White women to die from complications of pregnancy or childbirth.

Specific factors that contribute to this disparity include:

  • Black women are less likely to have health insurance prior to and after pregnancy (Medicaid covers costs associated with the pregnancy itself for U.S. citizens).
  • Black women have higher rates of diseases that increase risk of perinatal death including obesity, diabetes, and high blood pressure.
  • Because people tend to give birth in hospitals that are close to their homes, Black women are more likely to give birth at the lower quality hospitals that exist in or near Black communities.
  • Black women are less likely to be believed when they complain of symptoms that may indicate life-threatening complications of pregnancy such as headache, shortness of breath, stomach pain, and vision changes.
  • Black women experience chronic racial stress which may predispose them to heart failure during or after pregnancy.

Of note, this disparity is particular to race. Even when controlling for wealth and education, the racial disparity remains. As Raegan McDonald-Mosley, the chief medical director for Planned Parenthood Federation of America, said in the NPR article: “It tells you that you can’t educate your way out of this problem. You can’t health care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.”

Discussion

In our discussion group, we recognized the incredible difficulty that Black women in particular face when expressing their symptoms and concerns to a predominately White and male medical system. If they underplay their concerns, their symptoms will go unaddressed, but if they are too insistent they’ll be labelled a “difficult patient.” Similar dynamics are at play in the balance between being too emotive versus being too flat or being too verbose versus not providing complete information. As medical providers, we ask patients to thread this needle in ways that are very culturally specific, and often provide sub-optimal care if the person in front of us doesn’t “play the patient role” to white-cultural expectations.

This is fed in part by a medical education system which trains doctors to recognize certain words and behaviors as evidence of particular disease. For example, when a patient describes their chest pain as “crushing” and puts a clenched fist over their heart, we are taught to recognize this as a sign of a heart attack. However, there is little to no discussion about how much of this and other signifiers of illness are specific to English language and Western European culture. Nor is there much teaching about descriptors in non-English languages or non-European cultures that may be predictive of illness. This is one way in which White-normativity in medicine is propagated from one generation to the next.

Even when language is unambiguous and the needle is threaded perfectly, however, the symptoms experienced by Black women are too often dismissed. As such, the response to the death of Shalon Irving cannot be framed simply in terms of a communication failure (which creeps into victim-blaming), but rather a failure of the medical system to response appropriately to evidence of postpartum complication in a patient that was at elevated risk. This is on us. Taking ownership of being part of the problem, we took time to think of concrete and actionable steps that we as obstetric providers can take to improve the quality and safety of our perinatal and postpartum care:

  1. Anti-racism education for providers and staff: This should go without saying, but first and foremost we need to hold ourselves accountable to understanding the dynamics of racism, recognizing its effects in the clinical setting, and counter-acting those effects before they can harm patients. Specifically, this work needs to be integrated into the obstetrics education for our family medicine residents and continuing medical education for fellows and faculty.
  2. Rethink postpartum follow-up time: It is standard of care to have a follow-up visit one week after delivery for women with recognized hypertension in pregnancy and six weeks after delivery for women who did not have this complication. However, there is not a defined framework recommending closer follow-up for women who are at elevated risk of postpartum complication (as was clearly the case for Shalon). We can develop internal protocols to guide closer follow up for high risk patients who might otherwise fall through the cracks.
  3. Re-write patient instructions: Our residency uses a standard handout for moms after delivery which discusses (among many things) the signs of postpartum complications. This needs to be reassessed for its clarity at all levels of medical literacy. Additionally, our providers should have clear and consistent ways of talking to patients about these complications prior to discharge from the hospital.
  4. Make postpartum red flags a hard stop: In addition to improved patient education on the symptoms of postpartum complication, we need to reduce risk of underplaying symptoms when performing triage. Endorsing a postpartum “red flag” symptom (such as shortness of breath or worsening leg swelling) should automatically trigger an in-person evaluation and blood pressure check without opportunity for someone to downplay the symptom.
  5. Alternatives to postpartum office visits: It is often difficult for the mother of a newborn to make it to an appointment at their primary care doctor’s office. As such, if a patient does not show up to an office visit, this should trigger a phone conversation or a home visit. Having a community health worker perform this visit is likely the best option (though access to this resource in Seattle is limited).
  6. Increase diversity of physician workforce: Last but not least, having a diverse physician workforce gives patients the opportunity to have a doctor from a similar cultural background who may be more likely to appropriate assess the severity of a patient’s symptoms. This is no substitute for addressing the racism of White physicians, but it will help push the medical field in the right direction.

None of us is under the illusion that we are six short steps from solving racism in our medical system, but these are at least concrete tasks that we can begin to work towards to ensure and more equitable and just future for all of our patients. If you have additional ideas for intervention, please share them in the comments.

Update: The New York Times published an excellent article that continues this exploration of medical mistreatment of black women during pregnancy and racial stress as a cause of low birth weight and preterm birth. Read the full story here.

If you’re interested in hosting your own reading group on this particular article, ProPublica has a discussion resource guide available here.

 

Author: Harrison Kalodimos

I'm a family medicine resident at Swedish Medical Center in Seattle.

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