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I am a proud Black Caribbean woman born and raised in Brooklyn. I grew up getting my health check-ups in Brooklyn, but once I started working in the city it was easier for me to see doctors closer to where I worked. I couldn’t deny the stark differences that I noticed in the care I received. The offices were nicer, the wait was shorter and the doctors were more thorough. To put it bluntly, the care was better in every aspect, yet I was paying the same co-pay. I ended up moving all my care into the city. There was one other aspect that was evident — I was in the majority in Brooklyn. In Manhattan, I was lucky if I saw another Black patient enter the office. It made me wonder: Was it the norm for Black patients to receive less quality care and probably not even know it?
As a registered nurse I’ve worked in both boroughs, and once again, my theory was undeniably confirmed. Different boroughs deliver different quality of care. Five years into my career, when I heard the egregious statistics of Black women dying at disproportionately high rates compared to white women in NYC, it totally made sense to me. I have the means, opportunity and knowledge to advocate for myself, find the best doctors and demand high quality care; Many Black women don’t have that privilege, and even when they do, they are still ignored. The quality of care must be standardized city-wide to ensure that no Black mother is left behind to die.
The Problem
The ratio of pregnancy-related deaths (PRDs), has more than doubled in the U.S. in the past 15 years. It sickens me to say that we are the only developed country in the world to be trending upwards in PRDs. It is unacceptable to hear that in the U.S. Black women are three times more likely to die from PRDs than white women. And in New York City, they are 12 times more likely to die. Between 2006 and 2010, there were 56.3 deaths of Black women per 100,000 live births, compared to only 4.7 deaths of white women per 100,000 live births in NYC. It is even more appalling to hear that 60% of these deaths are preventable. So how do we stop the preventable from turning into the inevitable for Black women? Nursing 101 has taught me that the best way to treat the problem was to first determine the etiology, otherwise known as the cause.
Being Pregnant While Black
The problem starts with higher rates of chronic health issues facing Black women, such as hypertension, diabetes and cardiac issues, putting them at an even higher risk in pregnancy. Many of these conditions can turn into high-risk complications in pregnancy, like preeclampsia (hypertension disorder), hemorrhage (profuse bleeding) and embolisms (blood clots); a few of the main causes of PRDs which may end up costing them their life.
Unbeknownst to most, the risk of PRDs are split almost equally throughout the three phases of pregnancy: the 40 weeks of pregnancy, the delivery and the postpartum period up to a year after giving birth. A patient having the knowledge to inform a doctor that she gave birth within a year could be the little piece of information necessary to save her life. Patients with heightened risks should have additional appointments and education to ensure they know the signs and symptoms and possible complications to look out for. Education must be increased and standardized city-wide to start early in the pregnancy and continue for the full postpartum period.
In addition to not knowing their risk level, these mothers are also unaware of their rights as a patient or how to advocate for themselves. A Black mother can be educated, yet it won't matter if a doctor isn’t listening to their concerns and the patient doesn’t know how to advocate for herself. The likelihood of a Black, college educated, pregnant woman to suffer life threatening complications is more than double that of a pregnant white woman who never graduated high school. Studies have shown cases where white providers gave less information to Black patients and Black patients asked less questions than white patients. The concerns of the Black mother are falling on deaf ears and are being ignored due to the implicit biases seen in even the top healthcare institutions. The institution may fail them, but empowering the patient to speak up for themself can be a matter of her life and death.
A patient has the right to be heard and believed, the right to be an equal and active participant in the plan of their care, the right to question a doctor’s decisions, the right to ask for a second opinion, the right to refuse care, the right to more education and explanation, the right to ask questions and the right to equitable, high-quality care. It is the responsibility of all healthcare institutions to teach their patients their rights, their risks and how to advocate for themselves. To emphasize the gravity of this education, it should be added as an additional separate session in prenatal care education.
Different Borough, Different Race, Different Care
The racial disparities continue to be seen throughout the healthcare system as evidenced by the difference in the quality of care received. Recent data from the New York State (NYS) Department of Health showed that four out of the five hospitals in NYS with the highest rates of severe hemorrhage are located in central Brooklyn. These “Black-serving” hospitals are shown to have significantly higher rates of complications and deaths than “white-serving” hospitals. One study showed these hospitals performed worse in 12 of 15 quality indicators and in 6 out of 11 patient-safety indicators. Once again, different borough, different care.
Taking a closer look within the institutions, the current prenatal and postpartum care structure is outdated. The algorithm recommending the number of visits and education provided does not account for the heightened risk associated with being a Black woman due to the disparities in care. The education on risk factors is usually limited to prenatal care visits where providers are also teaching them a multitude of other topics in that limited time. Black mothers need additional education on how to survive being pregnant while Black.
Besides the structure of care, implicit bias from healthcare providers is another detrimental factor adding to the disparities. When the majority of institutions and providers treating the minority patients are white, they lack the personal experiences of discrimination and bias. This often leads to a lack of patient-provider connection, a lack of communication and trust, stereotyping, unconscious bias and the inability to host difficult conversations around the disparities in their care.
It's a fact that every person has their own unconscious biases, but it becomes a problem when these implicit biases of the providers have been shown to negatively affect patient outcomes. An unaware provider won’t make a change to their practice when they don’t see a problem and the difference in the care they are giving to Black women. They don’t know what they don’t know.
Standardizing the care must start with ensuring that all healthcare providers are treating all of their patients with the highest quality of unbiased care. This starts with mandating all hospitals and medical/nursing schools in NYC to implement recurring Implicit Bias training, as recommended by the N.Y.S. Task Force on Maternal Mortality and Disparate Racial Outcomes. With the proper training, it has been shown to reduce bias dramatically. The comprehensive training program would consist of learning how to be mindful of their biases and blind spots, apply strategies to reduce their bias, the impacts of their bias, as well as improve patient-provider interactions through empathy, understanding and improved communication. Increasing their awareness and concern of the effects of their bias has been shown to reduce the bias even further. It must be stressed that this training must be mandatory, not optional. If made optional, the providers that need the training the most will be the ones who don’t opt to take it because they don’t believe they have any biases. Mandating and standardizing the training city-wide is key.
The current prenatal and postpartum care system must be updated to account for the heightened risks of Black mothers. This requires adding comprehensive individualized education to account for the differences in risks and outcomes between Black and white women. To address the disparity between the quality of care between boroughs, all hospital systems in NYC must standardize education for providers and patients to ensure that Black mothers are receiving the same high-quality information as white mothers. This should include all providers being routinely educated on their biases and all Black mothers being informed of their health risks and learning how to advocate for their life.
As I researched this topic I came across a horrific story of a young woman from Brooklyn with my same name and age. She fell victim to this failing system and died after giving birth to her second child. Once again, I am speechless and heartbroken. Yes, I am a nurse and an advocate for my patients and for myself, but I am also a Black woman in NYC. That story could have been me. I don’t ever want to be a statistic of a Black pregnant woman dying because I chose to go to a Black-serving hospital where the quality of my care wasn’t the same as a white woman at a white-serving hospital — or because I chose to go to a white-serving hospital, where my concerns were ignored.
Please advocate for my life and the lives of other Black women. We can no longer leave Black mothers behind to die.
