Reversing the Tide of Black Maternal Mortality

Despite considerable research on maternal morbidity and mortality among Black women in the U.S., meaningful progress remains elusive. In 2018, Black women died at 3.3 times the rate of white women in pregnancy-related deaths, according to the Centers for Disease Control and Prevention.

The UCSF School of Nursing is leveraging its research power, classroom expertise and collaborative partnerships to create practical, effective interventions. This far-reaching approach not only provides immediate answers, but offers a framework to reduce harmful outcomes in the future. 

Giving Voice to Lived Experiences

To reverse the tide of Black maternal deaths — the majority of which are preventable — faculty are giving voice to the lived experiences of women of color and seeking their recommendations on how to improve care.

“We collect data from patients about their happiness, their satisfaction, but we don’t listen to their suggestions,” School of Nursing associate professor Monica McLemore said. “When you think about a Black maternal health crisis and the poor outcomes we see, we never ask them, ‘What do we need to do in order to make things better for you?’”

Monica McLemore, Linda Franck, Talita Oseguera McLemore, professor Linda Franck and alumna Talita Oseguera were part of a research team that interviewed 22 women of color who sought pregnancy-related care at a San Francisco health organization that provides care to low-income families. Their findings were recently published in the Journal of Midwifery & Women’s Health.

The women wanted to be heard and involved in the decision-making process of their care, but they said providers were not spending enough time with them to build trust. They expressed a desire “to be recognized as a person who was valued and whose knowledge was respected.” Among the women’s proposals were for providers to schedule longer visits, get to know patients as individuals, and inquire and address social determinants of health — like employment, housing and poverty level — that may be affecting their health.

The limited number of providers who are women of color and the lack of provider continuity were major concerns, the study found. Participants were frustrated that they were unable to see the same clinician, requiring them to retell medical histories. Participants recommended a mechanism for clinicians to more effectively share information to enhance the continuity in care.

“There’s so much lost in that lack of continuity,” Franck said. “It’s a revolving door and we’ve got to be able to solve that. It’s difficult to maintain a relationship if information doesn’t get transmitted. It puts the burden back on the patient.”

The study’s participants emphasized the importance of diversifying the health care workforce so that it mirrors its patient population. The participants felt “safer and more connected with providers of color and noted feeling suspicious and/or fearful of receiving judgment from white providers.”

Only 4 percent of physicians and 6 percent of registered nurses in the U.S. are Black. Where future clinicians of color, especially those specializing in pregnancy care, will be produced is uncertain. The largest producers of Black and Latinx STEM graduates are the nation’s historically Black colleges and universities, but none of the 29 academic medical centers at those institutions has a midwifery program, McLemore said. In addition, women of color would be less likely to become a doula or midwife if they have a poor health care experience during their pregnancy. 

“If we made strategic investments, we could actually diversify the health care workforce enough to provide the community genuine racially concordant care,” McLemore said. “If we improve care, we can excite them about the work we are doing.”

Molly Altman, a former postdoctoral scholar at the School of Nursing and now an assistant professor at the University of Washington, was the study’s lead author. Former School of Nursing faculty Audrey Lyndon, now a professor at New York University, was a co-author. 

Embracing Discomfort

To help students address and prevent racism in health care, the Certified Nurse-Midwifery specialty in the School’s Master of Science program offers “Racism and Health Disparity Prevention,” a course that examines the roots of health disparities and their links to racism. 

“We want to reinforce the message that race is not a biological construct, which is, unfortunately, something health care has had a hand in perpetuating,” said associate professor Kim Dau, who heads the midwifery specialty. “We need to help our students understand their own individual role and responsibility to understand social oppression.” 

Dau and assistant professor Ifeyinwa Asiodu have co-instructed the course past three years. It includes a mix of lectures, small group discussions and guest Kim Dau, Ifeyinwa Asiodu speakers, and emphasizes embracing discomfort.

“Only when conversations get uncomfortable do we realize how entrenched we are in systems of power,” Dau said. “Discomfort is a necessary part of transformation and if our goal is to create meaningful change in society, it has to be an uncomfortable conversation.”

A disconnect often exists between how health care is delivered and the true needs of a community, Dau said, so a primary objective of the course is highlighting meaningful community engagement. Midwives who play pivotal roles in their communities are featured as guest speakers, and students complete projects on community organizations that are making strides against health injustices. By understanding what communities desire, power structures involving race, gender and sexual orientation — as well as the provider-patient hierarchy — can be dismantled, Dau said. 

The School is further enhancing its commitment by working to implement Structural Competency content in its curriculum. Structural Competency content is a framework “to encourage health care professionals to recognize, analyze and intervene upon the structural factors that impact health disparities.” A pilot course is scheduled to begin in the 2020-21 academic year that focuses on understanding these structural factors.

Students were a driving force in instituting this change, said associate professor Linda Stephan, who has led two task forces advancing Structural Competency at the School. 

Improving the Student-Preceptor Dynamic

The School is also addressing issues of racial bias among students and preceptors. Exit interviews and evaluations from students of color showed a need for preceptors to develop a greater awareness of issues that can negatively affect students of color.

As a result, faculty and alumni developed a four-hour workshop to help preceptors identify and address racial bias. Through a mix of lectures, role playing, small group discussions and other techniques, the workshop promotes proactive strategies, such as engaging in critical self-reflection and building rapport, to help create a welcoming and safe learning environment for students. It also teaches responsive strategies, like employing reflective listening and empathy, compelling preceptors to respond to situations that reinforce stereotypes and racism in clinical learning environments. 

The workshop — developed by Dau, faculty member Rebekah Kaplan, alumni Ana Delgado, Kara Myers, Oseguera, Nancy Rivera-Hancock and Darcy Stanley, and colleagues Jennifer Braddock and Eva Goodfriend-Reaño from Alameda Health Systems — was initially designed for midwifery preceptors, but is now available to clinicians from all disciplines through the Teach for UCSF Certificate Program.

Developing the workshop was especially important to Goodfriend-Reaño (MS ’07). She recalled instances of racial bias in the classroom, which deeply affected her. Her clinical experience, conversely, was positive because of strong preceptor support. Today, as one of the few Latinx nurse-midwife preceptors in the area, she mentors primarily student midwives of color and feels a responsibility to improve their learning experience. 

“Because the health care system is laden with racism and bias,” she said. “how we approach these instances and our ability to talk about them to create healthy and safe learning environments for our students is important.”