Pregnancy-related complications and death in the U.S. occur disproportionately in Black people, even with social protections such as higher education and income,—a health inequity that continued as maternal deaths rose overall in the first year of the COVID pandemic—but questions of exactly how and why tend to focus more on individual factors such as age, weight, pre-existing health conditions, and a number of prior cesarean births. A growing body of research and thought suggests that the problem should be seen not as one of race, but of racism. Beyond factors like prenatal care access, insurance status, or chronic health conditions, inequities show up in poor quality of care provided to Black mothers and birthing people, resulting in disparate experiences of care during pregnancy, labor, birth and postpartum care.
Last fall, Boston Medical Center (BMC) launched its Health Equity Accelerator to examine and address drivers of inequities between white and BIPOC patients. An important piece of that initiative is looking at equity in pregnancy outcomes—not only with specific clinical metrics but by learning more about patients’ experience of pregnancy and maternity care. Tejumola Adegoke, MD, MPH FACOG, an obstetrics and gynecology physician and director of equity and inclusion at BMC, is co-leader of the equity and pregnancy initiative.
Karen A. Scott, MD, MPH, FACOG, has written widely on maternal health inequities and obstetric racism. She is the Chief Black Feminist Physician Scientist, founding CEO and owner of Birthing Cultural Rigor, LLC (BCR), a consulting practice focused on assessing and improving perinatal care quality, value, and safety for Black patients in health institutions. Using data from its national SACRED Birth Study, BCR developed the first and only quality improvement (QI) program that partners with hospitals, health plans, state perinatal quality collaborative Black women-led community organizations to recognize and respond to acts of obstetric racism during childbirth hospitalization. BCR’s QI program consists of a collection of novel trainings, techniques, and tools, such as the novel and valid PREM-OB Scale™ Suite (Patient-Reported Experience Measure of Obstetric Racism©), to provide guidance and support to hospitals in assessing and targeting racism in patient care and experience throughout pregnancy.
HealthCity spoke with Dr. Adegoke and Dr. Scott about obstetric racism and how BMC is partnering with BCR and the Resilient Sisterhood Project, a local Black-woman led community-based organization, to launch a pilot capacity-building program aimed at transforming hospital culture and improving the experience for Black birthing patients.
HealthCity: Could you start by defining obstetric racism?
Karen Scott, MD, MPH, FACOG: Obstetric racism is an explanatory framework defined in 2018 by Dr. Dana-Ain Davis, a Black feminist anthropologist. This form of racism deals with the mechanisms of subordination to which Black birthing people have been subjected that align with histories of anti-Black racism. It sits at the intersection of obstetric violence, where any hospital personnel exerts reproductive control and dominance over obstetric patients, and medical racism, where institutions determine treatment or diagnostic decisions in response to the patient’s race, leading to mistreatment, neglect, and/or abuse.
Obstetric racism reflects back to colonialism and slavery, where plantation and slave owners controlled the reproducing Black bodies – forcing or coercing enslaved Black people to partner, parent, and work in the best interests of sustaining or expanding slave labor and the economy. Slave masters routinely snatched Black babies out of the hands of their Black mothers and fathers as a reminder to Black people of the loss of their agency and autonomy in building and sustaining Black kinship and futures through sex, reproduction, and family planning during chattel slavery.
What we see [today in contemporary obstetrics care] is what Dr. Davis says is a continuous recalibration of slavery through hospital policies, protocols, practices, and procedures that violate the autonomy and dignity of Black mothers and birthing people. For example, there are many episodes in which babies are prematurely snatched out of the arms of a Black mother or father or family because of “standard of care”, a test must be done after birth. We’re not negating the need for newborn assessments. We are interrogating the standard of care that permits inappropriately timed, unnecessary, or non-urgent separation of Black babies from Black mothers, fathers, and families due to standard of care or routine nursing practice. Based on what learned from listening to Black mothers and birthing people about sacred moments immediately after the birth of a Black baby, we are exploring the lack of appropriate communication, explanation, and empathy as defined for, by, and with Black women and people as patient, community, and content experts. The obstetric racism framework allows for us to better understand the feelings, thoughts, and experiences of being “handled” like an animal for breeding, instead of “cared for” like a human being giving birth by healthcare professionals and the healthcare system.
HC: What's missing in obstetric care now, or what needs to change?
Tejumola Adegoke, MD, MPH, FACOG: As a woman of color within the health care system, you experience this cognitive dissonance. You know that people have great intentions, everyone talks about making sure they’re doing the right thing for the patient all the time. However, you sometimes witness the way we talk about certain patients, the assumptions we make, or how often we will escalate things to security, social work or protective services with certain patients. Then, you have patients who say, “I’m worried that if I don’t have a Black female physician or midwife or nurse practitioner, I’m not going to be treated well, my concerns are not going to be heard.” We have systems to track negative birth outcomes, but the fact that there is no severe maternal morbidity or mortality does not mean that we don’t cause harm. Black women in this country should be able to expect more than just “survival” as the goal when seeking care during birth.
KS: Hospitals and health plans tend to look at clinical outcomes—pregnancy age at time of birth, cesarean or vaginal birth, weight of the baby, and presence of chronic medical conditions such as hypertension and diabetes. But what we’ve found at BCR is that if hospitals and health plans don’t understand the process of care and its impact on the experience, they will minimize or erase the experience of harm and hurt that is not usually captured in an outcomes measure. Hospitals and health plans will miss opportunities for examining and providing a standard of care that better aligns with patient-defined experiences of quality and safety. Evaluating the quality, value, and safety of care through clinical outcomes alone stems from an attitude or belief that birth is an abnormal or pathological condition that requires continuous hospital surveillance, control, and management. Such beliefs influence quality leaders, hospitals, and health plans to then define “high quality” or “successful births” as the absence of a bad outcome. These misguided beliefs then undermine the reality that mistreatment, neglect, or abuse can still occur with a positive outcome during two dominant conditions: if the hospital only defines the outcome as the absence of pathology, and if the hospital excludes community voice and participation in naming and defining quality measures during childbirth. Thus, the absence of pathology alone can no longer define the presence of hospital quality, safety, and equity.
HC: What will this 15-month pilot capacity-building program entail?
KS: BCR’s capacity development program involves the participation of patients, community leaders, and hospital workers in assessments such as online surveys, interviews, and focus groups. BCR prioritized the leadership of Black-women-led community organizations and Black patient, community, and content experts. The goal is to get a culturally and scientifically robust and relevant picture of different perspectives and levels of power in providing care as hospital workers, seeking/utilizing care as Black birthing patients, and supporting Black birthing patients as community leaders.
We also provide online training to patient, community, and hospital participants to recognize and respond to acts of obstetric racism, as demonstrated in any text or narrative written in patient hand-offs, electronic health records, maternal mortality or morbidity reviews, or peer reviews. We explain and then model how to apply the PREM-OB Scale™ Suite to free text in order to demonstrate how obstetric racism gets manifested in behavior and language.
At the end of 15 months, BMC will have valid numbers and narratives to help them see more clearly see how and when hospital faculty, clinicians, and staff enacts acts of obstetric racism against Black mothers and birthing people as they navigate the system. We will provide BMC with guidance to highlight existing solutions or create new strategies to mitigate obstetric racism. We will also offer support to community leaders to identify how their existing services and programs can also mitigate obstetric racism during childbirth hospitalization.
HC: What role will the local community partner, Resilient Sisterhood Project, play?
TA: Resilient Sisterhood Project is a Boston organization dedicated to educating and empowering women of African descent about reproductive and sexual health and OB/GYN care issues through a cultural and social justice lens led by Lilly Marcelin. Their role will be to help us make this diagnostic tool available to patients and to the community so that we get a well-rounded perspective from as many different groups as we can. And working with us on seeing, once we have completed the capacity development program, what changes are happening. What are people in the community reporting? What are our patients who get care with us reporting? How much further do we have to go?
HC: How does the pilot fit in with BMC's Health Equity Accelerator?
TA: The Health Equity Accelerator’s mandate is to eliminate race-based gaps in health outcomes in a way that is data-driven and grounded in partnership with the community. This pilot helps to ensure we are partnering with the community and thinking about the experience of care. We want to ask, is the way we are interacting with patients, treating them, counseling them, and caring for them and their children, in line with BMC’s stated goal of “exceptional care without exception?” Are we actually achieving that each and every time? And when we’re not, what exactly is it that we can do differently?
HC: Will this program focus on Black patients specifically?
KS: Yes. Obstetric racism is an extension of slavery and the ways in which Black reproducing bodies were controlled and dominated. BCR’s work focuses on improving the healthcare system for all, by first examining the care experiences of Black mothers and birthing people who carry the greatest burden of death or near deaths, despite advances in reproductive technology, safe motherhood initiatives, access to care, insurance, or higher socioeconomic status. Improving the autonomy, dignity, and humanity of care provision to Black mothers and birthing people leads to higher quality, value, and safety of care for everyone else.
HC: What changes do you hope to see during the pilot?
TA: I’m hoping it brings a shared language and a shared understanding so that when we ask whether a patient’s background or race or appearance affected their care, we’re all talking about the same thing, and when we talk about what could we have done differently, we’re postulating based on the lived experiences of the people who are most affected.
KS: BCR’s goal in capacity-building is to collect and share culturally and scientifically accurate and relevant information about Black birthing experiences so hospitals can see the real problems, the root of the location, activities, and participants, regardless of intention. You can’t change what you don’t know, what you don’t name, what you don’t measure, and what you don’t monitor. We will be able to show hospitals the areas of misalignments between intent and impact. Impact (how the community feels and what the community experiences) matters more than intent (what the hospital plans and says on its website). BCR strives to build a more humane and just health system for all, by advancing transparency, truth, trust, and transformation in service provision to Black mothers and birthing people first.
HC: This pilot is just starting, but do you want to say anything about what might come after it has launched?
TA: BMC is the first academic medical center in the country to participate in this program and the program is the first of its kind. We are really proud of that. It’s been my goal from the beginning, for BMC, to follow this launch by participating in an implementation phase. Eventually, we will have this team of people across disciplines who really have a deep understanding of what obstetric racism is and how to eliminate it in our care, and who can really champion those changes.
KS: We hope that if BMC continues on with implementation with BCR, then they will benefit from customized training sessions across the three valid measures in the PREM-OB Scale™ Suite: humanity, kinship, and racism. BCR will offer technical assistance and roadmaps to better recognize and modify specific language and behaviors of hospital workers that reproduce obstetric racism in the form of policies and performance improvement plans that be utilized by hospital leaders in human resources. Let’s be honest: Ultimately, there are going to be behaviors that don’t align with the values of a department. We want to begin to build the capacity of hospitals to really think about, once we have data around humanity, racism, and kinship, who’s conducting themselves in a way that’s harmful? What leadership during those shifts is allowing people to harm Black birthing communities in this way?
The dream is to build up a group of champions who will be present across shifts so that as people see things, there’s someone who’s just totally committed to the cultural alignment to mitigating obstetric racism, and not just the clinical piece. But we first have to build the system’s capacity to do that. Our vision is to build a more humane and just healthcare system that integrates patient experiences and community wisdom into health services, design, provision, evaluation, and training.