Ep 72: How Structural Racism & Implicit Bias Create Disparities in Maternal Care for Black Families

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This episode is a bit different than what I usually talk about on the podcast, but I hope that you will tune in and learn something new about maternal healthcare and racism in our country.  It's important that we all help in the fight against racism in our own way. 

In this episode I'm talking about the disparities we see in maternal healthcare & outcomes for Black mamas and their babies. I describe some of the structural racism we see in the medical field (which also shows up in other systems throughout the US), what implicit bias is, and how these forces add up to create a difficult environment for Black people - including mamas - all over the country.

I also share some of my personal experiences with racism in my career, a few stories from friends and colleagues, and a couple instances where I witnessed the medical system mistreating Black women. I hope that this episode educates you and inspires you to think about what you can do to support Black people and help dismantle racism in our country, whether that's talking to your friends and family, committing to raising anti-racist kids, or helping reform your profession so it becomes truly equal for everyone.

In this Episode, You’ll Learn About:

  • Why it is important to talk about how racism contributes to disparities in maternal and infant care
  • Some of the numbers behind these disparities, including for hypertension, postpartum hemorrhage, and infant mortality 
  • What implicit bias is and how it affects doctors' approach to caring for Black patients
  • What "weathering" is and how racism affects the health of Black people, including moms
  • Some stories from myself and others about racism in the medical system, both as a physician and as a patient
  • Why we should all consider what we can do to be anti-racist in our lives and work

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Speaker 1: Not one of my typical episodes, but a very important episode nonetheless.

Speaker 2: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer@ at www.ncrcoaching.com/disclaimer. Now let's get to it.

Speaker 1: Well, hello. Welcome to another episode of the podcast. This is episode number 72. Thank you so much for spending some of your time with me today. So it is no secret that there's been unrest in our country and an awakening of sorts regarding racism. And although the discussion has been around the police, racism is a part of all of our society really, including healthcare. And today, I want to share a little bit about how racism contributes to maternal and infant disparities in care. And also share a bit about my personal experience with racism as a physician in medicine, and then a couple of notable experiences that I've seen in healthcare where black women have been mistreated. And I'm doing this because I hope that by understanding black people's lived experiences, you can have some empathy for what we go through. And if you don't already have that, or if you're not already inspired, it will inspire you to pick up the mantle, pick up the torch and do that anti-racist work that we need in our society.

: And whether you choose to do it in your own life, whether it's speaking out against racism amongst your family, your friends at work, whether you're intentional about raising your children to be anti-racist, whether you decide that you want to protest or take it on in a bigger fashion, donate to organizations that are doing anti-racist work. It really doesn't matter. We each have to all do our own part and do whatever we feel comfortable with. And again, I hope that by sharing this information that you can gain a little bit of a better understanding of just what things are like. Now, I know this is a bit of a heavy topic and we're all tackling it the best way that we know how so just hang with me, stick through the episode, we'll get through it. I think you'll learn a lot and I think it'll be really beneficial.

Speaker 1: So before I get into the episode, I do want to do a couple quick things. First, let me do a listener shout out. This is to CUyatm. The title of review says "knowledgeable and affirming!" With an exclamation point. And the review says, "Dr. Rankins is the perfect combination of knowledgeable, evidence-based, affirming and cognizant of what people who are pregnant are thinking about and feeling. I'm expecting my first and so appreciated hearing her caring and trustworthy information." Thank you. Thank you. Thank you for that kind review. That is so sweet of you. I really appreciate you taking the time to leave me that lovely review. You know, I have a heart and soul for this work and I just so appreciate you taking the time to leave me those kind words. And more importantly, that you find the information I provide useful. So thank you. Thank you. Thank you for that.

: Now, the other thing that I want to remind you about before we get into the episode is a couple of options or things that you can check out in addition to the podcast, because I know folks are still having babies. So do check out my free online class on how to make a birth plan that works. This is a great one hour class. You will learn how to approach the process of making your birth wishes. I say wishes because really no one can plan birth. I say birth plan, because that's the common usage, but really it's wishes. You'll get questions to ask your doctor or midwife before you write anything about your birth plan. I give you tips on how to get your doctors and nurses to pay attention to your birth wishes. And then what to include. This is an on demand class offered several times a day. So you can check that out at www.ncrcoaching.com/register.

: And making a birth plan is one of the components of my beautiful birth prep process, which is my unique childbirth education process that ensures you are knowledgeable, prepared, confident, and empowered to have a beautiful birth. This is in my online childbirth education class, The Birth Preparation Course, you can check out the course at www.ncrcoaching.com/enroll. It is deeply discounted right now because of COVID and will remain so for, for awhile. So do check that out at www.ncrcoaching.com/enroll. Okay, so let's get into the content of the episode.

: All right. So the first thing I'm going to do is talk a little bit about some of the racial disparities that we know exist in reproductive health. They are very, very well documented within OB GYN, and I'm really focusing on just the obstetrics piece. So just the pregnancy piece, but there are also plenty of disparities on the gynecology side and things like hysterectomy, treatment of cancer, that kind of thing, but I'm really just focusing on the OB side. So you've already heard me talk about many times on the podcast or social media about the differences in maternal death and how black women are three to four times as likely as white women to die from pregnancy related causes. This is a longstanding disparity that in some ways is getting worse. There's been a lot of attention to that recently. And rightfully so. However, there are also many other disparities that exist in healthcare as well in regards to obstetric disparity. So there's also quite a bit of disparity in not just mortality, but also morbidity and specifically severe maternal morbidity.

Speaker 1: And what that is, that is a life threatening event that happens during pregnancy, delivery or in the postpartum period. And based on data from the Centers for Disease Control, black women are up to 115% higher risk of having severe maternal morbidity when compared with white women. So not only are black women at an increased risk of death, they're at an increased risk of having severe life threatening complications as well, and that's a very increased risk. And this doesn't appear to be influenced based on people's underlying health status. So whether they have medical conditions or physical conditions, when you compare women who have health problems, either it's medical problems or physical problems, when you compare white women and black women who have similar problems, black women still have an increased risk of having that morbidity event happen.

: Okay. So another area that women are specifically at risk that can be part of that severe maternal morbidity is postpartum hemorrhage. And even when you adjust for characteristics of people, their underlying health status things called co morbidities, black women who had postpartum hemorrhage had worse outcomes and death compared to white women. A couple of other areas that we know where there are issues, preterm birth, again, even after adjusting for things that are what may be like confounders. So like underlying health status or self reports of stress, black women continue to be at a higher risk of preterm birth compared to white women. Black women are also at an increased risk of preeclampsia and pregnancy-related hypertension conditions in general, and also gestational diabetes when compared to white women. And then once babies are born, the other issue that we see quite a bit is a problem is infant mortality. Infant mortality is death within the first year of life. And it is about two and a half times higher in black babies compared to white babies.

Speaker 1: So lots and lots of instances, even outside of mortality where black women and black babies are at risk. And the reason that this happens, the reason that we're seeing or understanding a lot more that this happens is because of implicit bias and racism, and a systemic racism throughout the healthcare system. And then implicit bias on the part of individual providers. There is plenty, plenty, plenty of literature that demonstrates that black people are subjected to implicit bias on the part of physicians where they don't even realize that they're making different decisions, even though they're presented with the same type of patient scenario. And the only difference is one patient is black, and one patient is white. This has been shown to lead to less accurate diagnosis amongst black people. The treatment options that black people are offered are different, pain management is different. The perception of pain is different, even in children.

Speaker 1: This has been demonstrated. And as a result, this has led to worse outcomes and it's sort of a difficult thing and challenging thing because people will often recognize and say, sure, I know that disparities are a problem. When you look at studies, particularly I'm speaking about high risk pregnancy doctors, the society of maternal fetal medicine, posted some things on their Instagram, where doctors recognize that these things are a problem, but then only 30% recognized it in themselves personally. So it's a really, really challenging problem to address because people aren't necessarily even recognizing it. Although now I hope with things going on, that we are able to see things more. Now, one of the things that I've heard people say, and that I'll be honest, that I have struggled with myself is the role of personal responsibility in some of these outcomes. So of course I'm a physician and I believe in good health care and taking care of yourself.

Speaker 1: So yeah, I've had thoughts or some elements of, you know, people need to eat better. People need to exercise more. We need to take better care of themselves in relation to black women. I've had some difficulties or I don't know how the right way to put it, but like there's a lot of, you know, big is beautiful sometimes in our culture and celebrating being overweight, which isn't necessarily healthy. So there's that element of personal responsibility that folks sort of struggle with, but what I had to do and what I hope you do as well is you have to step back for a second and you have to think about what options and what things influence a person's options. So what options a person has available to them and what things influence the options that people believe they have available to them and that they have available to them because personal responsibility can be very hard when you're in an environment that is not supportive and in an environment that is sometimes actively hostile against you.

Speaker 1: Not everyone has access to the same resources, like a safe and supportive environment to live in, a safe and supportive environment to learn in, an education. Not everyone has access to quality healthcare, reasonably priced foods, or they may not have necessarily been exposed to examples and models of being responsible and how to do that for yourself. So just take a step back for a second and kind of think about that when you think about the role of personal responsibility, and that until we have made it so that people have equity and equal opportunities to take personal responsibility, then we can't hang our hat on personal responsibility as some of the causes for the differences that we see. I hope that that makes sense because it's a really important point. And even when you do have access to all the things, and I'm going to give you an example of myself and I have five black female physician OB GYN friends, and we all grew up in pretty well off environments, even speaking up for myself, you know, my parents have been married for 56 years.

Speaker 1: I grew up very middle class. I was a debutante, all that kind of stuff. And my other black female friends, you know, have done well, are successful. All five of us trained at Duke for our residency. We're smart, we're capable and accomplished. And of the five of us who birthed babies, three out of the five of us had preterm deliveries. Two of us had severe preeclampsia and four of us had cesarean births. And so when you look at us and you see that we've had all these things, we've had these advantages, we are otherwise healthy and eat well and exercise and all of those things, and still have these outcomes. You have to step back and take a look and be critical and think what else is there? And one of the things, and one of the hypotheses that is put forward is the concept of weathering.

Speaker 1: And what weathering is, is that these chronic sort of stressors and exposures to racism add up and they eventually kind of take their toll. And I want to just take a second and share some of my personal experiences with racism as a black woman physician, and then a couple of experiences from my friends. And then as well as a couple of notable experiences that I've seen from patients. And for me personally, this can go all the way back to medical school. I've always been like an academically bright student and done pretty well in terms of grades and that kind of thing. And so on my clinical rotations, after getting honors and several rotations in a row, it was like two or three rotations in a row. I get to this rotation. And I was pulled aside by a white male attending, told that I was lazy, told that I needed to do better, that I wasn't doing things right.

Speaker 1: That was a complete blow to me. And I had been working really hard, always a hard worker type, that kind of thing. And it just really sorta knocked me back. And then other instances, when I was in medical school, I was inducted into Alpha Omega Alpha, the honor medical society, which is reserved for the top 10 to 15% of students. And at the induction ceremony, one of my professors was like, wait, you're being inducted into AOA? And just gave me like this really puzzled quizzical look like really? Like you're here kind of thing? When I was a resident in training, I remember once I was making rounds and with an attending, it was on the weekend and we were dressed the same way. He was a white man. And then there was me, we both had on the Duke blue scrubs and white coats with Dr. Such and Such, our names on our jackets.

: And we go into a patient's room talking to the patient, you know, he's talking to the patient, I'm there. And she stops and looks at me and says, are you here to pick up my food tray? And then just other instances, and guys, I'm just giving like the highlights, this isn't even everything. I'm just kind of hitting on some of the ones that stand out. I've had plenty of times white males walk up to me and just interrupt the conversation while I'm talking to the nurse. I've had instances where people ask, you know, when is the doctor coming? And I'm in this unique position where I'm at the intersection of both being black and a woman. So in medicine, which is traditionally a male field. So are people doing this because I'm black? Are they doing it because I'm a woman or are they doing it because they're just a straight jackass?

Speaker 1: So it can be challenging to figure these things out. And like the instance of, you know, when is the doctor coming? We had these huge badges that we wear at work. That's a physician or at the last hospital I was at, it's a doctor. And it's like a big thing, a little placard that we put on top of our bag. So it's very visible. I've loved that thing. Some people think it's obnoxious because it's huge, but I like having it there because it's a really visible reminder. And I don't have to go through the like, yes, I'm the doctor. Yes. I'm the doctor. Yes. I'm the doctor. And even with that though, I've had instances where people, I'm standing in front of them right there, close to them within one or two feet. And they say, when is the doctor coming? And it's just such this moment of like, you're not even looking at me because if you took five seconds to look at me, you would see that I'm wearing this big badge that says doctor.

Speaker 1: So it's like, you're not even taking the time. It's not even the effort to really look at me for a moment. Like you're seeing through me, seeing past me. I've had my judgment questioned. I remember I was sewing up a woman's vagina after she had a small tear for her delivery. And her husband who was a physician was like leaning over, wait, is that right? Is that right? He wasn't even an obstetrician. Just all these little incidents that kind of happen and add up. And these aren't instances that are just unique to me, there are plenty of other instances where you can find stories of black people, black women, black men, sharing their stories of racism experienced throughout their life. And many of us, quote unquote professional.

: My friend, Dr. Keisha Reddick, who's been on the podcast a couple of times. And you guys should follow her on Instagram by the way, at DrKeishaLynn. I'll link her Instagram account in the show notes, she talks about fitness and fashion and cooking stuff. And then of course, pregnancy stuff as well. But she shared a very moving video of her husband talking about how he was stopped by the police, it's a really terrifying description of the encounter. She shared some stories and things that she's experienced as a physician. One of my other best friends, Kimberly Bullet Gatling, she was on the podcast talking about her VBAC. She shared her VBAC birth story on the podcast towards the beginning. And she is a very high powered attorney in her law firm. Her husband is a vice president at a university in town. She's very well known and well respected in her city and her son, her 16 year old honor student, swimmer son was stopped, accosted by the police frisked, because supposedly he matched the description of a suspect.

Speaker 1: And she is in a position where she was able to investigate further because she's an attorney and got the audio tapes pulled of the description of the suspect. And it did not match her son in any way, shape or form. So here is this 16 year old boy having to go through the experience of being stopped and aggressively frisked by the police in an unwarranted situation. And those are just some of the examples. And then a couple of examples of things that I've seen for how black women get treated. Two of the most horrific examples that kind of stick out in my mind. One is in the emergency room, seeing black women who are undergoing miscarriage, and I've been called to see them and help kind of manage things and seeing women sitting in bloody sheets, bloody gown, the IV site is bloody while the nurses are just kind of chatting at the nurses station.

Speaker 1: Another example, a woman came into the emergency room. She was 17 weeks pregnant and having pain. She kept saying she was having pain and she was hurting, hurting, hurting. The ER physician who saw her, did not do an exam. Just kind of got an ultrasound. The ultrasound supposedly look fine. And he was going to send her home, basically ignoring her pain. And she was in the bathroom just before he had sent her home in her 17 week. Baby fell out into the toilet at which point I was called down to help kind of manage and take care of things. And the thing that really stuck out about this particular instance is that a year or so later, she came back to the same hospital and she was visibly terrified having to have gone through that emergency department again, and remembering that experience of how she was treated.

Speaker 1: She was visibly shaken. She only came back to the same hospital because she got great treatment in the labor and delivery unit, and she wanted to stick with the same doctor, but that terrifying feeling for her, of going through the emergency room was very palpable. And guys, these things just kind of add up when you're chronically exposed to these things, that weathering, that stress that happens again and again and again, throughout your life, it adds up and it impacts our health as black women physically. It impacts our health as black women mentally. And I think that for so long, we have been trained. We have been educated. We have been conditioned to sort of move past these things and do the best to just ignore it or step it down and move on. You know, speak up sometimes where you can, or other times you ignore it. All of those kinds of things.

: And this moment in our country is just bringing all of those things up to the surface and it's all of that pain. All of those things are exploding. All of those things are coming out and we are just really realizing how tired and exhausted we are from all of this. So that is just a bit of background and understanding of the experiences of what black women go through. And I'm actually proud of myself that I got through this without crying, because I did a video similar to this on my social media accounts. And I couldn't do that without crying. I'm a crier by nature anyway. Y'all, I will cry at like an emotional TV commercial. It's kind of pathetic. So I am proud of myself that I got through this episode without crying. Although I think you can certainly understand why some of these things would make me cry.

Speaker 1: That is it for this episode. I know that the information may not help you directly with your own pregnancy or birth, but I do hope again, that it helps you appreciate the experiences of what black women go through during pregnancy and our lives and that stress that we carry and how that impacts things. Can you imagine being a black mother of a black boy, that is such a even higher burden to carry? So I hope that hearing these stories helps you if you aren't already doing so to give people grace and to have some empathy, and also inspires you to really, and truly commit to learning how to be the best human person that you can be and love thy neighbor, as you love yourself, and really taking care of our communities in a way that hasn't been happening before, so that all members of the community are cared for.

Speaker 1: All right. So that's it for this episode, please be sure to subscribe to the podcast in Apple podcast or wherever you listen to podcasts. And if you feel so inclined, please leave me an honest review on Apple podcasts. It helps other women find the show, helps the show to grow. And I love giving shout outs on episodes, and I just love hearing what people say. So definitely do that for me or send me a DM or send me an email. Either way, but those reviews in Apple podcast in particular, help the show to grow and help other women to find me.

: And don't forget to check out The Birth Preparation Course. You know, my beautiful birth prep process is my unique childbirth education process that ensures you are knowledgeable, prepared, confident, and empowered to have a beautiful birth. Get all the details of The Birth Preparation Course at www.ncrcoaching.com/enroll. And again, it is deeply discounted right now because of all of the closures of in person classes. So do check it out. Next week on the podcast, I have another OB GYN on, and we are going to talk about all things postpartum. So come on back next week. And until then, I wish you beautiful pregnancy and birth.

: Thanks so much for listening to this episode of the All About Pregnancy and Birth podcast. Head to my website at www.ncrcoaching.com to get even more great info, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on how to make a birth plan, as well as everything you need to know about The Birth Preparation Course. Again, that's www.ncrcoaching.com and I will see you next week.