Simpson, Kathleen Rice, PhD, RNC, CNS-BC, FAAN
MCN: The American Journal of Maternal/Child Nursing: September/October 2018 - Volume 43 - Issue 5 - p 300
doi: 10.1097/NMC.0000000000000456
ONGOING COLUMNS: Perinatal Patient Safety
There has been a lot of press recently about the increase in maternal mortality in the United States and how our data compare poorly with other developed countries. However, there are similarly poor comparisons among women right here in this country (Martin, Cillekens, & Freitas, 2017). Some mothers, such as those who are Black, American Indian, Native Alaskan, and Hispanic have significantly worse maternal and infant outcomes than White women. Granted, Black women and members of other ethnic minority groups may be more at risk for morbidities associated with hypertension and diabetes, which can lead to serious pregnancy complications and death; however, there is much more to this disparity than clinical predisposition for selected diseases (Society for Maternal-Fetal Medicine, 2017).
The Council on Patient Safety in Women's Health Care (CPSWHC) has published a number of patient safety bundles aimed at improving the health of mothers and babies by identifying and recommending safer care practices. Each bundle is arranged in four sections, readiness, recognition, response, and reporting and systems learning. The bundle Reduction of Peripartum Racial/Ethnic Disparities (CPSWHC, 2016) offers a number of suggestions including: patient and caregiver education; making sure everyone who needs interpreter services gets them; easier patient access to their health records; promoting shared decision-making; being aware of implicit biases; establishing ways for patients, families, and caregivers to report care that is not respectful or equitable; enhancing discharge teaching including warning signs of potential postpartum complications; offering better coordinated care after hospital discharge for childbirth; and examining care processes and operations for disparities based on race or ethnicity. These recommendations have now been supplemented by a conceptual framework and consensus statement prepared by the bundle workgroup that details many of the issues behind the racial and ethnic disparities in care and outcomes for minority women in the United States (Howell et al., 2018). The focus is on modifiable causes and potential solutions to promoting safe and equitable healthcare during childbirth (Howell et al.).
Underlying factors in racial and ethnic disparities in healthcare include challenges in knowing the full scope of the problem as issues involving healthcare disparities are not well studied; lack of recognition or awareness of inequitable care; lack of appreciation of the social determinants of health, poverty, and long-standing disadvantages; fragmented care through pregnancy, birth, and postpartum; miscommunication, poor communication, language and cultural barriers to understanding health information; and general misconception of etiologies and potentially successful strategies for improvement (Howell et al., 2018). Bundle workgroup experts offer suggestions for improvement including learning about personal, institutional, and system implicit biases and ways to tackle each of these problems (Howell et al.). Mindfulness and applying the Just Culture framework to equitable care may be beneficial. Advocating for processes to identify, report, and remedy instances of bias and inequitable health care has merit. Implicit bias can be addressed with self-awareness, a focus on concern for others (a characteristic of the vast majority of caregivers in all disciplines), and leadership support from the top of the organization and all others.
I encourage perinatal nurses to review these resources and to identify ways you can promote equitable healthcare for all women. An awareness of the issues and underlying causes, as well as actionable potential solutions are first steps to improving care for all mothers and babies in the United States. Equipped with this knowledge, we can work together to make these much-needed improvements. Surely perinatal care in the United States can be just as good as it is in other high-resource countries. This quality care should be available to all women.
References
Council on Patient Safety in Women's Health Care. (2016). Reduction of peripartum racial/ethnic disparities (Patient Safety Bundle). Washington, DC: American College of Obstetricians and Gynecologists. Retrieved from http://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Reduction-of-Peripartum-Disparities-Bundle.pdf
Howell E. A., Brown H., Brumley J., Bryant A. S., Caughey A. B., Cornell A. M., ..., Grobman W. A. (2018). Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. Obstetrics and Gynecology, 131(5), 770–782. doi:10.1097/AOG.0000000000002475
Martin N., Cillekens E., Freitas A. (2017). Lost mothers. ProPublica. Retrieved from https://www.propublica.org/article/lost-mothers-maternal-health-died-childbirth-pregnancy
Society for Maternal-Fetal Medicine. (2017). Racial disparities in health outcomes (Position Statement). Washington, DC: Author.