Grand Rounds at Sutter Santa Rosa Regional Hospital: Birth Equity (Jimenez, Lund, Bacon 9/8/2021)

Many thanks to Drs. Jimenez, Lund and Bacon for an important presentation on Addressing maternal health disparities and birth equity this week. A full recording of their excellent presentation is available HERE.

https://youtu.be/Y2uJEZyT1ZE

My notes:

What is birth equity? Birth equity is the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort

https://www.cmqcc.org

Dr. Jimenez led off with a review the concept of race.

The notion of race is a social construct designed to divide people into groups ranked as superior and inferior. Societies use race to establish and justify systems of power, privilege, disenfranchisement and oppression
Scientific consensus: race has no biological basis (we are all one race)
In a racialized society like the US, we are all assigned a racial identity, whether we are aware of it or not
Geographic ancestry (which does have genetic importance) is not the same thing as race (which does not)
1700s, Carl Linnaeus, father of modern taxonomy, classified our own species into races based on reports from explorers and conquerors

Americanus, Africanus, Europaeus, Asiaticus, Monstrosus
Western concept of race is based on a classification system that emerged from, and in support of, European colonialism

He followed with a review of racism and bias

Racism is an organized system premised on the categorization and ranking of social groups into races, and devalues, disempowers, and differentially allocates desireable societal opportunities to racial groups regarded as inferior (Bonilla-Silva 1996)
Racism often leads to the development of negative attitudes (prejudice) and beliefs (stereotypes) toward non-dominant stigmatized racial groups and differential treatment (discrimination) of these groups by both individuals and social institutions
Bias is a decision we make so quickly that it simply occurs to us as data; we don't even rela

Dr. Jimenez finished his section with real life examples of racism in maternity care (past and present) and an encouragement that we must begin to come to terms with our own past

The 2018 story of tennis star Serena William's emergency c-section, complicated by PEs and failure of her physicians to listen to her and diagnose her quickly
Slave-holding surgeon (Francois Marie Prevost) pioneered c-section surgeries on American enslaved women's bodies through repeated experimentation
In the 1840s, J Marion Sims, father of modern gynecology, was a plantation physician and then gynecological surgeon in Alabama--> experimental surgeries on enslaved women for vesico-vaginal fistulas. Did not use anesthesia, despite it being readily available. Got rich and famous from his work.
Consider reviewing the image below to understand how racism impacts obstetric care

Dr. Lund took part 2 of the presentation to review disparities in maternity care in the US

Black women experience far worse outcomes than any other racial or ethnic group. Black women:

are 3-4x more likely to die than their white counterparts
comprise 13.5% of live births, but 35.5% of pregnancy-related deaths
have higher preterm delivery (13.4% vs. 9%)
have higher c-section rate (RR 1.23)
have higher PPH rates (3% vs. 1.6%)
have higher peripartum infection (4.9% vs. 4.1%)

Pre-E, diabetes, and and unintended pregnancy are also higher for black women
American Indian/Alaskan Natives (AI/AN) are also at risk for adverse outcomes
Black and AI/AN infants are more likely to die in their first year of life

black infants diet at greater than 2x rate of white infants (11.4 vs. 5.2 per 1000 live births)

California has been working hard since 2006 to reduce our maternal mortality rates, and it's working!

(this graph below shows a decline by 55% 2006 to 2013)

However, despite tons of successful work to reduce maternal mortality, the disparity ratio (black women vs. white women) remains unchanged (see image below):

Dr. Lund also shared some of our local stats at SSRRH

~50% of our deliveries are to Hispanic patients (~ 20% US-born and 30% foreign born)
Another 37.5% of our deliveries are to non-Hispanic White identified Patients
4.5% of births to Asian or Pacific Islander patients
<2% of our deliveries to non-Hispanic Black identified Patients
About 2% “other” which primarily represent American Indian/Alaskan Native patients
A full 6% were race/ethnicity “unknown”

Dr. Lund shared important outcomes for our maternity patients, including NTSV c-section rates, maternal morbidity, preterm birth rates, unexpected newborn complications, and exclusive breastfeeding at discharge:

Hispanic born US rates of pLTCS are the lowers of all, much lower than state average
Non-Hispanic black patient cesarean rates are about 4% higher than almost all others but lower than state average.
Our “other” category (largely AI/AN) exceptionally high NTSV c-section rate. Total # of patients in the “other” category higher than for non-hispanic black but still only about 145 patients over 5 years.

And for preterm birth:

Non-Hispanic Black preterm birth rate is similar to others at our facility and lower than state average, however note that #’s are quite small so should continue to trend over time 11 patients out of 124 patients total in 5 years.
Rate of PTB among white patients higher than the rest of CA
“Other” preterm birth rate is quite high, mostly represented by AI/AN individuals, numbers still low 28 patients out of 144 over 5 years.

What can be done?

Dr. Bacon capped off this week's Grand Rounds presentation with a series of recommendations of how you might engage in local advocacy and beyond to work on birth equity:

Individual work: if you are unsure where to begin and/or unsure about what you think about this information, individual work is the place for you

consider reading and/or listening to podcasts, listening to the experiences of others (particularly BIPOC), assessing your own personal unconscious bias, and work on retraining your brain on these biases
Listen to Dr. Camara Jones
Visit Project Implicit
I personally recommend Seeing White on Scene On Radio as a good place to start (we have been listening to this as a faculty for our anti-racism work)

Institutional work

there are lots of robust toolkits and trainings to help guide institutions
these might help you help guide YOUR institution
try: CMQQ, ACOG/SMFM, https://blackmamasmatter.org/, CDC's Hear Her campaign
Locally, attend CEDAWG grand rounds, September 22 Foundations for Health Equity Workshop, UCSF Differences Matter, Trauma informed care trainings
Check out the SSRRH Labor Culture Committee (LCC) at SSRRH (inquire with Julie Barajas or

Community Work

Workforce development, pipelines
Community health workers
Doulas
Black midwifery
Centering pregnancy

Statewide and National work

Pay attention to what is happening in politics and policy:

SB65: a bill that creates a committee to investigate maternal deaths, examines adding a doula benefit to medi-cal funding, and helps low income communities have access to midwifery care
California AB4: removing documentation status for Medi-cal benefits
Governor Newsom's 2022 budget, which includes California extension of OB Medi-cal to 1 year postpartum