It’s Not “Them,” It’s Us: Real Life Adventures in Health Equity and Discrimination, Part Two

By Cecelia Ottenweller
December 18, 2020

In the last post, I introduced myself, and today, I’m introducing the context surrounding my research.

Maternal Health Disparities

We know that there’s definitely something not working right in interactions between Black women and their provider teams; the differences in outcomes between Black women versus other ethnicities are statistically stark. In Harris County, women identified as “Black” in government and academic research are 3 to 5 times more at risk for negative health outcomes (death or severe debilitating illness) than any other ethnicity. The rates vary from ZIP code to ZIP code—this rate is not consistent as you move from one part of the population to the other. 

Let’s put that statistic in a frame, starting with the national picture. Maternal mortality rates in the U.S. are an embarrassment: The United States ranks at the bottom of developed countries for maternal death. Between 1999 and 2017, the mortality rate of all women in the United states—regardless of ethnicity — rose from 9.9/100,000 live births to 30.7/100,000 live births. That’s just deaths; once you begin looking at severe life-threatening complications resulting from pregnancy, the numbers explode: an additional 500,000 mothers annually suffer these complications (which are professionally referred to as “severe maternal morbidity” or SMM) in the year following pregnancy. And that’s across all ethnicities.

But, in a country that’s at the bottom of a list, Black and Indigenous women are in even worse shape. Once you begin to break these numbers down based on ethnicity and other factors, a huge disparity is revealed: Black and Indigenous moms bear far more of the maternal mortality burden than their sisters of other ethnic backgrounds. In the same time period, from 1999 to 2017, their mortality rate in the U.S. went up from 24.3/100,000 to 56.7/100,000. This translates to a two- to three-times greater risk than White or Non-Hispanic women and their odds of surviving the birth experience is comparable to the rates of countries regarded as having medical systems inferior to that in the U.S.

What happens when we get more local? It’s not pretty. Texas ranks near the bottom of the list in the U.S.; Texas has one of the highest maternal mortality rates in the country. 

In Texas, SMM (severe maternal morbidity, see above) rates rose 15% across all ethnicities between 2008 and 2015. That’s death and disability due to issues related to pregnancy in the year following delivery. The rates in Harris County were more than four times the state’s rate: In Harris County, the SMM rates for the same time period are 53% for all ethnicities. All women in Harris County are at a greater risk of either dying or being disabled following pregnancy. 

Breaking it down by ethnicities, Black women, especially in particular ZIP codes, are between 3 and 5 times more likely to die or be debilitated than their sisters from other ethnicities

Houston’s Black women are near the bottom of a list that’s near the bottom of a list, that’s at the bottom of still another list.

That’s sickening.

And here’s the thing: maternal mortality and morbidity is the proverbial canary in the coal mine, a tip of a much larger iceberg. If all women in Texas are more likely to either die or be debilitated because of pregnancy, then what is happening to women who aren’t pregnant? If pregnant Black and Indigenous women are 3-5 times more likely to suffer death or debilitation than their sisters of other ethnicities, then what’s happening to the women of those communities who are not pregnant?

When you look at statistics around maternal health, Black women are at greater risk for everything: gestational diabetes, preeclampsia, placental rupture… you name it. But that doesn’t make any sense, because Black bodies are the very same as white bodies. “Black” and “white” are cultural constructs; there is no such thing genetically, empirically as “Black” or “white.” In fact, there is less genetic difference between Black and white people in the U.S. as there is between

Between 2015 and 2017, only 7.5 percent of women in the United States were actively pregnant. Ninety-five percent of women in the U.S. see a doctor at least every two years. If discrimination is affecting health outcomes for pregnant women, it’s very safe to assume that the discrimination is occurring during those other visits as well. 

There’s something else besides biology behind this inequity, and I believe it’s a cultural issue. I began this project to learn more about why this was happening on a cultural level and to contribute to the dialogue around the subject of maternal health equity. 

Implicit Bias

So, how does implicit bias affect the medical interaction? A good example comes from this study cited in Women, Ethics and Inequality in U.S. Healthcare by Aana Marie Vigen. Physicians treating patients with cardiac issues, “…rated Black patients as less intelligent than White patients, even when patient sex, age, income and education were controlled. Physicians also reported less affiliative feelings toward Black patients…. In general, physicians gave lower socio-economic status (SES) patients more negative ratings on personality characteristics (lack of self-control, irrationality) and level of intelligence. In addition, lower SES patients were rated as less likely to be compliant with cardiac rehabilitation…”  Yet the docs believed that their biases towards their patients did not affect the quality of care the doctor provided to the patient. 

I wanted to hear from the players themselves about what happened in the clinical setting between patients and providers and I wanted to hear about how they interpreted those occurrences. I also wanted to gain a better understanding of the world view of both sides of the equation and look at why and how the disconnects were happening. 

What’s more, I wanted to find a way to draw attention to the unfairness of the top-down delivery of solutions from a few experts to the general population. Implicit bias in medicine easily—unfairly—creates barriers to achieving good health because our system is predicated on a few experts dispensing solutions to the larger population. That’s a bland way of describing how power stays at the top without the communities affected participating in the generation of solutions. As Gandhi said, “Whatever you do for me, but without me, you do against me.” Public health decisions affecting a general population that are made behind closed doors is patronizing and treats people as if they are children. So, I designed a project that could gain as many points of view as possible, which I’ll share in next week’s post.