Delivering Culturally Competent Maternal Care

Culturally competent healthcare is person-centered: it considers the person's preferences as well as their unique experience from a cultural perspective. This perspective is particularly important in light of longtime racism and inequities experienced by people from historically marginalized groups.

Seeking better outcomes for BIPOC women and infants

In maternal care, culturally competent and person-centered care is foundational to systematic shifts needed to change the growing dire outcomes experienced by mothers and babies of color. The inequities they experience further erode medical trust and minimize healthcare utilization, both essential for overall health and well-being.

Maternal health disparities point to systemic racism

“There are huge disparities that have been revealed in maternal health. Maternal and child health care has seen some of the bleakest outcomes of implicit bias in medicine," stated Dr. Amanda Williams, chief of the OB/GYN Department at Kaiser Permanente Oakland Medical Center in California.

The Journal of Clinical Obstetrics and Gynecology noted that while maternal health disparities have existed for centuries, they have worsened in the past 100 years, representing “the largest disparity among all the conventional population perinatal health measures." A few statistics bear this out:

• Non-Hispanic Black women have had the fastest rate of increase in maternal deaths that is up to 12 times higher in some cities than Non-Hispanic White women.
• Black women are 3 to 4 times more likely to die from pregnancy than their White peers.
• During labor, Black mothers are less likely to receive pain medication, and more likely to report that their providers didn't address their pain adequately during delivery.
• Black and American Indian/Alaskan Native (AIAN) babies are twice as likely to die during their first year of life compared to White babies.

New CDC report provides latest research on pregnancy-related deaths

Covered in JAMA, the research reveals that nearly 80% of pregnancy-related deaths were preventable:

• 14% of deaths were due to hemorrhage
• 7% were due to hypertensive disorders of pregnancy
• More than 50% of deaths occurred after the first week through 1 year after delivery
• 50% (approx.) of maternal deaths were among White individuals
• 31% occurred among Black individuals who represent only 14% of the US population

When race is the primary difference among mothers

Even when education, financial status, and insurance coverage are not barriers, race impacts maternal care. Ethnographic analysis of highly educated Black women's perinatal care experiences indicated racism. Black women faced presumed incompetence and disrespect while undergoing painful procedures and interventions without consent.

Culturally competent maternal care starts with cultural humility that gives respect and builds trust

Dr. Williams from Kaiser points to becoming an ally through a posture of cultural humility. She states, “This effort to understand and humble yourself to the patient's perspective is the first step in becoming an ally to your patient and providing equitable health care."

The Advancing Health Equity: Guide to Language, Narrative and Concepts, published by the American Medical Association (AMA) and the AAMC Center for Health Justice, cite cultural humility as the basis of a “lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations."

The CDC report highlighted earlier found that 1 in 10 Black patients experienced mistreatment because of their race or ethnicity compared with about 1 in 100 White patients. About 10% of Black patients reported rough handling and rude or threatening language, compared with ~8% of White patients.

A University of Minnesota study through the Roots Community Birth Clinic, found that “BIPOC clients reported feeling more autonomy and respect when they received culturally centered care when compared to participants in the national survey."

Tools like the Cycle to Respectful Care supports patients and works to lessen biased practices and beliefs, structural and institutional racism, and eliminate policies that perpetuate racism.

Changing the dynamic and demonstrating humility can lead to greater trust, but it starts with the practitioner or provider and not the patient. According to the National Birth Equity Collaborative (NBEC), “Patients are not trusted by their healthcare providers to be honest, to care for themselves, to follow directions, or to be autonomous over their bodies." This approach has created an environment of authority, fear, and dehumanization. Cultural humility that is expressed with respect builds trust.

Culturally competent maternal care supports access, communication, and shared decision making

“Every mama is an expert on their own body. If providers believed that, mamas would not have pain crises ignored, signs of hemorrhage questioned, and preventable deaths. Mamas would not have to get into squabbles with nurses about unnecessary restraints or have their requests to walk in labor or drink water denied. Applying this knowledge in labor and delivery is the beginning of shared decision making." National Birth Equity Collaborative (NBEC)

The pregnancy, labor, and delivery journey is an opportune time to embed a culture- and patient-centered approach because of the length of patient relationship, and because of the many decisions that must be made at each milestone.

The Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) survey uncovered a host of barriers to seeking or maintaining maternity care:

• Lack of insurance coverage or money for services
• Unable to schedule an appointment at a convenient time
• Fear of others knowing they were pregnant
• Lack of transportation
• Behavioral health or substance use disorders
• Unplanned or unwanted pregnancies
• Desire for more transparency and communication in prenatal care
• Lack of relationship with providers
• Perceived insignificance of prenatal care due to lengthy wait time and short visit time
• Inflexible work schedule
• Trouble navigating the health system

When women of color don't trust the healthcare system, have adequate information or support, or feel misunderstood, they avoid prenatal care or don't have enough resources to overcome barriers.

Culturally competent maternal care requires self-awareness, assessment, and honesty

Every healthcare practitioner and physician has a personal and professional obligation to look at their role in creating culturally competent maternal care or exacerbating existing inequities and bias.

Pediatrician Dr. Patricia Castañeda-Davis reflected on her own personal bias related to maternal health, stating, “I realized I subconsciously thought African American women were more likely not to breastfeed, but I assumed a Latina mom would be breastfeeding and therefore biased my counseling towards that. So I saw my individual bias is what was leading to an individual health disparity."

As an American physician born to a Mexican mother and a Jamaican father, Dr. Castañeda-Davis points to performing the difficult task of internal reflection regarding her own biases. “Part of cultural humility is checking in with yourself on things that you're doing when you're in an uncomfortable situation." She poses questions that highlight biases:

• How often am I having to change my automatic response?
• What is my bias?
• Why do I have this bias and what can I do about it?
• Have I ever been surprised?
• What kind of detrimental things is the bias leading to?

While implicit bias training for healthcare clinicians and staff is required by law in California, training creates a foundation of language, terms, and opportunities to self-assess.

Improving self-awareness can lead to enhanced communication with diverse patient populations and facilitate exceptional care experiences through transparency and honesty. In maternal healthcare, better communication and understanding can save lives. Even speaking the same language has been associated with fewer medical errors and better outcomes.

What does culturally centered maternal care look like?

Looking at the total woman-child healthcare journey is important for putting maternal healthcare in perspective. From reproductive justice to infant wellness, there is a continuum of care that will benefit from more culturally centered maternal health. Better communication, provider relationships, and trust can yield more opportunities over a woman's lifetime to educate, support decision making, and help her achieve better health for herself, her child, and community.

Creating more joy, awareness, and self-advocacy

A recent JAMA article quotes a maternal health strategist and podcaster, Seals Allers. “There has been an overly negative doom-and-gloom narrative. What it has done to Black birthing people is stoke fear." She shares joyful birth experiences and stories of successful recovery after difficult birth experiences to dispel misconceptions, bring greater awareness without fear, and focus on self-advocacy while promoting clinician education.

The Roots Community Birth Center is a Black-owned, midwife-led freestanding birth center in North Minneapolis. Their maternity care model holds potential to reduce disparities and costs by focusing on the root cause of racism. By offering culturally centered, community-based care, they have helped 284 families over 4 years with no preterm births.

Other research, including the CDC report, emphasizes the importance of using culturally centered community health workers (CHW), which could include doulas and midwives. These professionals are a supplement to the traditional maternal care medical team and are included in the birth journey to care for, support, and advocate for mothers during pregnancy and labor. Having a midwife-attended birth is associated with improved experiences and better outcomes for Black, Indigenous, and Latina patients. More than 50% of Listening to California participants said that they wanted or would consider using a doula or midwife. States including Illinois, Minnesota, New Jersey, and Oregon have expanded Medicaid coverage to include doulas, which can act as an additional patient advocate.

More provider organizations are creating culturally competent maternity programs

Johns Hopkins Center for Indigenous Health: Their Family Spirit program was created in collaboration with more than 100 tribal communities in 16 states. The program has shown improvements in parenting practices, reducing drug use and depression among patients after delivery, and improving children's emotional and behavioral development during their first 3 years.

The Maternal Health Multilevel Intervention for Racial Equity (MIRACLE): This study investigated whether a three-pronged intervention could lower maternal morbidity in Genesee and Kent counties, Michigan. The program offers telehealth for Medicaid-eligible mothers who don't choose prenatal and postnatal home visits. Their anti-bias training for clinicians was created and deployed by community leaders. They created quality improvement bundles for community care health professionals, including a checklist for clinicians to support postnatal care transitions.

The Respectful Maternity Care (RMC) movement

RMC is a global movement and approach to care that emphasizes the fundamental rights of women, newborns, and families with goal of achieving equitable access to evidence-based care while recognizing unique individual needs and preferences.

NBEC's Respectful Maternity Care framework: In collaboration with Johns Hopkins University and Ovia Health, NBEC has developed a comprehensive framework that guides hospitals and health systems toward anti-racist healthcare practices and provides practical tools to measure and track progress.

AWHONN's Respectful Maternity Care Implementation Toolkit (RMC-IT): The Association of Women's Health, Obstetric and Neonatal Nurses has created a set of tools and resources to implement their 10-Step “C.A.R.E. P.A.A.T.T.H."

Dr. Wanda Barfield, Director of the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC), leads efforts to provide optimal and equitable health to women, infants, and families. “A maternal death is more than just a number or part of a count. It is a tragedy that leaves a hole in a family."

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Our clinical, data science, health equity, quality improvement, and digital health experts work together to ensure healthcare providers offer quality, equitable maternal care services across the entire woman-child journey. Contact us.