Healers and Biases: Biases Exists, Stop Pretending They Don't.

I am a nurse who belongs to various social media nurse groups.  Twice, in a matter of ten days, in two different nursing groups, I have seen, what I can only describe as willful ignorance regarding the Black maternal and infant morbidity and mortality public health crisis.  This ignorance is disheartening and disturbing, but ultimately, not surprising.

Both original posts referenced recent mentions of the Black maternal and infant morbidity problem. One article referenced Senator Elizabeth Warren speaking on the topic at a panel.  In that case, I think posters took more issue with the messenger, Senator Warren, than the actual message itself: Black maternal and infant morbidity and mortality is a very real and dangerous problem. The second post was about a young woman whose first child passed away due to being born too prematurely. The headline stated, "A black mother told not to scream in labor asks: Can California fix racism in maternity care?"  Instead of focusing on the article, some posters hyper-focused on the headline with responses of "well screaming during labor isn't effective.", "I was told not to scream and I'm white.", "This is not a racial thing, but an efficiency thing.", "I take exception to this, articles like this are only mean to divide us more.", and so on and so on.

I and many other posters responded with "better" examples, though this one in this story should have been enough.  People did not bother to read those examples, and just went right back to their same spiel. What more does one need to do to show that racism and implicit bias in healthcare exists?  How bad does it make one feel, when Black nurses and other nurses of color are responding with their own stories of inadequate or questionable care, and their peers are ignoring it, or worse coming up with excuses and saying that wasn't racism.  There is one thing we should know as nurses, is that we not only have to acknowledge but also accept a patient's answer to a question.  If a patient states their pain is a 10/10, but from your observations, you feel it's more like a 5/10, you must report the ten.  So if a fellow nurse is telling you they felt discriminated against, you do not get to tell them no, they weren't.  Now THAT is dismissive and divisive.

There may be people that read this post and feel the example above is good enough either, so I present to you several examples where implicit bias caused severe injury or death to mother or child.

1. Shalon Irving

2. Kira Dixon Johnson

3. Simone Landrum

4. Serena Williams

Aside from these examples, I have more highly-educated professional Black friends who have had premature births, and unfortunately, some deaths, than I do Black friends who have delivered term babies. The reason I bring up class is that even accounting for SES, age, education and more, the Black maternal and infant mortality rates are still leaps and bounds higher than that of their White counterparts.

How do you fix a problem if you do not believe a problem exists?  I was a public health epidemiologist before going to nursing school, so I know numbers. Numbers do not lie.  The Black maternal and infant morbidity and mortality rates are so high that it is considered a public health emergency.  Read that again, in 2019, the Black maternal morbidity and mortality rates is a public health emergency.  To be fair, the state of maternal and morbidity rate for the United States is abysmal compared to other developed countries, but it is far worse for Black Mothers and babies.  The Black Maternal Health Caucus would not exist if it was not warranted or needed.

Here are some statistics from an Evidence-Based Research (EBR) paper I did on the effect of community care (centered) vs. traditional care on Black infant mortality and morbidity rates.

Eighty-six percent of countries that participated in a World Health Organization (WHO) study reported significant decreases in maternal mortality from 2000 – 2014, while the United States saw and continues to see increased maternal mortality (Lu, 2018). To put in perspective, the United States ranked next to last with maternal mortality data reported to the Organisation for Economic Cooperation and Development and reports rates three times higher than similar countries like the United Kingdom and Canada (Lu, 2018).  

African American women and other people of color (POC) experience negative outcomes three to four times higher than Caucasian women.  Caucasian women, women of other races, and African Americans experience the following maternal mortality ratio (MMR), 12.4 deaths/100,000 live births, 17.8 deaths/100,000 live births, and 40.0 deaths/100,000 live births, respectively (Centers for Disease Control, 2018).  Infant mortality rates are higher in African American infants.  African American infants die at a rate of 11.4/100,000 live births, compared to non-Hispanic White infants at a rate of 4.9/100,000 (CDC, 2018).

Now that we have the stats out of the way, let's look at this thing called implicit bias.  You do not have to be a racist to say or do things that racially insensitive.  I think that is where nurses and other healthcare professionals get caught up when trying to talk about race in healthcare. Many may feel as though they are being personally attacked, or their character questioned, and immediately go on the defense.  However, you cannot learn from a defensive position. 

To say that you treat ALL patients the same regardless of race, gender, creed, SES, sexual orientation is simply not true.  If for no other reason, then we know as nurses there are very few absolutes. How many times throughout our nursing education, have we been taught to not choose an answer for a test question that has an absolute like, always, never, every, etc.? But yet, we get offended when someone says, just maybe, implicit bias and racism may play a role in maternal and infant morbidity and mortality rates. I score very high on cultural competency assessments, I believe in part, due to me being a minority, but does that mean I do not have room to learn, or that I may have unconsciously displayed a bias towards a patient.

Implicit bias could be the following:

1. Expressing surprise that a Black patient has a supportive husband at delivery.

2. Rolling your eyes in report when you hear your patient's name and making assumptions based off of that name.

3. Making comments like "they" always have a lot of people in their rooms and are so demanding.

4.  I'd have a lot of kids too if the government was paying for them.

5. Shortening a person's name without their permission, because you deem it to hard to pronounce.

6. Expressing surprise at a patient's education level

7. Not responding to call lights or rounding on that patient like you should

8. Discounting a patient's pain or believing the old stereotype that Black patients feel pain differently.  Study shows it is still a common belief amongst doctors.

So you see, you do not have to call a patient a derogatory name or give an attitude to do things that are racist or perpetuate implicit bias.

As a person and as a nurse, I was taught to be a part of the solution and not a part of the problem.  I would be remiss if I did not offer to you an opportunity to see if you have trouble with implicit bias and are culturally competent.  Use this link to take a cultural assessment.  The first step of the nursing process is to assess the situation.  Self-assessment is no different. Be honest with yourself when you take the assessment and learn from it.

To see there is a problem, hear from your peers that they have experienced said problem and still say the problem does not exist is to be willfully ignorant.  Not only that, it is is the height of privilege.  There are fewer things that are more hurtful and ignorant than to dismiss a person's pain, especially because acknowledging it makes you uncomfortable.  Black women, myself included, and other people of color do not have the luxury of being ignorant or privilege, we are too busy advocating for ourselves, against the people who do not think we need advocating from.  The truth hurts sometimes, but without acceptance of it, change cannot come.

References

Centers for Disease Control and Prevention.  Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/index.html. Accessed January 30, 2019.

Centers for Disease Control and Prevention. Infant Mortality. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm. Accessed January 30, 2019.

Lu M.C. Reducing Maternal Mortality in the United States. (2018). JAMA. 320(12), 1237–1238. doi:10.1001/jama.2018.11652

Lu, M. C., Highsmith, K., de la Cruz, D & Atrash, H. K. (2015). Putting the "M" back in the maternal and child health bureau: Reducing maternal mortality and morbidity. Maternal and Child Health Journal, 19(7), 1435-1439. doi:10.1007/s10995-015-1665-6

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