Uprooting Racism: The Role of Nurses in Cultivating Improved Maternal Outcomes for Black and African American Women

Abstract

After controlling for education, socioeconomic status, and genetic factors, Black and African American patients in the United States are three to four times more likely to die in childbirth than are White patients. The literature is replete with strategies to improve maternal outcomes for Black and African American patients. Existing strategies focus on addressing poverty and individual risk factors to reduce maternal mortality, yet maternal outcomes are not improving for these patients in the United States. Recent literature suggests that a nuanced approach that considers the effects of individual and structural racism could improve maternal outcomes, especially for Black and African American patients. As nurses comprise the largest component of the health-care system, their collective power and influence can provide a powerful tool for dismantling structural racism. Some important concepts to consider regarding the care of the Black and African American population are cultural intelligence (CQ), allostatic load, and humanitarian ethos. By developing CQ and consistently including the four CQ capabilities (drive/motivation, knowledge/cognition, strategy/metacognition, and behavior/action) in all aspects of practice, nurses can help to uproot racism and cultivate experience to improve maternal health outcomes for Black and African American patients.

Keywords

racism professional nursing role maternal mortality bias cultural intelligence humanitarian ethos

A lice Jones is 32 years old and 34 weeks pregnant. She identifies as female, is college-educated, and is from an upper middle-class background. Alice and her partner have attended prenatal classes and all scheduled prenatal visits, and she has completed the screenings recommended by her provider. Alice has all the resources to ensure the likelihood of a positive birth outcome, but Alice is Black, and due to this single factor, she is four times more likely to die in childbirth than a White patient with the same demographics (Hoyart & Minino, 2020).

Despite documented strategies to improve maternal health outcomes, the United States continues to experience the highest maternal mortality rate of all similarly developed countries (Petersen et al., 2019). A stratification of maternal mortality rates by race shows that non-Hispanic Black women experience a mortality rate of 10.74 deaths per 1,000 live births within 42 days of delivery, in contrast to a rate of 4.63 deaths for non-Hispanic White women (Hoyart & Minino, 2020). Race-related health disparities are neither new nor unstudied; widely available applicable data has resulted in strategies aimed at improving access to and quality of care among patients of color (Centers for Disease Control and Prevention [CDC], 2019); however, maternal outcomes for Black and African American patients remain significantly poorer than for White patients. Existing strategies focused on poverty and individual factors to reduce maternal mortality outcomes have not eliminated disparities. Recent literature suggests that the underlying issue preventing significant improvement in maternal outcomes for Black patients is the impact of structural racism (Howell et al., 2018).

Structural racism refers to oppression resulting from policies, practices, or procedures (Powell, 2008). Structural racism is pervasive within a society; therefore, in order to change the disparity in maternal outcomes, racism must be addressed systemically within our profession and practice communities. This article presents a summary of how race directly affects maternal outcomes, and offers suggestions, based on the cultural intelligence (CQ) framework (Early & Ang, 2003), for addressing structural racism in nursing practice.

Background

The term allostatic load refers to the bodily response to physically degrading or weathering effects of chronic stressors (McEwen, 2005). Prolonged exposure to antagonistic social systems creates chronic stress that

Adverse maternal outcomes of Black and African American women occur when the effects of structural racism reverberate through the determinants of health.

increases allostatic load and negatively affects the overall health of Black and African American people. By analyzing the data from the 1999 to 2002 National Health and Nutrition Examination Survey, Geronimus et al. noted that Black women had a higher allostatic load than White women and Black men, regardless of socioeconomic status (2006). A review of the literature by Chaney et al. (2019) suggests that exposure to racism, specifically during pregnancy, can negatively affect the immune, cardiovascular, and neuroendocrine systems. The positive correlation between stress and preterm labor and birth are well documented in the literature (Shapiro et al., 2013; Tanpradit & Kaewkiattikun, 2020), and Black patients are more likely to experience a preterm birth than members of any other race (Hamilton et al., 2016).

Patient satisfaction is used as a measurement of quality of care. Discussions regarding health inequity often focus on quality of and access to care; however, structural racism adversely affects both access to and quality of health care. A study by Benkert et al. (2006) revealed a correlation between racism and provider mistrust, providing an explanation for why racism obstructs access to care, and explained that a patient's perception of racism pertaining to a provider or staff member could erode patient-provider trust and compromise maternal outcomes. Patients may feel reluctant to disclose critical health information or to follow medical advice if their provider appears to minimize or dismiss their concerns, or fails to respond to symptomatic complaints due to racism.

In a survey of more than 2,000 patients representing diverse socioeconomic levels, Ertel et al. (2012) confirmed findings from previous studies in demonstrating that up to 78% of Black and African American women reported exposure to racism and discrimination during daily interactions. Furthermore, the results of the survey suggest that patients who experience higher levels of discrimination are more likely to experience depressive symptoms. As depression and mental health issues during pregnancy contribute to unfavorable maternal outcomes, the effects of structural racism experienced regularly could contribute to compromised maternal outcomes for Black and African American women. Strategies to reduce exposure to structural racism and discrimination may reduce the incidence of depressive symptoms in patients; thus these strategies should prioritize provider training in racial equity and management of bias.

Structural racism in maternity care does not affect only the mother. The results of a retrospective cohort study by Palarnik et al. (2019) of more than 16,482,745 births revealed that the race of the paternal parent was an independent and significant variable in poor fetal outcomes; when the paternity of the father was Black, the mother was more likely to experience preterm birth and low birthweight.

Almost 700 women in the United States died in childbirth in 2018; the CDC estimates that up to 60% of these reported deaths were preventable (CDC, 2020). As maternal mortality statistics for Black and African women are disproportionately high, a plan to address individual and structural racism could be the key to improving maternal outcomes overall, and for Black and African American patients in particular.

The Role of Nurses

As health-care professionals, nurses must care for all patients according to holistic and impartial humanitarian principles. It is imperative that nurses approach racism with a humanitarian ethos and a goal of promoting health equity for all human beings. In an editorial on the humanitarian ethos in the International Review of the Red Cross, Bernard (2015) defined its principles as impartiality, service, compassion, sympathy, and respect for human life and dignity; additionally, Bernard noted that humanitarian principles must focus on neutrality and consistent efforts to build trusting relationships with those in need. The humanitarian ethos is complementary to holistic nursing, which espouses principles of completeness, totality, awareness, and interconnectedness within systems (Rosa et al., 2019). Holistic nursing calls upon nurses to approach health care in a manner that is inclusive and promotes and protects well-being (Rosa et al., 2019). To that end, embracing and understanding the culture and specific needs of Black and African American women holistically is essential to advancing health equity and improving maternal health outcomes among this population.

Systemic injustices and inequities cannot be dismantled through recognition and acknowledgement alone. Society has long been aware of discriminatory practices and racially motivated antagonism. Outcomes-driven initiatives aimed at sustainable reform must be prioritized. Due to their roles within health systems, government offices, national and international professional organizations, boards, and other prominent professional placements, nurses are uniquely positioned and empowered to develop strategies and implement action plans to uproot racism and promote health practices that benefit Black and African American women. Holistic nursing endorses humanitarian concepts of respect for human life and dignity along with respect for cultural diversity (Rosa et al., 2019).

Moving nursing practice toward health equity requires intenrionality, mutually beneficial collaboration with patients, and nursing practices that support the social, physiological, economic, and environmental determinants of health (Rosa et al., 2019). Adverse maternal outcomes of Black and African American women occur when the effects of structural racism reverberate through the determinants of health. Dismantling systemic bias and racism requires a lifelong commitment from nurses and other health-care professionals. Nurses ‘commitment to advocacy should include encouraging others to create and maintain organizational systems that support equitable maternal health outcomes.

For nearly two decades, nursing has been declared the most ethical and trusted profession (Reinhart, 2020). Of the more than 3.9 million registered nurses in the United States, 85% are engaged in practice (Smiley et. al., 2018). As nurses make up the largest component of the health-care system, their work to uncover and dismantle structural racism could improve maternal outcomes for pregnant Black and African American patients.

Dismantling Structural Racism

Dismantling structural racism and erasing racism requires gaining an understanding of culture and cultural influences and embracing cultural differences. It is important to acknowledge that anti-racism initiatives require skills acquisition through lifelong participation in appropriate and effective educational venues. Educational training must be strategic, sequential, and based on the acquisition of foundational knowledge.

An example of a framework that provides this foundational knowledge is CQ, the ability to function effectively in culturally diverse situations or settings (Early & Ang, 2003, p. 59). The CQ framework is based on four capabilities: drive/motivation (interest in interacting with people from other cultures); knowledge/cognition (knowing and understanding cultural commonalities and differences); strategy/metacognition (preparing for culturally diverse interactions while acknowledging and understanding that there are differences within cultures); and behavior/action (flexibility and adaptability within multicultural contexts). An individual's overall CQ is based on proficiency within each domain, along with skill in practicing them collectively (Early & Ang, 2003; Liver-more, 2011, 2015, 2016).

Patients may feel reluctant to disclose critical health information or to follow medical advice if their provider appears to minimize or dismiss their concerns, or fails to respond to symptomatic complaints due to racism.

Explicit and unconscious biases are common in all humans and are affected by cultural influences and lived experience. Inactive biases are harmless; however, once activated in the health-care setting, biases can result in “isms,” discriminatory practices, and negative health outcomes. A culturally intelligent nurse has the ability to recognize and manage biases in such a way that bias-influenced outcomes can be mitigated.

Cultivating Change through Advocacy

Nursing can apply each of the CQ capabilities to address patients ‘daily exposure to racism by developing and promoting advocacy for Black and African American women:

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Drive/Motivation: Joining local and national organizations that support Black and African American women and advocate for them (e.g., March of Dimes, Sister Song)

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Knowledge/Cognition: Regularly attending educational programs and training workshops aimed at educating health professionals about racism and bias (e.g., opportunities presented by experts in CQ, diversity, and inclusion seminars)

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Strategy/Metacognition: Developing strategies to promote anti-racist practices (e.g., paying attention to implicit biases, addressing macroaggressions, and creating opportunities for social interaction with diverse groups)

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Behavior/Action: Moving beyond planning and educational programs toward implementation of anti-racist initiatives that improve maternal outcomes for Black and African America women (e.g., implementing events designed to promote anti-racism and oppose tolerance for racist language and behaviors)

Psychological factors such as the impact of racism and discriminatory practices on health outcomes should

Moving nursing practice toward health equity requires intentionality, mutually beneficial collaboration with patients, and nursing practices that support the social, physiological, economic, and environmental determinants of health.

be priority considerations in providing quality health care; therefore, nurses should assess patients for exposure to racial discrimination and racially-related uneasiness, and should create a space in which all patients have the opportunity to feel safe, respected, and comfortable. This recommendation is consistent with Provision 1 of the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (ANA, 2015), which states that nurses should “practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. v).

Support during the pregnancy and birth experience can influence birth outcomes (Kozhimannil et al., 2016). Nurses can encourage patients to have a trusted support person (partner, friend, family member, or Doula) present for the birth and the postpartum period. Doulas can attend prenatal visits and provide support from early labor through postpartum; the support offered by Doulas has been linked to lower rates of Cesarean deliveries, improved patient satisfaction scores, and higher overall quality of care (Kozhimannil et al., 2016).

Conclusion

Despite data demonstrating health inequities experienced by Black and African American patients, and numerous strategies for addressing the problem, there has been little change in maternal outcomes for women in this population (Carroll, 2017). Ensuring adequate access to quality care, a supportive patient environment, and optimal outcomes requires nurses to be prepared to consider the effects of structural racism and to address it as professionals. Nurses make up the largest component of the health-care system; therefore, by developing CQ skills and including the four CQ capabilities in all aspects of practice, nurses can work to uproot racism, promote equitable and holistic care, and significantly improve maternal health outcomes for Black and African American patients.

Footnotes

Jacquelyn McMillian-Bohler, PhD, CNM, CNE (she/her), is an Assistant Clinical Professor at Duke University School of Nursing in Durham, North Carolina, teaching Health Promotion and Perinatal Nursing in the pre-professional and Master's Degree programs. As a Certified Nurse-Midwife, she provided women's health care in Charleston, South Carolina.

Angela Richard-Eaglin, DNP, MSN, FNP-BC, CNE, FAANP (she/her), is an Assistant Clinical Professor, at Duke University School of Nursing in Durham, North Carolina. She is a Certified Professional Cultural Intelligence (CG) l&ll and Unconscious Bias Facilitator and Coach. She is committed to initiatives aimed at supporting and advancing opportunities for underrepresented minorities and marginalized populations.

Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.

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