I've seen first-hand experiences in which cultural biases led to sub-par care. A few stories come to mind immediately:
- Assumptions had been made that a patient was uninsured and based solely on the fact that she was African-American. The patient was, in fact, a government employee, with great insurance.
- In another, I wanted to know if any of the staff had requested an interpreter so that we could ask a Spanish-speaking patient if she was experiencing any pain. The nurse told me no, they hadn't seen signs indicating pain, so no translator had been summoned. Yet, had the patient been an English speaker, asking about their experience of pain would have been standard protocol.
- A Filipino patient who originally was deemed "non-compliant" for being a no-show for her prenatal appointments confided in me that she'd been having difficulties with the father of the child at home, but had felt defeated by a healthcare system that had been quick to judge her missed appointments as a failure on her part. No one had asked her what they could do to help.
In order to close the gaps in care caused by these biases, healthcare providers need to understand the profound and pervasive practices that contribute to biased care. They also need to know what can be done to curb instances of cultural bias, especially in labor and delivery.
First, healthcare providers in a labor setting need to take patient's claims of pain seriously. Numerous studies show pain is often undertreated in black patients for conditions from appendicitis to cancer. In a labor setting, pain can be an indicator of more than discomfort, including injury to the spinal cord or nerves, organ failure, infections, severe bleeding, or stroke. Pain left untreated can cause undetected damage in labor that can risk the patient's life up to a year later.
Second, healthcare providers need to be cognizant that patients who do not speak English are not uneducated. With a few exceptions, women who are nearing full term have self-managed their care every day for up to 40 weeks – they know their bodies and have likely had informative prenatal care. In an era of healthcare empowerment, patients are highly attuned to their personal health and knowledgeable about ordinary standards of care. Therefore, speaking English is not a prerequisite for accessing and comprehending information. In fact, some patients express difficulty deciphering the highly accented English of some foreign-born healthcare providers.
Third, any patient that presents deserves attention regardless of their appearance. Certainly, healthcare providers who examine a patient should consider behavior, orientation, motor activity, and consciousness. However, appearance such as dress or hygiene should not diminish care quality before, during, and after pregnancy. Most healthcare providers standardize approaches for responding to such obstetric circumstances. Care cannot include neglecting or ignoring standard patient care because of outward appearance.
Fourth, patients are entitled to a birth experience free from non-delivery-related stress. Pregnancy is believed to be one of the most physiologically complex and emotionally vulnerable times in a woman's life. Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Black women are 49% more likely than white women to deliver prematurely (and, closely related, black infants are twice as likely as white babies to die before their first birthday). Stress caused by the discomfort of delivery, unanswered or ignored questions, and discrimination can cause pregnancy and delivery complications in the near and long term.
Stereotypes, prejudices, and discrimination unfairly categorizes and humiliates patients. That is why healthcare providers should search for hidden biases that may lead to discrimination. Many third parties, including health insurance and health systems, offer training resources aimed at improving cultural competence. This includes resources to help providers understand diverse values, beliefs, and behaviors, as well as cultural, and linguistic needs. In addition, cultural competency training also includes awareness of other important areas impacting healthcare, such as chronic conditions medically linked to ethnicity, diet, nutrition, communication, work/family patterns, and lifestyle.
On May 7, the on maternal mortality and preventable deaths. The report, "Vital Signs: Pregnancy-Related Deaths," painted a disturbing picture: 700 pregnancy-related deaths occur each year in the United States, nearly 31% happen during pregnancy, 36% happen during delivery or the week after, and 33% happen one week to one year after delivery. The report also raised important questions about cultural competence and cultural bias in maternal care. The report found Black and American Indian/Alaska Native women are roughly three times as likely to die from a pregnancy-related cause as white women. This is unacceptable, and largely preventable.
I believe the U.S. healthcare system can make inroads in addressing cultural competence, but in order to do this, providers must take strides to check their own assumptions. Do I know for a fact that this patient lacks insurance? Am I making judgments based on their appearances alone? Have I not just heard, but listened to the patient? Eliminating preventable deaths should be an alarm to which healthcare providers respond quickest and by being on the frontlines, we can work together to ensure that no patient gets left behind.
, is an experienced obstetrical hospitalist and medical director who joined Ob Hospitalist Group in 2016 where she leads programs in central and northern California. She earned a BS in chemical engineering from the Illinois Institute of Technology and her medical doctorate from Rosalind Franklin University of Medicine and Science in Chicago; she completed her ob/gyn residency with Summa Health System. She is a fellow in the American College of Obstetricians and Gynecologists.