Current Resources for Evidence-Based Practice, November 2020

Abstract

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.

A review of new resources to support the provision of evidence-based care for women and infants.

Marit L. Bovbjerg, PhD, MS

Diversifying the Maternity Care Workforce May Ameliorate Racial Disparities in Maternal–Child Health Outcomes

In a recently published, intriguing article, Greenwood and colleagues (2020) used hospital discharge data from Florida, 1992–2015, to explore whether racial concordance between newborn and pediatrician during hospitalization at birth was associated with infant death during the initial hospital stay. By studying pediatricians and newborns specifically, the authors were able to eliminate the effects of verbal communication with the patient and any potential biases held by the patient, if we assume humans are indeed born bias-free. Thus, any differences in outcomes would ostensibly be related to physician bias, physician practice, and so forth. To the extent that parents with learned biases still communicate with physicians with learned biases, the distinction is not entirely clean, but it is nonetheless a unique approach.

Greenwood et al. (2020) reported that racial concordance between pediatricians and newborns was associated with a reduction in the known racial disparity around neonatal deaths. Black newborns always died at higher rates than White newborns, but if newborns were cared for by Black pediatricians or neonatologists, this disparity was somewhat ameliorated. Specifically, if cared for by White physicians, Black neonates experienced an excess of 430 mortalities per 100,000 births, compared with White neonates, but if cared for by Black physicians, this rate was reduced to an excess of 173 mortalities per 100,000 births. This interaction between race of newborn and race of physician was not affected by whether the physician was board certified. The reduction in disparities effect was stronger in hospitals in which there were more Black neonates. Available data suggested this was because of poorer performance by White physicians in these hospitals rather than better performance by Black physicians. A similar pattern of results was seen for racial concordance of childbearing women and their obstetricians, but given low numbers of maternal mortalities, this part of the analysis was underpowered and there were no statistically significant differences.

This analysis has limitations. Hospitalized newborns are invariably cared for by more than one physician and by other nonphysician members of maternity care teams. Furthermore, newborn race was available in the dataset, but physician race was not. The researchers relied on internet searches and images to assign race to physicians. Nonetheless, this research by Greenwood and colleagues (2020) is an intriguing first step that lends weight to the idea that diversifying the maternity care workforce may be one piece of the puzzle necessary to address the vast racial disparities in maternity care outcomes in the United States. Greenwood et al. (2020) cautioned that merely providing all infants with physicians who looks like them may help but will be insufficient, because of heterogeneity in physician practice patterns and outcomes. Additional efforts beyond just patient/physician race matching will be necessary.

Greenwood et al. (2020) did not speculate about possible mechanisms for the observed pattern of data. However, from the extensive literature on unconscious biases in the workplace, wherein without realizing it, we all tend to gravitate towards and reward people who are more like ourselves (i.e., homosocial reproduction; Pager & Shepherd, 2008; Rivera, 2012), it is possible a similar unconscious mechanism is at work in maternity care. Alternatively, perhaps culturally shared, lived experiences—assuming that an epigenetic or other life-course mechanism affects the health of neonates—allow Black physicians to genuinely provide better, more intuitive care to Black infants.

Regardless, diversifying the maternity care workforce would almost certainly improve maternal-child health in the United States in other ways. The concept of community-based participatory research explicitly calls for the inclusion of members of the target population in planning and conducting research. Why would we not do the same in the provision of maternity care? Not just including consumers and advocates but emphasizing diversity at all levels, up to and including physicians and administrators? A growing literature on diversity in science exists and suggests that better solutions to problems stem from having a diverse team working together to address them:

The ability to see the problem differently, not simply “being smart,” often is the key to a breakthrough. As a result, when groups of intelligent individuals are working to solve hard problems, the diversity of the problem solvers matters more than their individual ability. Thus, diversity is not distinct from enhancing overall quality—it is integral to achieving it. (Gibbs, 2014, paragraph 7)

The current racial and ethnic disparities in rates of maternal and infant death in the United States are certainly “hard problems.” Ensuring that a diverse a group of professionals as possible is at the table and participates meaningfully in addressing this problem should be a top priority for all of us who work in this field.

Acknowledgment

The authors acknowledge Sabrina Pillai, MPH, for assistance with the literature searches for this column.

Biographies

Marit L. Bovbjerg, PhD, MS, is an assistant professor, Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR.

Dawn Misra, PhD, MHS, is a professor and Chair of Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.

Jonathan M. Snowden, PhD, is an associate professor, Epidemiology Program, School of Public Health, Oregon Health and Science University-Portland State University, Portland, OR.