Can Perinatal Quality Collaboratives Address Racial (In)Justice?

The recent police murders of Black men and women have forced discussions of racism and led to statements of solidarity from every medical and public health professional society. These statements, by and large, acknowledge what countless scholars and activists have been saying for decades: the root cause of racial inequities is structural racism. In pregnancy, the intersections of race and substance use are uniquely charged. For more than a century, both reproductive health and substance use have been racialized and policies of punishment deployed to systematically devalue Black motherhood, motherhood in poverty, and motherhood among people who use drugs (see Appendix, available as a supplement to the online version of this article at http://www.ajph.org).

The legacies of these histories remain visible today. The contemporary response to addiction, driven to a large extent by the association of Whiteness with the modern opioid crisis,¹ has focused on public health and treatment and shifted drug policy away from an overwhelmingly criminal justice reaction. Not so in pregnancy. State policies related to substance use in pregnancy are becoming more punitive,² a trajectory driven primarily by an increase in restrictive reproductive health statutes.³

In their article, Peeler et al. (p. 1828) examined medication for opioid use disorder (MOUD) in pregnancy and newborn withdrawal by maternal race/ethnicity using data from the Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN). Their findings highlight a substantial disparity in medication receipt: whereas almost 90% of non-Hispanic White people received MOUD in pregnancy, only 75% of non-Hispanic Blacks and 77% of Hispanics did. In fact, Black people had 0.3 times the odds of MOUD compared with White people. The rate of MOUD in pregnancy is far higher in Massachusetts than elsewhere in the United States. In a recent review of National Survey on Drug Use and Health data from 2007 to 2014, we found not only that only 35% of pregnant people with opioid use disorder received any treatment, much less medication, but we also found an almost identical disparity: among pregnant people with substance use disorder, Blacks had 0.3 times the odds of any treatment compared with Whites.⁴

ARE INEQUITIES ATTRIBUTABLE TO RACISM?

Language matters. Euphemisms, whether deliberate or not, obfuscate, and vague terms lead to vague interpretation. The authors discuss “differences” and “disparities.” They touch on “inequities,” but the most important question remains unstated: is the observed difference in MOUD attributable to racism?

The authors describe their findings as “striking,” particularly in a state where pregnant people are all Medicaid eligible and receive priority treatment access. However, unequal outcomes in the context of universal care demonstrate the limitations of “color-blind” policy in addressing racial inequities.

SUCCESSES OF PERINATAL QUALITY COLLABORATIVES

Perinatal quality collaboratives (PQCs) are voluntary multistakeholder associations, often state-based, that engage in quality improvement projects to advance maternal and newborn health care quality. Data collection and health care process intervention tend to focus on the delivery hospitalization. PQCs have had some incredible successes such as a reduction in iatrogenic preterm deliveries and, in California, a reduction in maternal mortality. Although several PCQs have the explicitly stated goal of ending (or reducing) racial disparities, it is worth investigating how this might be possible.

To this end, the PNQIN Statement About Racial Injustice is illustrative (https://bit.ly/35MOPEn). This document acknowledges inequities and calls out racism and violence toward people of color as barriers to equity “for all Massachusetts families.” They name two forward steps: (1) process and outcomes data collection by race and (2) inclusivity and diversity within the project leadership team—suggestions they concede are “basic.” Indeed, there is no mention of structural factors and no recognition of intersectionality.

ADOPTING CRITICAL RACE THEORY

A decade ago, Ford and Airhihenbuwa introduced Critical Race Theory to the public health community as a framework for addressing inequities⁵—a framework that could and should be adopted by PQCs. Central to the Critical Race Theory is the recognition that racism is not an aberration nor categorically overt; rather, it is subtle, persistent over time, and characterized by its ordinariness. In the pursuit of racial equity via public health, Ford and Airhihenbuwa argue to “center on the margins.” In contrast to the standard epidemiological approaches that begin with the majority group’s perspective, PQCs could center on the experiences on Black pregnant and parenting people. Concretely this could mean interrogating the system(s) of care from the perspective of a Black person with, for example, an opioid use disorder: what systems does she encounter through pregnancy and postpartum, and does her experience align with the data points collected (and analyzed) by the PQC?

Black people are by no means a monolith. And racism is not the exclusive system of domination and privilege. All people have multidimensional identities. And sexism, heterosexism, and ableism (to name a few) also contribute to the embodiment of health inequities⁶ The concept of intersectionality, specifically when viewed with a reproductive justice lens, highlights the holistic nature of these “markers of difference” and problematizes standard epidemiological methods of data analysis. Categories such as race, gender, pregnancy, poverty, immigration status, sexual orientation, and medical comorbidities interact in an integrative (not additive or multiplicative) fashion. Logistic regression, even when augmented by sensitivity analyses, therefore executes a leveling effect on the data and, with each turn of the model, whittles away the richness, nuance, and suffering that is the human experience.

The antiracism praxis (the iterative process by which research, practice, theory, and personal experience inform knowledge) Ford and Airhihenbuwa detail dovetails with the driver diagram method, central to the quality improvement projects that form the core of PQC work. However, to capture structural and intersectional domains, data collection must be oriented to social theory—something that can only be accomplished by centering the PQC on the most marginal rather than the mainstream.

Peeler et al. are to be commended for leveraging a PQC to investigate racial inequities in MOUD. In so doing, their work has exposed the current limitations of PQCs to address racism. The specific lack of attention to structural factors and proclivity for euphemisms distorts analysis and undermines racial justice.⁷ However, with explicit attention to racism, emphasis on the repeal of punitive policies, and application of Public Health Critical Race Theory praxis, PQCs can seize antiracism as quality improvement and thereby improve maternal and newborn health quality for all.