As unconscious bias and discrimination comes to the forefront of national conversation, it is fitting to discuss bias in the healthcare system. Though we pledge to treat all patients fairly and to the best of our capacity, regardless of their background, increasing evidence suggests that healthcare providers, too, have bias and exhibit behaviors perceived by their patients as discrimination.
In a study published in the September issue of Medical Care, Attansio and Kozhimannil describe how in maternity care, perceived discrimination can lead to decreased attendance at postpartum healthcare visits. Though this issue matters in all settings, pregnancy and postpartum care is salient.
Women’s reproductive healthcare includes a several healthcare visits to assess the appropriate course of pregnancy, but after birth, ACOG recommends a visit within 6 weeks to address potential complications of the pregnancy and delivery, as well as to discuss future reproductive goals. This is a vital opportunity to not only further clinician-patient rapport, but also to prevent long-term difficulties with issues such as diabetes, hypertension and incontinence.
In this study, participating women, via the Listening to Mothers III Survey, responded to the question, “During your recent hospital stay when you had your baby, how often were you treated poorly because of…” Options included race/ethnicity, health insurance status, and “a difference of opinion with…caregivers about your right to care for yourself or your baby.” The response options were always, sometimes, usually, or never.
The dependent variable was whether or not the participating women had a postpartum visit with a qualified maternity healthcare provider, including an OB-Gyn, a family practitioner or other physician, or a midwife within 8 weeks of giving birth. The results were analyzed and stratified based on race, socioeconomic status, insurance type, age, obesity, hypertension, gestational diabetes, provider type and delivery mode.
Previous research by Vedam et al, among others, has found that women from racial/ethnic minorities experience higher rates of pressure from healthcare providers to accept interventions they may not want, including epidurals, c-sections and inductions. Furthermore, there were increased rates of reported racism and discrimination in minority women. This culminated in an overall decrease in the rate of “respectful maternity care” for women of minority backgrounds.
In line with these findings, Attansio and Kozhimannil found that minority women were less likely to have postpartum healthcare visits, citing discrimination as a factor. Similarly, women who experienced health complications during pregnancy, including gestational hypertension or diabetes, women who were first-time mothers, and women who were uninsured reported increased rates of discrimination. Race-based discrimination and insurance status-based discrimination had the largest impact on healthcare follow up—nearly twice as many women who experienced discrimination did not have postpartum medical care, compared with women who did not report discrimination.
An interesting conclusion discovered through this study is that non-OB/GYN providers had higher rates of reported perceived discrimination by their patients than did OB/GYNs (P<.001). This is an area for further consideration—could other non OB/GYN physicians benefit from additional training, in particular with reproductive healthcare, to address potential unconscious bias?
The concerns with reduced postpartum follow-up are multitude. By losing the opportunity to address potential complications, healthcare providers miss out on early intervention, which can not only improve overall outcomes, but also reduce costs for many health conditions. Furthermore, contraception/future childbearing goals are an important area of discussion for women, as women may begin menstruating, and be able to become pregnant, soon after childbirth. Depending on whether or not this is a desired result, women should consult with their healthcare provider to discuss their options with safety and satisfaction as paramount.
This study is not without limitations. The data are largely based on self-report by patients, without input from the corresponding healthcare providers. Because bias has two individuals in play—the individual experiencing the bias, and the person who is exuding the bias—it is critical to understand both sides, especially to begin to design solutions. Furthermore, without information from clinicians, it is difficult to know whether the type of clinical setting (i.e. private hospital, community hospital, etc.) may have played a role, or if data are skewed by patient characteristics.
On a positive note, the study includes a sample of women representative of the population of US women of childbearing age. This increases the generalizability of the results. At the same time, discrimination itself is a nebulous concept, and lends itself to many definitions based on who is asked to define it. For this reason, it is difficult to assess the true burden of discrimination, and what discrimination is being perpetrated.
In terms of future directions, healthcare providers can benefit from sensitivity and awareness training. As a rising physician, I am acutely aware of the fact that I may hold opinions based on my own experiences that influence the way I see the world. While these opinions feel harmless to me, I do have an index of concern for the impact it may have on the care I provide for my patience. This is an area that is not often considered in medical education.
In order to truly address the whole patient, and to optimize individualized healthcare, we must be able to learn and grow throughout the course of a career. Ultimately, evidence suggests that women who perceive discrimination are not seeking postpartum care. Further research about how discrimination manifests in the healthcare system, and what can be done to combat its deleterious effects, is needed.