Battling racism is the Rx for safer and healthier moms and babies, educator says.
Disproportionately high mortality rates for black women aren’t caused by genetics, says an expert in healthcare disparities that affect maternal care; the cause appears to be systemic racism.
Black women can be “healthy as a marathon runner” and receive ample prenatal care, yet they still face a higher maternal risk, says Mykale Elbe, DNP, APRN, FNP-BC, director of the MSN Nurse Practitioner Program and Assistant Professor of Nursing at Maryville University in St. Louis. Elbe, also an active family nurse practitioner at Mercy Health, has devoted a large part of her practice to minority care.
The maternal mortality rate for black women in 2021 was 69.9 deaths per 100,000 live births, or 2.6 times the rate for white women, at a rate of 26.6 deaths, according to the U.S. Centers for Disease Control and Prevention.
Studies and articles have borne out that “racism, classism, and gender oppression are at the root of unequal health outcomes—not simply the conditions in which people are born, grow, live, work, play, and age,” according to a National Institutes of Health’s National Heart, Lung, and Blood Institute article.
Elbe spoke with HealthLeaders about these troubling numbers and what nurses and nurse leaders can do to help lower them.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: The death rate among black Americans has been substantially higher than the rate for white women for decades. What are some reasons that such an imbalance has persisted for so long?
Mykale Elbe: It's something that we have seen for generations. People in healthcare have known about it for a while, but with the pandemic data and higher death rates, it's brought some more attention to it. Studies have looked at this and we have seen that despite their socioeconomic status, their insurance status, or how many prenatal care visits they get, there is this higher risk factor for poor maternal outcomes and even fetal outcomes. They have higher rates of NICU admissions and preterm birth.
Some of that can be genetics, but some other studies have noticed if you are a first-generation immigrant from Africa, you do not have this predisposition. You are at the standard mortality risk factors as a Caucasian or other race female, so the thought is, this is an effect of the American culture around underlying bias and racism and the stress that women of color live with day to day around racism, and the underlying stress that they may not even themselves know that they're dealing with. Is that putting increased stress on their bodies and leading to increased mortality rates? They can be healthy as a marathon runner and active and have no underlying diseases, but they still have a higher risk.
Mykale Elbe, DNP, APRN, FNP-BC, director of the MSN Nurse Practitioner Program / Photo courtesy of Maryville University
HL: Unconscious bias, or maybe conscious bias, among practitioners causes some women to skip pre-natal checkups. What is the impact of that?
Elbe: It's not just for prenatal; it’s even in healthcare in general. We do see African-American women and African-American patients in general, but there is this concern that with the stress that’s put on them, maybe they’re not as vigilant on following up with their healthcare providers routinely. And, if you are living in a predominantly African-American neighborhood, you have less healthcare services available to you.
HL: Healthcare is making efforts now to increase diversity in its workforce, including nurses. What effect will that have on these disturbing outcomes?
Elbe: The hope is it will, but until we see that, it’s hard to say. When I first started as a nurse practitioner, I was the minority at the practice where I worked and most of our providers were providers of color. But it's still that access to care that creates limits. We have to get providers to open practices in areas that are predominantly serving those communities of color to see if we can increase that.
HL: What should be nurses’ responsibilities in addressing healthcare disparities, particularly when you say that it's not so much social determinants as ingrained racism?
Elbe: Making sure our programs educate about that. In my class, I have my students watch a video that addresses healthcare disparities, and it is amazing how many of the working nurses we have in our program respond with, “I'd never thought of this.” We have to make sure in our nursing programs—in our health professions—we are educating our future providers about microaggressions and how to address microaggressions that they may not even know they have. We also have to provide education about diversity, equity, and inclusion, and make sure students are doing self-reflections and are not afraid to discuss this topic.
HL: How well do nursing schools, in general, address this issue?
Elbe: Every time this comes up, even at Maryville University, the consensus is, “Oh, nursing has got this,” but do we have this? It’s one of those things where we need to be more active about, aware of, and make sure we're more diligent. I know the National Organization of Nurse Practitioner Faculties (NONPF) has a significant interest group on diversity, inclusion, and equity, and we just put out a toolkit on how to educate about microaggressions and addressing microaggressions in nurse practitioner education.
We have to be more diligent about that. As healthcare providers, we're getting better about including that in our education, but we have to make students aware and thinking about those microaggressions and diversity inclusion aspects of care—not just when it comes to race but also to gender and sexual orientation to prepare our future providers to truly be ready to help patients of every background.
HL: What can nurse leaders do now to begin lowering the maternal death rate among black Americans?
Elbe: Having open dialogues with their staff to make sure that we are aware of our own microaggressions and microbiases that we may not think about, but they can be there. We need to make sure that we, ourselves, are self-reflecting and addressing them so that we're not producing bias that make patients feel uncomfortable because if a patient feels uncomfortable with their healthcare provider, they’re not going to want to come back. That’s going to stop them from seeking healthcare.
“We have to make sure in our nursing programs—in our health professions—we are educating our future providers about microaggressions and how to address microaggressions that they may not even know they have.”
— Mykale Elbe, DNP, APRN, FNP-BC, director, MSN Nurse Practitioner Program, Maryville University
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
Systemic racism, which creates underlying stress, appears to be the cause of higher maternal mortality risk in black women.
The maternal mortality rate for black women in 2021 was 2.6 times the rate for white women.
Nurses and other clinicians must self-check to ensure they’re not producing bias that makes patients feel uncomfortable.