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A Presentation at SMFM Reminded Me to Check My Implicit Biases

At the beginning of every year, the Society for Maternal Fetal Medicine (SMFM) hosts its annual meeting where thought leaders from the U.S. and around the world convene to present their research. Research presented at this meeting has changed guidelines and the practice of Obstetrics around the US including, but not limited to, the use of late antenatal corticosteroids, adjuvant azithromycin in those undergoing cesareans in labor, and the ARRIVE study about elective induction of labor at 39 weeks.

Research, however, is only one of the pillars of the Society’s missions. The society also focuses on eliminating health care disparities for high-risk pregnant women by building an advocacy network.

The Society, under the guidance of their Chief Advocacy Officer, Kathryn Schubert, started the State Liaison Network which helps connect people from across the United States to find unique solutions to common problems. A recent success by SMFM’s Health Advocacy team, in conjunction with the American College of Obstetrics and Gynecologists (ACOG) and other organizations, has been the Reducing Maternal Mortality Bill passed by Congress at the end of 2018. The SLN also provides resources to leaders in the states that are working towards the development of Maternal Mortality Review Committees (MMRC). It allows people from states that are still in the process of developing these MMRCs to connect with people who have successfully developed and implemented them thereby allowing an exchange of ideas that furthers the health of our patients. People interested in developing MMRCs in their states can access this information on the website to discover where their state lies in the process and ask to be connected to people in other states that have succeeded.

The past two years have seen an increased awareness about the rising rates of adverse maternal and neonatal outcomes amongst African American women. While maternal mortality rates continue to decline in other developed countries, the U.S. notes increasing rates of maternal mortality and widening disparity between black and white women. This highlights the urgent need for us to identify and address the cause of this difference so as to improve maternal and infant outcomes for all U.S. women. Dr. Joia Crear-Perry, Founder and President of the National Birth Equity Collaborative, addressed the physicians at the State Liaison Network meeting. Their mission is “reducing black maternal and infant mortality through research, family centered collaboration, and advocacy.”

In her short presentation, Dr. Crear-Perry highlighted the interplay between historic and current institutional racism, class oppression, gender discrimination and exploitation, causing wealth imbalances which finally impact the social determinants of health leading to a disparity in disease distribution. She reminded us of the impacts of Redlining and its effect on health outcomes and infant mortality rates. But most importantly, she reminded us that language matters. Using the white opioid epidemic vs the Black "crack baby" epidemic as an example she demonstrated the roles that physicians play in advancing racist beliefs and how important it is to be mindful of not perpetuating beliefs that further health inequities.

While not explicitly in her presentation I began to think about our own implicit biases. As a chief resident I remember having a discussion with the others about how they emphasize going back to “clinic” patients and ensuring they have a reliable form of contraception prior to discharge but we did not do the same for “private” patients. While good-intentioned, this policy had a two-fold impact. An important aspect of allowing women to have reproductive choice and control is allowing them to make the choice. So, although it was coming from a good place (she is 24-years-old with five children, all of them unplanned), the final decision must be made by the patient after analyzing her own values and her family’s needs. Unfortunately, the golden rule does not apply in health care equity — it is not “do unto others as you would have others unto yourself,” but in fact, “do unto others as they would like to have unto themselves." On the other hand, not addressing contraception in a similar way with “private” patients makes assumptions about their lives which may disadvantage them. A patient with private insurance seeing the private practitioner is just as likely to be in an abusive relationship requiring discreet counseling and contraception as one on public insurance, and not addressing contraception equitably violates the ethical principle of justice – equals must be treated equally. Listening to Dr. Crear-Perry’s talk reminded me of the importance of having these conversations with our students, residents, and colleagues. These conversations allow us to identify our own biases and hopefully prompts us to work on them so we can provide the best care for our patients no matter where we practice.

The State Liaison Meeting has different speakers each year, and each year I learn a little more about myself and the work we have to do to improve ourselves, our field, and our policies to optimize the care we provide for our patients. This meeting allows me to meet with other leaders and advocates and share ideas and frustrations about regulations that negatively impact our practice. The network provides us with a family of people who are equally dedicated to reducing health care disparities and work tirelessly in their clinical work, their research, and their advocacy efforts to try and do so. And like a family everyone serves a different role or has different expertise, but everyone works together for a common goal — our patients.

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