Insights

The racial implications of medical debt: How moving toward universal health care and other reforms can address them

By Andre M. Perry, Joia Crear-Perry, Carl Romer, and Nana Adjeiwaa-ManuOctober 05, 2021

Obstacles tied to how health systems conceptualize and provide care have resulted in many people feeling silenced or disrespected in their birthing experience. We are in a crucial time where we can rethink our systems and provide Respectful Maternity Care (RMC).

A 2022 March of Dimes report shows the number of counties in the United States categorized as maternity care deserts increased by 2% since 2020. More than one-third of all counties are designated as maternity care deserts, mostly in rural areas. Seven million women live in areas with limited or no access to maternity care services.

Did You Know…

  • Black women experience worse reproductive, prenatal, and postpartum health outcomes than any other racial or ethnic group.
  • Even when accounting for social determinants, Black women die at 2.5 times the rate of their White counterparts.
  • More than one-third of childbearing people in maternity care deserts are people of color.

Maternity care deserts are just one example of how health systems are failing birthing people, especially those from Black and Indigenous communities. Respectful Maternity Care provides a framework and an opportunity for healthcare systems to better their health outcomes. Health systems play a critical role in determining the type of care birthing people receive. By changing the culture surrounding care provided, institutions can be transformed to better benefit who they serve.

The push for Respectful Maternity Care is not only a national effort. The Global RMC Council, born out of initiatives from the White Ribbon Alliance, includes 450 people from 45 countries. To supply health systems with tools to provide respectful, high-quality care, the council incorporated RMC principles into various curriculums and initiatives around the world.

As part of the National Birth Equity Collaborative’s Respectful Maternity Care webinar series, experts explored how health practitioners and health and hospital systems can improve and implement respectful maternity care. Expert panelists included: 

  • Moderator: Susan Perez, Researcher at the National Birth Equity Collaborative
  • Elena Ateva, JD, Advocacy & Communications Manager at White Ribbon Alliance
  • Joy Lewis, MPH, MSW, Senior Vice President of Health Equity Strategies and Executive Director of the Institute for Diversity and Health Equity at the American Hospital Association
  • Jennifer Villavicencio, MD, FACOG, Lead for Equity Transformation at the American College of Obstetricians and Gynecologists
  • Alzen Whitten, MPA, Director of the Maternity Hospital Quality Improvement Network at the NYC Department of Health and Mental Hygiene

Having solution oriented discussions allows for healthcare providers and systems to implement changes and create tangible and effective changes.

Solution 1: Acknowledging that structural racism and interpersonal racism create a culture where White supremacy and physician hierarchies are mutually beneficial.

For systems to implement Respectful Maternity Care effectively, they first need to make structural and cultural changes. Healthcare systems were created under ideologies of racism and dominance; we must acknowledge and recognize the ways it continues to show up in our systems today.

“It took a lot of time talking to the providers about racism and how to incorporate different things and just having them look at themselves. There is a centrality of Whiteness in institutional cultures and policies, as well as the strategies for talking about racism and unconscious biases.”

  • Alzen Whitten

“Allowing and teaching our colleagues to create more welcoming spaces for historically marginalized people, I think, is a huge business case for helping with burnout and retention. It’s a lot easier to take care of patients when you do it through a respectful care model. I want to be clear that when we talk about racism contributing to racial inequities and disparities in healthcare, we’re talking about interpersonal racism and unconscious bias at the bedside. But, far more, we are talking about racism at the systemic and structural level.”

  • Jennifer Villavicencio

I think we all acknowledge that culture is probably one of the harder things to shift, and it won’t change overnight, but it’s that intentionality and that commitment from across the organization that I think is important to move the needle.”

  • Joy Lewis

“At the AHA, we’ve moved away from the term cultural competence, and we now talk about, how do you render care with cultural humility? So that’s a much more open stance, a stance where you’re questioning more and you’re wanting to learn and you’re wanting to elicit feedback, versus a position of mastery or achievement.”

  • Joy Lewis

“Women were asking us to acknowledge systems of oppression like racism and sexism and colonialism. Women were very clear that they know when they’re discriminated against and they know that they receive different services because of who they are, what they look like, what they sound like.”

  • Elena Ateva


Solution 2: Healthcare systems need to center and connect with the patient to reduce power dynamics.

For far too long, healthcare systems operated under a culture that centers Whiteness. This shows up in the way healthcare practitioners treat and serve their patients. To combat that power dynamic, it is crucial to center the voices of those who have been systemically and culturally silenced.

I think when patients and providers meet, there is an understanding about what is expected, and I think there’s just a lot of work to be done. It takes time. It’s not something that can be done overnight. It might take a few months, or it might take a few years until there’s common ground.”

  • Alzen Whitten

“I think too often we swoop in, and we assume we know what the outcome is that folks are after, or what the best strategy might be. We need to lean in way more than we currently do to the knowledge, recognizing that patients are the true primary care providers over their own bodies, and really put the patient in the center of that care team.”

  • Joy Lewis

I have been taught as a physician, and all healthcare professionals are taught that we’re the experts in the room and we’re there to provide the expertise to the patient and they’re there to receive it, that’s a one-way very imbalanced power dynamic that we understand to be problematic. I think relearning how to engage with the person in front of you, to who you are offering care, is to recognize that there are two or three experts in that room. There’s the nurse, there’s the doctor, and there’s the person in front of you, and they all bring something to the table.”

  • Jennifer Villavicencio

“Women are saying that they want to be accepted as experts on their bodies. They know their bodies best, and they know what’s happening when it hurts or when it doesn’t hurt. In training, they can participate in provider associations or regulatory bodies and provide input on what is best for them based on that, their knowledge, and their experience.”

  • Elena Ateva

 

Solution 3: Healthcare systems need to cultivate a community of care.

We often treat the assurance of good health as an individual process; however, engaging a patient’s trusted community is necessary to improve health outcomes. When healthcare systems incorporate communities into their care, they can address multiple concerns and develop solutions that advance the patient’s goals and needs. 

When I learned how to provide respectful care and how to engage in a team-based collaborative model with midwives and doulas, the amount of professional fulfillment that I had, the amount of relief that when I step onto a labor floor, I’m not by myself. I have a team with me. I have doulas that will stay in the room and help that patient who’s going through a hard time, and then I can run to the next room… I have midwives who can push with patients for hours, and I can go and do the C-section that I need to do. There is an immense amount of relief there.”

  • Jennifer Villavicencio

You have to infuse the community, promoting patient advocacy and empowerment. We’ve done this at the New York City Department of Health by really looking at community-based organizations and having them as our birth justice hubs. We work with community members around the city, which we call birth justice defenders, who are passionate about birth justice in order to really educate other community members about what their rights are.”

  • Alzen Whitten

“Women are also very clear that they want to be taken care of by people who look and sound like them. For example, indigenous women in Mexico were talking about the need to be taken care of by indigenous midwives from their communities who understand their culture, and understand where they’re coming from, what they care about. At the end of the day, childbirth is not a medical event. It’s a social event..”

  • Elena Ateva


Interested in learning more about the National Birth Equity Collaborative’s Respectful Maternity Care Initiative? Click here to access the RMC webinar series.