Expanding health equity and anti-racism in maternal and infant care
Michelle Ellis, RN, perinatal nurse in the labor and delivery and postpartum units at UCLA, has seen both sides of the patient experience – providing care and receiving it.
In 2019, she was hospitalized for uncontrolled bleeding due to an ongoing gynecologic health issue. It was the experience of seeking the nearest emergency care in Orange County, Ellis recalls, that showed her what it was like for patients, particularly Black women, to feel unseen and unheard.
“I told the (ED) doctors on call that I was bleeding a significant amount, and every time I attempted to walk, I would get very dizzy, lightheaded and have shortness of breath, which caused me to faint multiple times at home,” Ellis says. “After a physical exam, some lab work and many consultations, the gynecologist on call decided I was stable enough to go home. The recommendation was a follow-up with my doctor in three days.”
Ellis insisted she did not feel comfortable with leaving, as she was still bleeding and unable to walk without assistance. After several conversations, she sought another opinion by calling the OBGYN residents lounge at Ronald Reagan UCLA Medical Center.
“I handed the phone to the on-call gynecologists and they had a discussion regarding my situation,” Ellis says. “After that conversation, everything changed.”
Ellis was recommended to stay overnight to monitor the bleeding. In the morning, she was rushed to the Intensive Care Unit (ICU) because her heart beat had become unstable and her level of hemoglobin, a protein that carries oxygen throughout the body, had dropped to 4.8 grams per deciliter of blood. For women, the normal range is 12.0 to 15.5 grams.
She had to have an emergency procedure followed by eight days of hospitalization.
“I can't help but wonder, what would have happened if I had not been insistent on staying in the hospital? What if I did not work with OBGYN residents at UCLA and been comfortable enough to call them?” Ellis says. “Would I have made it through that weekend if I went home? Would I be alive now to tell it?”
Ellis says when she began to learn more about Black mothers not feeling heard when they speak with their doctors, it “struck me very deeply as a Black woman who had to fight for the care required to stay alive,” she says.
“Care is meant to be easily accessible to all.”
While the national maternal mortality rate has continued to rise over the past decade, California’s rate has declined by 55%.
Despite this reduction, Black and Indigenous birthing people experience three to four times the average rate of maternal mortality compared to white mothers (40.8 and 29.7 vs. 12.7 per 100,000 live births), according to the California Maternal Quality Care Collaborative and the Kaiser Family Foundation.
In 2019, California passed SB-464, the Dignity in Pregnancy and Childbirth Act, which mandates implicit bias training for all health care professionals working in perinatal services. The bill also contains state requirements for reporting and tracking outcomes for birthing people, and mandates hospitals to provide patients with information on how to file discrimination complaints.
At the height of the national outrage and protests seeking justice for the murder of George Floyd, many Americans began to discuss racial inequity, its systemic roots and how it impacts workplaces. The UCLA Health Perinatal and Neonatal teams moved to develop coalitions and working groups to assess their own departmental biases in order to fulfill the requirements of SB-464 and improve birth equity.
Debbie Suda, RN, MN, senior director of Mattel Children’s Obstetric Services, says a distressed colleague confided in her about online microaggressions from other colleagues that were affecting working relationships. Suda was asked if she could address the staff about microaggressions during their next meeting.
“I felt to not address it would be disingenuous,” Suda says. “I wanted to provide a situation where we could talk as a staff and ask, ‘How do you feel about this, what’s your reaction to that, how does this translate into the workplace and patient care?’ It was a vehicle to start the conversation.”
In an open forum following their monthly meeting, staff discussed the Black Lives Matter protests and their impact, and the fear and trauma that Black people experience on a daily basis.
This conversation and the initiative to improve maternal and infant mortality for Black, Indigenous and people of color (BIPOC) sparked the formation of the Perinatal EDI Coalition, a group comprising 80 members including physicians, nurses, obstetrician-gynecologists, anesthesiologists, pediatricians, midwives, administrators, social workers and others.
Ellis was initially skeptical about the coalition, she says.
“Last summer a lot of corporations and institutions were trying to do equity and inclusivity work and I didn’t know what to expect from it,” Ellis says. “I talked to a couple of staff members who are also Black and a lot of them didn’t want to join the coalition.”
Ellis says she felt the coalition was doomed to fail if it didn’t have representation from people of color, so she volunteered to join.
“I spent the first few meetings listening and observing,” she says. “I was actually very surprised by how much of an appetite there was from other staff members across disciplines, who wanted to know how they can change things and make a difference.”
Ellis says the first few months consisted of increasing awareness of the coalition throughout the departments.
Katie Siedel, MPH, MSW, director of Women’s Health at UCLA, was looking for ways to implement the requirements from the California Dignity in Pregnancy and Childbirth Act. She joined the coalition and made it her first priority to meet the state mandate of required implicit bias training for all perinatal health care professionals. The training was ready and made available to all perinatal services employees in January 2021.
Additionally, Siedel and Mya Zapata, MD, obstetrics service chief at Ronald Reagan UCLA Medical Center, collaborated with the California Maternal Quality Care Collaborative to implement the QI pilot initiative, a survey on birth equity.
The ongoing survey will anonymously collect data from patients in the postpartum unit, says Dr. Zapata, and the findings will help “ensure we have a good experience for every patient no matter their background or what they look like.”
In December, the group created a document called “language matters” to address patient descriptors used during bedside handoff or in physician-to-physician reports.
The flyer contains a column of terms and phrases with negative connotations and a column for possible alternatives, and aims to bring awareness to the way patients are talked about with the goal of “having a neutral assessment of the patient,” Ellis says.
Suda says residents taught her that the term “drop-in,” when referring to patients that come from county clinics, can have a negative connotation. When a nurse or health care professional uses this term, it evokes a bias or stereotype that they may associate with patients from county clinics.
“I didn’t recognize that this term had a different meaning to a different audience,” Suda says. “It’s wonderful that we’re having these ‘aha’ moments and we’re going down this EDI journey together.”
The Coalition also has created three focus groups – faculty practice, inpatient nurses and ambulatory staff – to allow participating members to explore questions about racism in health care and experiences among BIPOC patients and staff in a safe and inclusive environment.
The focus groups “allow people to speak freely without having their supervisors or anyone in their unit having to know how they feel,” Suda says.
“I think what I find is that people are at least more willing to listen, even though they may not be willing to share. I think they are maybe more open to the fact that this is something that we should talk about, learn about, educate ourselves about and try to do something about.”
Ellis says she wants the UCLA Health System to know the commitment the Perinatal EDI Coalition has made and continues to make to its patients and their families.
“We're working hard,” she says. “We're really working on changing the culture on our perinatal unit to affect change and better serve all patients.”
Learn more about the HEDI initiative at UCLA Health.