You Can’t Have Quality Without Equity
Why It Matters
The greatest impact of any public health crisis is felt most deeply by populations already experiencing inequities, causing additional trauma and harm as care gaps widen. Joia Crear-Perry, MD, is the founder and President of the National Birth Equity Collaborative. She is also a member of the Advisory Network for IHI’s Better Maternal Outcomes: Redesigning Systems with Black Women initiative, funded by Merck for Mothers. In the following interview, Crear-Perry explains the importance of being explicit about race and racism to address health equity and create better outcomes for every woman and her family. This guidance is applicable in any context, but is especially important during the COVID-19 Pandemic.
What are your biggest concerns about black maternal health during the COVID-19 pandemic?
I'm concerned that the added trauma and stress [of the pandemic] that we are feeling across the globe will increase the risk of harm to black women.
What guidance can you offer providers and organizations who are trying to address birth equity during this public health crisis?
Providers and organizations need to build trust with black birthing people so they can thrive during birth. This means ensuring they have access to the social support and trusted provider of their choice. That may have to be done electronically at this point [to maintain physical distancing], but it is essential.
What resources would you recommend to promote black maternal health right now?
How do you define birth equity?
Birth equity is the assurance of the conditions of optimal births for all people. This means we all need to be willing to address racial and societal inequalities in a sustained effort. We can’t do this in a single rapid cycle improvement effort. We have to have multiple, quick rapid cycle improvements for all to thrive.
Why is it important to make the distinction between health disparities and health inequities?
In the dictionary, disparity just means difference. Using the word inequity makes it clear that we’re talking about injustice. Talking about “health inequities” instead of “health disparities” helps illustrate how we create differences that we can avoid by prioritizing justice and fairness.
For example, the differences when comparing birth outcomes between black and white mothers is well-documented in the United States. The rate of black maternal death is three to four times higher than the rate for whites.
Talking about inequities forces us to ask questions: How did we get here? What were the systems, structures, and the policies that created these inequities? Asking these kinds of questions help us understand the historical and current context that have led to a hierarchy of human value based upon skin color. If you center the people who are the most impacted [by health inequities], and then build from there, you will get to equity. You can’t start in the middle and then add on.
What do you say to those who may wonder if centering improvements in maternal health around black women means ignoring other women?
The people who get most concerned [by this approach] are in communities that are accustomed to being the most centered. They’re used to care being designed for them. They feel a sense of loss, so we must first honor that sense of loss and recognize it.
We then have to be clear that, if we center black women in this conversation around maternal health and get equity right, we will end up improving maternal health for everyone. If we get better at listening to black women, we will get better at listening to all women.
We know that across the United States, no matter your race or age, all women are not being listened to enough. But we have to acknowledge that we specifically don’t listen to black women. The data shows that we often ignore their pain and we don’t evaluate their hypertension in a timely manner, for example. But once you fix a problem for a group [that is experiencing inequity], then everybody else will do better.
An example of that is curb cuts. One of the results of the American with Disabilities Act was the creation of curb cuts in sidewalks. These were originally meant to support persons with disabilities, especially those using wheelchairs.
But we all benefit from curb cuts. We use them when we’re pushing a baby in a stroller or when we’re pulling wheeled luggage. We acknowledged that people with disabilities had a harder time moving around their neighborhoods. We created a way to make that easier. It’s a good example of what it means when you center the people who are the most impacted by a problem. Everyone ultimately benefits.
When talking about maternal mortality, you have said, “Race is not a risk factor. Racism is.” Would you say more about what you mean?
I say this because it’s not what I was taught when I was trained. As an OB-GYN and as a person who works on policy and advocacy, I’m still learning how to articulate the impact of racism on our bodies.
I was taught in medical school that there were three races: Mongoloid, Caucasoid, and Negroid. I was told that we had disparities because we are different human beings. But the truth is that there is no genetic basis for race. Genes might influence what we look like on the outside, but the research tells us that I’m more likely to be genetically similar to a white person than a fellow black person.
So, what is the real reason for differences in outcomes? We know that race is a social and political construct created around a hierarchy of human value. I’ve learned from experience that, because of my black skin, I don’t always know how someone is going to treat me. Worrying about that has a physical impact. Chronic stress is linked to heart disease and preterm birth, for example. So, that’s an example of how racism is a risk factor.
There are also structural reasons for differences in outcomes rooted in racism. Many people see Medicaid as a benefit for black people, even though we know that there are many people of all races and ethnicities who are on Medicaid. Medicare, on the other hand, which is a benefit you get when you retire, is seen to be something that benefits many white people, so it’s a benefit you get without controls put on it by each individual state. Many providers don’t accept Medicaid. This means large numbers of people don’t necessarily have access to the best care. That’s not interpersonal racism. That’s structural racism.
What will it take to create a more equitable health system?
A lot of people tell me, “Joia, you’re not going to end racism” because they know I believe that ending racism will lead to more equitable health. Ending patriarchy would also lead to more equitable health.
But the truth is that we don’t need everyone to stop being racist. We do need to hold individuals and institutions with power accountable. We need them to recognize that the status quo is not acceptable and that they can transform these systems. For justice — and health equity is about justice — you need movement, organizing, and a cultural shift to believing that we should all be able to thrive. When leaders at the top in health care, public health, research, and government create a cultural expectation and accountability around ending racism in their institutions, change will follow.
What have you learned from co-designing improvements to maternal health?
When we’ve done Equity Action Labs with IHI where we’ve invited the community in to co-design improvements to care, the community said to us, “We want all of the providers in this hospital to understand implicit bias and structural racism.” This is where co-design is so important because I don’t think we would have started with that focus without getting that input. And the community was clear that it was important to do more than spend a few hours in one training. They want our hospitals to think about this as a lifelong culture change.
The other important point about doing these Equity Action Labs with IHI is that [they prove that] equity can be a part of the quality improvement movement. There are so many places I go where people think of equity as one strategy and QI is another. There is no quality without equity. If only some people benefit from the improvements you make, how can you say you’re providing high-quality care?
For example, there are places that have done a great job of improving their outcomes for maternal health. The state of California is a great example, but the difference between outcomes for black women versus white women increased in the years since they started working to improve the quality of care for pregnant women.
Let’s unpack this. California has focused on using certain clinical toolkits for things like providing treatment within an hour of diagnosing a pregnant woman with high blood pressure. If a California hospital didn’t look at its data by race, it might look like they did well with that.
But when they looked at the data by race, they saw that black women do not get this treatment in a timely manner. One possible explanation for this is that many of us assume that black women always have hypertension and so we don’t take it seriously when we see it. We’ll say, “Oh, it was only 150, 160. She’s black. Let’s wait.” The next thing you know, [the patient] is in the ICU seizing because of our own biases. This is why it’s so important to collect and analyze race and ethnicity data until we stop seeing differences by race and ethnicity. If you don’t, you don’t know for sure that you’re providing better care [for all patients].
If you don’t go deeper, if you’re not willing to go looking for inequities in care, you’re going to assume everything is fine when it’s not. We all have blind spots. We need to be willing to figure out where they are and do something about them.
Editor’s note: This interview has been edited for length and clarity and was updated on April 9, 2020.