Tackling Systemic Racism in Maternity Care

(Illustration by Nyanza D)

Maternal health is drastically affected by systemic racism, not just in the United States but all around the world. In Brazil, data from the Ministry of Health indicates that while maternal mortality decreased by 55 percent from 1990 to 2013, it has since increased annually, with more than 64 recorded deaths per 100,000 children born in 2017. Despite the overall improvement for all mothers, 2018 data from the Ministry of Health shows that more than 54 percent of all maternal deaths are among Black women. In Brazil, Black women have twice the chance of dying during pregnancy and childbirth than white women.

Black scholars and activists have shown the effects of racism in health care in Brazil, particularly in the inequities in maternal outcomes. At a maternal-health level, systemic racism shows up in many ways: Black women receive less anesthesia during birth, are subject to discriminatory and obstetric violence through microaggressions by health-care workers, and have less access to prenatal care. The intersection of classism, poverty, and racism contributes to why women are dying in childbirth, in situations that are mostly preventable.

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In 2013, Brazil launched an agenda to address systemic racism in the public health-care system. Its Política Nacional de Saúde Integral da População Negra (National Policy for Health and Healthcare for the Black Population) promotes policies that formally categorize race and ethnicity, with the goal of documenting disparities in health care and instantiating race-conscious health-care programs.

But while policy is important, translating it into hospital protocol and practice is very difficult. Hospitals have a multitude of priorities and demands from the national and/or state governments, and therefore must choose to act on policy priorities set by policy changes. Furthermore, the lack of understanding of structural racism at the interpersonal and institutional levels has affected how quickly hospitals enact this policy. American grassroots-organizational scholars Kenneth Jones and Tema Okun’s workbook on white supremacy culture enumerates the factors that counteract the prioritization of policy to address systemic racism: paternalism, individualism, and power hoarding by individuals with decision-making authority.

Paternalism plays a role in setting priorities for system-wide actions and reforms in Brazil’s hospitals. Those with power generally make decisions without consulting patients; health-care workers; or experts from Black, Indigenous, or underrepresented populations. In the Brazilian health-care system, solutions are designed by established experts rather than by those on the frontlines and/or with lived experience—that is, the people whose lives are directly affected by these solutions.

With the support of Merck for Mothers, a global initiative to reduce maternal deaths, the Institute for Healthcare Improvement (IHI) and The Excellence Office of Hospital Israelita Albert Einstein are working together on a collaborative called Abraço de Mãe to reduce maternal mortality in 19 public-hospital, maternity-care units across Brazil. The initiative’s particular focus is on addressing racial bias that adversely affects the care and health outcomes of Black and Indigenous pregnant women.

The participating hospitals have two goals. The first is to reduce maternal mortality related to the three most prevalent, life-threatening conditions (LTC) for all pregnant women (hemorrhage, eclampsia, and sepsis). The second is to reduce maternal mortality through the lens of anti-racism, with a focus on improving hospital teams’ understanding of structural racism and ability to acknowledge social vulnerabilities so that they can provide equitable care.

Creating Systemic Change

Changing the culture of maternal care in Brazil—to one where hierarchies are less pronounced, patient voices are heard, and collaboration occurs—requires addressing systemic racism. Strong facilitation and transformation tools can help build trust and provide actionable mechanisms for hospital teams. The Abraço de Mãe collaborative in Brazil uses IHI’s Model for Improvement, the BTS Breakthrough Series Collaborative Model, and the IHI Psychology of Change Framework to bring forth a structured process for change in its participating hospitals.

The Model for Improvement asks three questions to determine how to create systemic change:

• What are improvement teams trying to accomplish?
• How will we know that a change is an improvement?
• What change can we make that will result in improvement?

These questions drive change by helping improvement teams set an aim, establish measures to determine if a specific change leads to an improvement, and select evidence-based changes that are then tested on a small-scale using Plan-Do-Study-Act (PDSA) rapid-learning cycles. PDSA cycles are small, iterative tests that enable teams to learn on a small scale before implementing changes more broadly throughout the organization.

Currently in Brazil, health-care workers on the frontlines and others with lived experience—especially those on the margins like Black and Indigenous mothers—have little-to-no decision-making power. As part of the Model for Improvement, IHI examines how power can be distributed to nurses, technicians, mothers, and other staff through improvement teams that focus on learning, distributing tasks, and incorporating a process of centering patients in their care. Abraço de Mãe has incorporated the Model for Improvement, which includes actively working with community groups and the health-care providers to improve the system. The model enables maternity unit teams to become more comfortable with change by testing revisions to care processes and learning on a small scale, and then refining these processes using iterative PDSA cycles before implementing the changes more broadly.

The core of the IHI Psychology of Change Framework is the idea that to improve the system there must be intentional ways for people to become involved in decision-making processes. Creating the conditions for people to have the courage to stand up and speak their mind in order to change the system needs practice and intention. The tools in the framework provide the foundation by which health-care leaders can build their emotional intelligence to better understand how to distribute power, codesign with those most vulnerable in the system, adapt in action, unleash intrinsic motivation of the staff, and coproduce change through authentic relationships. These five components provide the emotional tools that hospital leaders need to navigate the complexities of tackling systemic racism in their maternity units.

Adopting a Liberatory Consciousness

Brazil is steeped in the myth of “racial democracy,” or what historian Ana Lucia Araujo explains as the myth of harmonic racial relations in Brazil enforced by the government, which espouses the rhetoric that all people are equal even though ample data proves the contrary. Addressing the systemic racism in Brazil’s health-care system is a multifaceted endeavor that requires individuals to understand that “racial democracy” is a fallacy.

In Abraço de Mãe, participating hospital teams codesigned their approach to confront racism in maternity care with health-care workers, mothers, and social workers using social justice advocate Barbara Love’s concept of “liberatory consciousness.” This consists of four steps to undo the socialization of racism in the form of conscious and unconscious biases: awareness, analysis, action, and accountability.

Abraço de Mãe’s equity and anti-racism operational group focused on interventions to help health-care workers bring theory into action and to learn through testing evidence-based interventions to reduce racism within systems. These interventions focused on understanding maternity through a racial equity lens, and included testing and modifying the processes each maternity unit had in data collection and analysis by race; trainings that demonstrated how structural racism affects maternal outcomes; trust-building exercises with mothers; community-building events with organizations that focus on Black and Indigenous maternal health; and the creation of a multidisciplinary team to respond to women suffering from additional forms of oppression, such as poverty.

The first two steps of creating a liberatory consciousness—awareness and analysis—were done through a process of reflection and constant coaching. The steps of awareness and analysis were developed through interventions that focused on recognizing racism as a problem in Brazil. The collaborative, for example, led an anti-racism training session in August 2019 for maternal-health leaders and social workers in the hospital teams. This training explored how history shaped the current system and the myth of racial democracy through a personal, interpersonal, structural, and institutional lens. The monthly coaching sessions meanwhile gave leaders an opportunity to create awareness and analysis in community. The stratification of data by race enabled teams to see the inequities in the system, helping them to build the awareness and analysis of their microsystem in ways that allowed the production of specific pathways forward toward action.   

In March 2021, all 19 maternal-care units participating in Abraço de Mãe created action plans to confront racism in their systems. These focused on the five primary drivers for change, with the aim of achieving transformation at each level of the system. The idea was to create a liberatory consciousness, not just on an individual level but systemwide. This experience not only has been a personal journey for all involved, but also has led to system and interpersonal transformation that has prioritized maternal care centered on equity. The five primary drivers include:

1. Developing communication and education strategies that deconstruct anti-Black stigmas and prejudices, and that reinforce a positive image of Blackness in Brazilian culture, health, and health care by gaining a clear understanding of structural racism and its history.
2. Including ongoing accountability processes for leaders on equity, anti-racism, and inclusive working environments.
3. Strengthening the participation of social movements and Black and Indigenous community organizations to inform the co-design of care in the system.
4. Establishing the main processes that allow for equity and anti-racism work to continue without burdening the maternity-care team with more work.
5. Improving the quality of Brazil’s national public health-care service information systems, Sistema Unico da Saúde, regarding the collection, processing, and analysis of data disaggregated by race, color, and ethnicity.    

These five change concepts help leaders guide transformation focused on equity. Tackling systemic racism in maternity care in Brazil is a conscious, collective journey that focuses on enabling systemic change at the individual, interpersonal, and systemic levels. At the systemic level, stratified maternal-health indicators based on race are important to ensure that health-care leaders and providers understand outcomes and experience of patient populations, and see how changes to the system affect outcomes over time. At the individual and interpersonal levels, leaders and staff in maternity and all hospital units must have facilitated processes to talk about racism within the system, and pathways for individuals to use their power within the system to create changes focused on the most vulnerable.

Seven Questions to Catalyze Anti-Racist Efforts

To replicate a similar strategy in your organization, health-care team leaders can use the following questions to help both maternity-unit staff, and health-system staff more broadly, prioritize systemic change to address structural racism:

1. What facilitated opportunities do we provide for staff to talk about structural racism in the maternity unit or in the health-care system, and how it affects their day-to-day work?
2. How do we reinforce positive images of Blackness in our system’s culture?
3. How are the leaders in the system using stratified data to understand inequities of care, process, and outcomes? And how does this build accountability for ongoing growth to achieve health equity in the unit and in the system at large?
4. In what ways is the maternity unit or health-care system connected to Black and Indigenous community movements? How are we learning about their experiences and the need for a more equitable health-care system?
5. What partnerships are we establishing to bring more interns, experts, and community members into our work to address structural racism, to help inform and drive systemic change?
6. What processes are in place to incorporate a multidisciplinary approach to designing the system more equitably, paying particular attention to patients who are at the intersection of socio-economic risk?
7. Does our team have a clear understanding of how to respond to racism when it happens? How are you holding leaders accountable to have the emotional intelligence skills and the foundational knowledge of structural racism in the review and feedback processes in the organization?

A Recurring Practice, Not a One-Time Solution

Addressing systemic racism has no direct or easy path. That there is no one or final solution underpins Barbara Love’s liberatory consciousness model, which affirms that anti-racist work is always ongoing: “The significance of a liberatory consciousness is that we will always question, explore, and interrogate ourselves about possibilities for supporting the efforts of others to come to grips with our conditioning into oppression and give each other a hand in moving outside of our assigned roles.” Addressing structural racism in health-care workplaces must be a collective process, where at every step we create systems and processes that question why we do things, how we do it, and how those actions may or may not create harm, intentionally or not.

Read more stories by Jussara Francisca de Assis dos Santos & Santiago Nariño.