Bias, Before First Breath

How structural racism and implicit bias impact America’s babies, even prior to birth


Becoming a new mother in America is more dangerous for some mothers than it should be. Each year, 700 women die in childbirth or from pregnancy-related causes in the United States, the highest number of any developed nation. 

Health inequities in America mean that overwhelmingly, Black women and their infants are the ones impacted: Black mothers are 243% more likely to die from pregnancy than white ones. These discrepancies are wide ranging: American Indian and Alaska Native women are also 2x more likely to experience an adverse outcome as compared to  their white counterparts. Too many of our mothers are dying of preventable causes. The CDC estimates that 70% of maternal deaths are avoidable – which helps underscore the urgent need to create tangible change. 

Recent forces have helped shine a long overdue spotlight on the Black maternal mortality crisis in America. In April, the Biden Administration released a proclamation during Black Maternal Health Week, and planned legislative changes to address implicit bias in healthcare and apply funding where it is truly needed. Congress is fielding the “Momnibus” bill, which would fund grassroots organizations at the community level, actively establish bias training programs, and fill gaps created by social determinants of health (SDOH). Late last year, the HHS released an action plan to reduce maternal mortality and adverse outcomes by 50% in five years.

It is heartening to see action finally being taken: our mothers deserve more. At the same time, while we champion standardized and equal access to care for all of our mothers, we cannot overlook the newest cry in the room: the infant’s. Even before drawing her first breath, a baby girl’s future will be irrevocably shaped by structural racism and socioeconomic factors way beyond her control. 

That’s why, to address health inequities, we must begin with our babies. Despite great advances in NICU technology and managed healthcare, infant mortality is on the rise – and it disproportionately affects Black babies. Today, black infants are twice as likely to die as their white counterparts

While we need new standards set at a governmental level to help equalize access to care, expand coverage, and provide funding for much-needed programs, it takes all of us to create change. Here are three steps individuals and care teams can begin to put into action today:

Diagnose and treat your implicit bias

Implicit bias is all too common and can be hard to recognize. Two out of three clinicians hold unconscious implicit bias against Black and Latino patients. Doctors were also more likely to recommend more advanced and effective medical treatments for their white patients than for their Black ones. Barriers to care impact both mother and baby, long after the delivery date. 

It’s no longer enough for clinicians to focus on documenting   symptoms, case notes, and diagnoses — they should also have training for recognizing and overcoming bias. A good first step is building inclusive language vocabularies. Words like “minority,” “underserved,” “failed,” “lapsed,” and “non-compliant” are loaded with prejudice and limited in their ability to paint a full picture. By opening our ears, hearts, and minds, we can help eliminate biases that can have a long-term impact on the health of our mothers and their new babies. 

Make room for more voices in the delivery room

All too often, the first time a pregnant woman meets her attending physician is after her water breaks, in the delivery room. Fortunately, midwives and doulas are helping to fill the gap. They act as teachers, friends, and advocates by providing support, resources, information, and education to new moms-to-be. Experienced in delivery and medical jargon, they can help navigate the healthcare system and access benefits that expand coverage.

A recent study showed that states with higher midwife integration scores saw significantly lower rates of preterm birth and low birth weight babies. Many doula and advocacy services are provided pro bono via non-profit groups. True expansion of care at scale calls for state Medicaid agencies to improve reimbursement rates for out-of-hospital birth options, and for midwives and doulas to receive living wage compensation for their very important work. In the hospital setting, care providers can help reduce obstacles by embracing new care team members and listening to all voices in the room.

Becoming a true care team, from preconception to postpartum

From family planning to prenatal visits, through delivery, and postpartum follow-ups, a care team should be in place every step of the way. Experts recommend a minimum of 13 prenatal visits. Infants whose mothers did not receive prenatal care are 3x more likely to have a low birth weight, and 5x more likely to die in infancy.

Unfortunately, recurring doctor’s visits, especially for prenatal care, are all too often skipped. In 2016, 24% of pregnant women received fewer than the recommended number of prenatal visits. 10% of Black women, 12% of American Indian or Alaska Native, and 8% of Hispanic women received late or no prenatal care, as compared to 5% of white women. State-based expansions to Medicaid can help ensure more equitable access to vital care. Lack of workday flexibility, food insecurity, limited access to transportation, and other SDOH can interfere with a mother’s ability to keep appointments. On the provider side, small changes can help account for and overcome these care gaps, including: de-stigmatized screening programs for nutritional or financial needs, community outreach, local partnerships, and offering telemedicine appointments during evenings and weekends. 

Every baby deserves equal access to the necessary health care services to have a healthy first year of life and beyond. By taking small steps today to improve the quality of care for all of our mothers, we can work to lighten the burden on our young ones. We can all play a part in addressing the pervasive framework of implicit bias and structural racism that yield health inequities and care gaps caused by SDOH. Ultimately, we are all working toward a reality where we break the cycle of inherited systemic bias, so that every baby can begin their life with a healthy start.

Ellie Stang, MD is the Founder and CEO of ProgenyHealth.

5 replies »

  1. Dear Dr. Coli,

    Yes, that would be an absolutely welcome change. I agree there are many worthwhile initiatives to help eliminate implicit bias, structural racism, and health inequities in America, and addressing the problematic roots of biological races and hierarchies would be helpful. I look forward to learning more about HGIP, BSCS, and the significant work being done.

    Thank you for your comment,
    Ellie Stang, MD

  2. “By providing accurate genetic information to 8th-12th grade Americans, widespread biology class adoption of the HGIP curriculum might ultimately help dismantle both structural racism and the implicit bias on which it is based.”

    If we did that where would Republicans get their votes?

  3. Dear Dr. Stang,
    As you can see in these links, although it is not yet widely known beyond geneticists, the Humane Genetics Intervention Program (HGIP) curriculum has demonstrated that many adolescents and adults can eliminate implicit racial bias or prevent its development by correcting three common genetic misconceptions.

    https://bscs.org/our-work/rd-programs/towards-a-more-humane-genetics-education Towards a More Humane Genetics Education Overview

    https://www.nytimes.com/2019/12/07/us/race-biology-genetics.html (12/7/19) Can Biology Class Reduce Racism?

    https://onlinelibrary.wiley.com/doi/full/10.1002/sce.21506 (3/18/19) Toward a more humane genetics education: Learning about the social and quantitative complexities of human genetic variation research could reduce racial bias in adolescent and adult populations

    By providing accurate genetic information to 8th-12th grade Americans, widespread biology class adoption of the HGIP curriculum might ultimately help dismantle both structural racism and the implicit bias on which it is based. Wouldn’t that be an equitable, unifying and welcome change for all Americans?

    All the best,
    Bob Coli, MD

  4. Hi Pedro,

    Thank you for reading and contributing your thoughtful response. I believe you are right that there are broader stories at play in our communities: widespread alcohol and drug addiction, opioid misuse, poor nutrition, and many more. These factors contribute to adverse health outcomes and limit access to care that could otherwise help reduce maternal and infant deaths.

    I believe that getting to the root cause of these issues can be the best way to address them, and that at core, systemic racism, entrenched poverty, and social determinants of health (SDOH) result in the health inequities and outcome disparities that we see reflected in some of the statistics above. These socioeconomic factors go behind hospital staff and care delivery – although I think we can make inroads there by broadly adopting SDOH screenings, care team inclusivity, and awareness of implicit bias. SDOH – like economic stability, access to healthy foods and quality nutrition, and a robust community context – are widely understood to influence 80% of an individual’s health outcome in life.

    By working to solve for gaps in care caused by SDOH, we can improve conditions in everyday life that will have dramatically positive influences on long term health outcomes and general wellbeing.

    -Ellie Stang, MD

  5. “American Indian and Alaska Native women are also 2x more likely to experience an adverse outcome as compared to their white counterparts.”

    Just throwing out data with no context can weaken your argument. If you understand Alaska and the remote native communities there then you’ll have a better understanding of why this occurs – it’s not racism. Alaska natives have much higher alcohol and drug addiction than whites and poorer diets. They may choose not to seek timely free medical care and transportation from villages, including free air ambulance. Alaska native medical center in Anchorage has some of the best medical staff and care anywhere.

    Much of your argument is due to racist created historical poverty, statistically higher in black and latino communities with poor educational foundation. What may look like racism could be exasperation with giving advice that will not or cannot be followed. Medicare for all would go a long way to create a level payment system for equal care.

    I agree that racism and bias pervades every aspect of American life, but again some context would help correct the root causes.