Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence.

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Sexual orientation and experiences with police contact in Canada.

PURPOSE: To investigate the relationship between sexual orientation and police contact-including police contact with intrusion (i.e., use of intrusive verbal or physical force) and police contact with harassment (i.e., actions making one feel inferior based on appearance, identity, or demographic background)-among a national sample in Canada. METHODS: Logistic and multinomial logistic regression were used to assess the association between sexual orientation and experiences with police contact among a sample of 940 persons ages 16-30 across Canada. RESULTS: Compared to heterosexual participants, persons identifying as bisexual were significantly more likely to report having any police contact in the past 12 months (OR = 1.72, 95% CI = 1.09, 2.70). Bisexual (RRR = 3.45, 95% CI = 1. 83, 6.50) and queer, questioning, and other (RRR = 2.33, 95% CI = 1.15, 4.73) identifying participants were more likely to report having experienced police contact with harassment relative to no police contact, compared to heterosexual individuals. CONCLUSIONS: The current study provides the first analysis of the relationship between sexual minority identity and experiences with adverse police contact in Canada, revealing higher levels of police contact and police contact with harassment, especially among bisexual and queer, questioning, other individuals. Findings suggest that sexual minority persons in Canada experience potentially harmful police contact at elevated rates, which may have significant ramifications for health and traumatic stress responses.

Health Equity Considerations in State Bills Related to Doula Care (2015-2020).

INTRODUCTION: Racial inequities in birth outcomes persist in the United States. Doula care may help to decrease inequities and improve some perinatal health indicators, but access remains a challenge. Recent doula-related state legislative action seeks to improve access, but the prioritization of equity is unknown. We reviewed recent trends in doula-related legislation and evaluated the extent to which new legislation addresses racial health equity. METHODS: We conducted a landscape analysis of the LegiScan database to systematically evaluate state legislation mentioning the word "doula" between 2015 and 2020. We identified and applied nine criteria to assess the equity focus of the identified doula-related legislative proposals. Our final sample consisted of 73 bills across 24 states. RESULTS: We observed a three-fold increase in doula-related state legislation introduced over the study period, with 15 bills proposed before 2019 and 58 proposed in 2019-2020. Proposed policies varied widely in content and scope, with 53.4% focusing on Medicaid reimbursement for doula care. In total, 12 bills in 7 states became law. Seven of these laws (58.3%) contained measures for Medicaid reimbursement for doula services, but none guaranteed a living wage based on the cost of living or through consultation with doulas. Only two states (28.6%; Virginia and Oregon) that passed Medicaid reimbursement for doulas also addressed other racial equity components. CONCLUSIONS: There has been an increase in proposed doula-related legislation between 2015 and 2020, but racial health equity is not a focus among the laws that passed. States should consider using racial equity assessments to evaluate proposed doula-related legislation.

The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study.

OBJECTIVE: National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect. METHODS: To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race. RESULTS: Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care. CONCLUSIONS FOR PRACTICE: Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

From a Place of Love: The Experiences of Birthing in a Black-Owned Culturally-Centered Community Birth Center.

Introduction: Racial and ethnic disparities in perinatal health outcomes are among the greatest threats to population health in the United States. Black birthing communities are most impacted by these inequities due to structural racism throughout society and within health care settings. Although multiple studies have shown that structural racism and the disrespect associated with this system of inequity are the root causes of observed perinatal inequities, little scholarship has centered the needs of Black birthing communities to create alternative care models. Leaning on reproductive justice and critical race theoretical frameworks, this study explores good birth experiences as described by Black birthing people. Methods: Thematic analysis of two focus groups and three one-on-one interviews conducted with clients at a Black-owned free-standing culturally-centered birth center (n=10). Results: We found that Black birthing persons' concerns centered on three main themes: agency, historically- and culturally-safe birthing experiences, and relationship-centered care. Many participants pointed directly to past experiences of medical mistreatment and obstetric racism when defining their ideal birth experience. Conclusion: Black birthing people seeking care from culturally-informed providers often do so because they have been mistreated, disregarded, and neglected within traditional care settings. The needs articulated by our study participants provide a powerful framework for understanding alternative patient-centered models of care that can be developed to improve the care experiences of Black birthing people in the pursuit of birth equity.

Association of Residence in High-Police Contact Neighborhoods With Preterm Birth Among Black and White Individuals in Minneapolis.

Importance: Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at <37 weeks' gestation). Existing knowledge of racial disparities in policing patterns and their associations with health suggest redesigning public safety policies could contribute to racial health equity. Objective: To examine the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US. Design, Setting, and Participants: This cross-sectional study used medical record data of 745 White individuals, 121 US-born Black individuals, and 193 Black individuals born outside the US who were Minneapolis residents and gave birth to a live singleton at a large health system between January 1 and December 31, 2016. Data were analyzed from March 2019 to October 2020. Exposures: Police contact was measured at the level of the census tract where the pregnant people lived. Police incidents per capita (ie, the number of police incidents divided by the census tract population estimate) were dichotomized into high if the value was in the fourth quartile and low for the remaining three quartiles. Main Outcomes and Measures: Preterm birth status was based on the International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification (ICD-10-CM) code. Preterm infants were those with ICD-10-CM codes P07.2 and P07.3 documented in their charts. Results: Of 1059 pregnant people (745 [70.3%] White, 121 [11.4%] US-born Black, 193 [18.2%] Black born outside the US) in the sample, 336 White individuals (45.1%) and 62 Black individuals who were born outside the US (32.1%) gave birth between the ages of 30 and 34 years, while US-born Black individuals gave birth at younger ages, with 49 (40.5%) aged 25 years or younger. The incidence of preterm birth was 6.7% for White individuals (50 pregnant people), 14.0% for US-born Black individuals (17 pregnant people), and 5.7% for Black individuals born outside the US (11 pregnant people). In areas with high police contact vs low police contact, the odds of preterm birth were 90% higher for White individuals (odds ratio [OR], 1.9; 95% CI, 1.9-2.0), 100% higher for US-born Black individuals (OR, 2.0; 95% CI, 1.8-2.2), and 10% higher for Black individuals born outside the US (OR, 1.1; 95% CI, 1.0-1.2). Secondary geospatial analysis further revealed that the proportion of Black residents in Minneapolis census tracts was correlated with the number of police incidents reported between 2012 and 2016 (P = .001). Conclusions and Relevance: In this study, police contact was associated with preterm birth for both Black and White pregnant people. Predominantly Black neighborhoods had greater police contact than predominantly White neighborhoods, indicating that Black pregnant people were more likely to be exposed to police than White pregnant people. These findings suggest that racialized police patterns borne from a history of racism in the United States may contribute to racial disparity in preterm birth.

Racial and Ethnic Diversity in the Nursing Workforce: A Focus on Maternity Care.

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are an increasing focus of attention in the wake of rising rates of maternal morbidity and mortality in the United States. Efforts to achieve racial equity in childbirth should include attention to the nurses who provide care before and during pregnancy, at childbirth, and postpartum.

Roots Community Birth Center: A culturally-centered care model for improving value and equity in childbirth.

Pernicious racial disparities in birth outcomes in the United States have their roots in structural racism-the systematic allocation of opportunities and resources based on race. These inequities, caused by systemic factors which contribute to lower quality of care, negatively impact the lives of Blacks/African Americans. The development of new maternity care models hold potential to reduce disparities and costs by focusing on the root cause of racism. Roots Community Birth Center is an African American-owned, midwife-led freestanding birth center in North Minneapolis. Roots provides a culturally-centered model of care during pregnancy, childbirth, and the postpartum period. The culturally-centered care model utilized by Roots Community Birth Center offers culturally-centered care that is community based, accepts Medicaid beneficiaries, and provides prenatal and postpartum visits that are customized to the needs of the birthing individual. Like other institutions, this birth center faces the financial challenges associated with maternity care payment models and inadequate Medicaid reimbursement, challenges that directly interfere with the center's culturally-centered care model which advocates for longer prenatal visits and close follow-up postpartum. The birth center model of care has proven effective; over the last four years Roots has had 284 families with zero preterm births. The culturally-centered care model used by Roots is not currently well-supported by maternity care payment models that were designed in large part to reflect typical care provided by obstetricians and hospitals.

Identifying the Key Elements of Racially Concordant Care in a Freestanding Birth Center.

INTRODUCTION: There is empirical evidence that the quality of interpersonal care patients receive varies dramatically along racial and ethnic lines, with African American people often reporting much lower quality of care than their white counterparts. Improving the interpersonal relationship between clinicians and patients has been identified as one way to improve quality of care. Specifically, research has identified that patients feel more satisfied with the care that they receive from clinicians with whom they share a racial identity. However, little is known about how clinicians provide racially concordant care. The goal of this analysis was to identify the key components of high-quality care that were most salient for African American birthworkers providing perinatal care to African American patients. METHODS: We conducted semistructured interviews (30 to 90 minutes) with clinicians (N = 10; midwives, student midwives, and doulas) who either worked at or worked closely with an African American-owned birth center in North Minneapolis, Minnesota. We used inductive coding methods to analyze data and to identify key themes. RESULTS: Providing racially concordant perinatal care to African American birthing individuals required clinicians to acknowledge and center the sociocultural realities and experiences of their patients. Four key themes emerged in our analysis. The first overarching theme identified was the need to acknowledge how cultural identity of patients is fundamental to the clinical encounter. The second theme that emerged was a commitment to racial justice. The third and fourth themes were agency and cultural humility, which highlight the reciprocal nature of the clinician-patient relationship. DISCUSSION: The most salient aspect of the care that birthworkers of color provide is their culturally centered approach. This approach and all subsequent themes suggest that achieving birth equity for pregnant African American people starts by acknowledging and honoring their sociocultural experiences.

The Experience and Motivations of Midwives of Color in Minnesota: Nothing for Us Without Us.

INTRODUCTION: Racial disparities in birth outcomes originate with a confluence of factors including social determinants of health, toxic stress, structural racism, and barriers to engaging, high-quality perinatal care. Historically and currently, midwives are disproportionately white, and attention to the racial and ethnic diversity of midwives is an increasing focus in birth equity efforts. This qualitative study helps fill the gap in literature by assessing the perspectives and motivations of midwives of color. METHODS: Building on concepts from critical race theory, semistructured interviews (30-90 minutes long) were used to elicit an authentic voice from midwives of color, who primarily identified as African American. Participants (N = 7) were midwives who were affiliated with an African American-owned birth center in north Minneapolis, Minnesota. Participants represented an estimated 58% of all midwives of color in the state of Minnesota. Emergent themes were identified using a grounded theory, inductive approach. Three rounds of coding were conducted, and key themes were identified and analyzed. RESULTS: Three primary themes emerged as motivations for midwives of color: 1) offering racially concordant care to the community, 2) racial justice as a primary motivation in their work, and 3) providing physically and emotionally safe care. Racially concordant care was identified both as a motivating factor and as a way of providing physically and emotionally safe care. DISCUSSION: Findings suggest that midwives of color maintain a critical analysis of and commitment to eliminating racial perinatal inequities. Their motivation to provide racially concordant care elicits an urgency in current efforts to recruit and train more midwives of color, recognizing the current lack of racial and ethnic diversity in the field. Understanding how to support the work of equity-minded midwives of color may help to improve access to racially concordant health care providers and care that better meets the unique needs of African American individuals.

Developing a Medical School Curriculum on Racism: Multidisciplinary, Multiracial Conversations Informed by Public Health Critical Race Praxis (PHCRP).

Background: To fight racism and its potential influence on health, health care professionals must recognize, name, understand and talk about racism. These conversations are difficult, particularly when stakes feel high-in the workplace and in interracial groups. We convened a multidisciplinary, multi-racial group of professionals in two phases of this exploratory project to develop and pilot an intervention to promote effective dialogues on racism for first year medical students at the University of Minnesota Medical School. Methods: Informed by a Public Health Critical Race Praxis (PHCRP) methodology in Phase I, initial content was developed by a group of seven women primarily from racial and ethnic minority groups. In a later phase, they joined with five White (primarily male) colleagues to discuss racism and race. Participants met monthly for 12 months from Jan 2016-Dec 2016. All participants were recruited by study PI. An inductive approach was used to analyze meeting notes and post intervention reflections to describe lessons learned from the process of employing a PHCRP methodology to develop the aforementioned curriculum with a multidisciplinary and multi-racial group of professionals dedicated to advancing conversations on racial equity. Results: Participants from Phase I described the early meetings as "powerful," allowing them to "bring their full selves" to a project that convened individuals who are often marginalized in their professional environments. In Phase II, which included White colleagues, the dynamics shifted: "…the voices from Phase I became quieter…"; "I had to put on my armor and fight in those later meetings…". Conclusions: The process of employing PHCRP in the development of an intervention about racism led to new insights on what it means to discuss racism among those marginalized and those with privilege. Conversations in each phase yielded new insights and strategies to advance a conversation about racism in health care.

Naming Institutionalized Racism in the Public Health Literature: A Systematic Literature Review.

OBJECTIVES: Although a range of factors shapes health and well-being, institutionalized racism (societal allocation of privilege based on race) plays an important role in generating inequities by race. The goal of this analysis was to review the contemporary peer-reviewed public health literature from 2002-2015 to determine whether the concept of institutionalized racism was named (ie, explicitly mentioned) and whether it was a core concept in the article. METHODS: We used a systematic literature review methodology to find articles from the top 50 highest-impact journals in each of 6 categories (249 journals in total) that most closely represented the public health field, were published during 2002-2015, were US focused, were indexed in PubMed/MEDLINE and/or Ovid/MEDLINE, and mentioned terms relating to institutionalized racism in their titles or abstracts. We analyzed the content of these articles for the use of related terms and concepts. RESULTS: We found only 25 articles that named institutionalized racism in the title or abstract among all articles published in the public health literature during 2002-2015 in the 50 highest-impact journals and 6 categories representing the public health field in the United States. Institutionalized racism was a core concept in 16 of the 25 articles. CONCLUSIONS: Although institutionalized racism is recognized as a fundamental cause of health inequities, it was not often explicitly named in the titles or abstracts of articles published in the public health literature during 2002-2015. Our results highlight the need to explicitly name institutionalized racism in articles in the public health literature and to make it a central concept in inequities research. More public health research on institutionalized racism could help efforts to overcome its substantial, longstanding effects on health and well-being.