面對美國黑人孕產婦保健中的種族主義
孕產婦健康研究員和產科醫生 Kecia Gaither 概述了挽救更多黑人母親生命所需的研究。
Frances Gatta / 2022 年 12 月 12 日 / 自然
產科醫生 Kecia Gaither 制定了一項計畫，以篩查有色人種孕婦是否存在心血管問題，這些問題可能會增加她們發生併發症的風險。圖片來源：Kecia Gaither
非殖民化科學
科學充滿了不公正和剝削。 來自邊緣人群的科學見解已被抹去，自然歷史標本在未經同意的情況下被採集，遺傳學數據被操縱以支持優生學運動。 如果不承認和補救這一遺留的問題，許多少數族裔群體對科學缺乏信任，當然也不會在學術界感到受歡迎——這是許多大學聲稱所追求之多樣性水準的持續性障礙。
在關於生物科學非殖民化的一系列簡短文章中，產科醫生和婦科醫生 Kecia Gaither 提倡採用多管齊下的方法來解決黑人孕婦醫療保健中的結構性種族主義問題。 Gaither 是紐約市布朗克斯區 NYC Health + Hospitals/Lincoln 的母胎醫學主任，他解釋了在懷孕期間更好地進行篩查和加強對醫生的反偏見培訓如何有助於扭轉孕產婦死亡率的趨勢。
作為一名產科醫生、婦科醫生和研究人員，我對為黑人和棕色人種服務的興趣源於我在紐約哈林區長大，在那裡我看到黑人是如何得不到高品質的醫療保健。
非殖民化科學工具套組
我在紐約布魯克林和新澤西州紐瓦克進行了住院醫師培訓和獎學金培訓。 我看到散居在外的非洲人難以獲得醫療保健且缺乏保險，他們罹患肥胖症、糖尿病、慢性高血壓、糖尿病、愛滋病毒/愛滋病和物質使用障礙等疾病的機率很高。
然後我在佛羅里達州富裕的城市西棕櫚灘工作，在那裡我看到富有的白人女性與社會經濟地位較低的女性相比，在對待和照顧方面存在明顯差異。 人們似乎更尊重有錢的白人； 他們會在需要時盡快傾聽並提供幫助、治療和分娩鎮痛。 但有色人種因其社會地位而被貼上嚴厲的標籤。 他們被定型為懶惰、吸毒的人等等，沒有聽取他們的意見。
我記得有一次，一名患有自體免疫性疾病狼瘡和嚴重先兆子癇（懷孕期間血壓突然升高）的黑人孕婦正在分娩。照護團隊中沒有人費心去決定她將如何分娩。 她不得不等待大約 12 個小時，直到我來上班並為她進行剖腹產手術。我從未見過任何白人母親會出現這種程度的冷漠。
由於許多因素，黑人特別容易出現不良的孕產婦健康狀況，其中系統性種族主義是主要驅動因素。 與白人女性相比，在美國，有色人種女性不太可能擁有保險、交通和醫療服務。 此外，無證移民往往因害怕被驅逐出境而避免接受醫院治療。
黑人患心臟病、糖尿病、愛滋病毒和高血壓等潛在疾病的機率也較高，這使他們在懷孕期間和懷孕後面臨併發症的風險。 他們可能患有周產期心肌病，這是一種罕見的心力衰竭類型，可以在懷孕的最後一個月和分娩後五個月之間開始。 黑人在懷孕和早產期間也更容易出血。
我在我工作的地方看到了這些併發症，它是美國最大的公立醫院系統的一部分，2021 年為 202,881 人提供服務。南布朗克斯是一個以黑人和西班牙裔為主的社區，是該國周產期發病率和死亡率最高的地區之一。
種族主義增加懷孕壓力
為什麼黑人更容易罹患上這些併發症？ 經歷種族主義和偏見當然是促成因素，這些壓力因素會損害免疫功能和控制血液循環的功能。 此外，作為一名黑人女性，生育孩子帶來的額外壓力增加了不良後果的風險。 然而，需要更多的研究來了解黑人女性面臨的特定壓力源如何影響她們的健康。
2019 年，在觀察到患有未確診心臟病的黑人孕婦周產期心肌病發病率很高後，我在我工作的醫院啟動了一個名為「母親的心」的計畫。 我使用紐約州婦產醫院品質改進網絡、跨國製造公司寶潔公司和 TD 慈善基金會的贈款資金來確定有心血管疾病風險的人。
「母親的心」是為來自非洲僑民和拉丁美洲國家的女性設計的。 我們根據肥胖、糖尿病、高血壓和心臟病家族史等風險因素對孕婦進行篩查並將其納入該計畫。 該計畫已經確定了患有心律失常、結構性心臟缺陷和其他問題的人。 我們還檢查營養狀況、健康水準和遺傳，並在某些情況下篩查胎兒的心臟。
我們建立了一個心產科團隊——一個包括母胎醫學專家、產科醫生、遺傳學家和心臟病專家在內的多學科團隊。
自該計畫啟動以來，與我在 2017 年看到的情況相比，林肯大學居民的心血管死亡發生率明顯下降。例如，沒有產後心肌病或未確診的心血管代償失調的病例，這些症狀顯示心臟無法支持正常的循環。
因為心臟病在不良後果中起著重要作用，我認為應該有一個更協調和嚴格的篩查過程作為產前和產後照護的一部分。 我們確實需要進行研究，看看嚴格的篩選是否會改善結果。
設立更多類似於「母親之心」的計畫，尤其是在服務不足的有色人種女性占主導地位的美國農村地區，不僅可以幫助黑人和棕色人種女性，而且可以幫助所有孕婦獲得更好的孕產婦健康結果。
我們還應該對如何使用醫療支持人員（例如幫助人們在醫療系統中導航的人員、導樂［doulas，註］和助產士）進行更多研究，以改善黑人孕產婦的健康狀況。
「第四」孕期照護
還值得去關注世界上孕產婦健康狀況較好的地區並且從中學習。 與許多國家的人不同，美國有很多人在產後無法獲得低成本的醫療保健服務。 近一半的美國新生兒由 Medicaid 覆蓋，它為低收入人群提供免費或低價的醫療保健，但只涵蓋母親在嬰兒出生之後的前 60 天的照護。 研究人員說，為了及早發現更多的醫療問題，醫療補助計畫應該至少在「第四個孕期」或嬰兒生命的前三個月提供經濟保障，最好是在出生後一整年。 （2021 年，美國國會批准將 Medicaid 延長至出生後 12 個月，目前已有 27 個州採用了此類計畫。）每個州對妊娠晚期照護的健康保險覆蓋範圍都有不同的政策，這使許多人處於弱勢地位。
另一個重要方面是，我們需要培訓醫生，從醫學院開始，消除偏見，並在醫療保健期間以黑人的經歷為中心。 美國大學可以透過四年的學習來創建一個課程，專門教授醫學生更多地了解偏見和種族主義在醫療保健中的影響。 這種培訓可以繼續並納入執照更新過程，因此打擊種族主義和偏見仍然是醫生們最關心的問題。
事實是，很難改變人心，尤其是在改變他們對某些群體的看法時。 為黑人患者的健康結果對醫生進行經濟補償或紀律處分可能是讓他們牢記種族主義和偏見如何導致不良結果的好方法。
總的來說，我們需要更多像我們一樣的醫生和研究人員。 根據美國醫學院協會的數據，截至 2019 年 7 月，只有 5% 的美國醫生被認定為黑人或非裔美國人。
數據顯示，黑人患者在有黑人醫生照顧時情況會更好。 不幸的是，研究顯示，大約 53% 的美國黑人很難在他們居住的地方找到一位被認定為黑人的醫生 。
從研究的角度來看，如果你因為與參與者來自相同的背景而熟悉一組特定的問題，那麼你可以更容易地解決研究中的細微差別並建立融洽和信任。
doi: https://doi.org/10.1038/d41586-022-04409-6
為了篇幅和清晰度，對這次採訪進行了編輯。
參考文獻：Lyn, D. P. J. Gen. 《內科醫學》37, 1310–1312 (2022)。
［註］導樂 (doulas) 是一名訓練有素的專業人員，他為他人的服務提供專家指導，並透過重要的健康相關經驗（如分娩、流產、人工流產）支持另一個人（其客戶）或死產，以及死亡等非生殖經歷。導樂還可以為客戶的伴侶、家人和朋友提供支持。
導樂的目標和作用是幫助客戶感到安全和舒適，補充為客戶提供醫療服務的醫療保健專業人員的作用。與醫生、助產士或護士不同，導樂不能進行藥物治療或其他治療，也不能提供醫療建議。個人可能需要完成培訓才能擔任導樂，儘管培訓和認證過程在世界各地各不相同。
一些導樂作為志願者工作；其他人的服務費用由他們的客戶、醫療機構或其他私人和公共組織支付。Doulas 接受的培訓量不同，他們的專業水平也各不相同。
導樂在生殖經歷和臨終關懷中的貢獻已經過研究，並已證明可以使他們的客戶受益。例如，在分娩期間提供支持的分娩導樂可能會增加陰道分娩（而不是剖腹產）的可能性，減少分娩時對止痛藥的需求，並改善對分娩的認識分娩經歷。
導樂提供其他類型支持的好處尚未得到充分研究，但可能會改善客戶的醫療體驗或幫助個人應對健康轉變。
Confronting racism in Black maternal health care in the United States
Maternal-health researcher and obstetrician Kecia Gaither outlines the research needed to save more Black mothers’ lives.
Frances Gatta / 12 December 2022 / Nature
Obstetrician Kecia Gaither instituted a programme to screen pregnant women of colour for cardiovascular problems that can increase their risk of complications.Credit: Kecia Gaither
Decolonizing science
Science is steeped in injustice and exploitation. Scientific insights from marginalized people have been erased, natural-history specimens have been taken without consent and genetics data have been manipulated to back eugenics movements. Without acknowledgement and redress of this legacy, many people from minority ethnic groups have little trust in science and certainly don’t feel welcome in academia — an ongoing barrier to the levels of diversity that many universities claim to pursue.
In this next in a short series of articles about decolonizing the biosciences, obstetrician and gynaecologist Kecia Gaither advocates a multi-pronged approach to address structural racism in the health care of Black pregnant people. Gaither, who is director of maternal fetal medicine at NYC Health + Hospitals/Lincoln in the Bronx, New York, explains how better screening during pregnancy and enhanced anti-bias training for physicians could help turn the tide on maternal death rates.
My interest in serving Black and brown people as an obstetrician, gynaecologist and researcher stems from growing up in Harlem, New York, where I saw how Black people weren’t getting high-quality health care.
Decolonizing science toolkit
I did my residency and fellowship training in Brooklyn, New York, and Newark, New Jersey. I saw how people from the African diaspora who had poor access to health care and lacked insurance had high rates of conditions such as obesity, diabetes, chronic high blood pressure, diabetes, HIV/AIDS and substance-use disorder.
I then worked in West Palm Beach, an affluent urban area in Florida, where I saw a stark difference in how wealthy white women were treated and cared for compared with women in lower socio-economic groups. There seemed to be greater respect for rich white people; they were listened to and offered help, treatment and labour pain relief as soon as needed. But people of colour were labelled harshly because of their social situation. They were stereotyped as lazy, substance-using people and so on, and not listened to.
I remember one incident in which a Black pregnant woman with the autoimmune disease lupus and severe pre-eclampsia (a sudden rise in blood pressure during pregnancy) was in labour. Nobody in the care team had bothered to decide how she was going to have her delivery. She had to wait about 12 hours until I came to work and performed her Caesarean surgery. I had never seen this level of indifference happen with any of the white mothers.
Black people are particularly prone to poor maternal-health outcomes owing to many factors, with systemic racism being a primary driver. Women of colour, in the United States are less likely to have insurance, transportation and access to medical care compared with white women. Furthermore, undocumented immigrants often avoid hospital-based care for fear of deportation.
Black people also have a higher incidence of underlying conditions, such as heart disease, diabetes, HIV and high blood pressure, which puts them at risk of complications during and after pregnancy. They can have peripartum cardiomyopathy, a rare type of heart failure that can start between the last month of pregnancy and five months after delivery. Black people are also more likely to experience bleeding during pregnancy and premature delivery.
I see these complications where I work, which is part of the largest US public hospital system, and served 202,881 people in 2021. The south Bronx, a community with predominantly Black and Hispanic people, has among the country’s highest perinatal morbidity and death rates.
Racism adds to pregnancy stress
Why are Black people at greater risk for developing these complications? Experiencing racism and bias are certainly contributory factors, and these stressors can compromise immune function and functions that control blood circulation. Furthermore, the extra stress that comes with carrying a child as a Black woman increases the risk of poor outcomes. However, more research is needed to understand how the particular stressors faced by Black women affect their health.
In 2019, I started a programme called A Mother’s Heart at the hospital where I work, after observing a high incidence of peripartum cardiomyopathy in Black pregnant people with undiagnosed heart diseases. I set it up to identify people at risk of cardiovascular diseases using grant funding from the New York State Maternity Hospital Quality Improvement Network, multinational manufacturing company Procter and Gamble and TD Charitable Foundation.
A Mother’s Heart is designed for women from the African diaspora and Latin American countries. We screen pregnant people and include them in the programme on the basis of risk factors such as obesity, diabetes, high blood pressure and family history of cardiac disease. The programme has identified people with cardiac arrhythmia, structural heart defects and other problems. We also check nutrition status, fitness levels and genetics, and screen the heart of the fetus in certain cases.
We established a cardio-obstetrics team — a multi-disciplinary team including maternal—fetal medicine specialists, obstetricians, geneticists and cardiologists.
Since the programme started, there has been a marked reduction in the incidence of cardiovascular deaths in people at Lincoln compared with what I saw in 2017. For example, there have been no cases of postpartum cardiomyopathy or undiagnosed cardiovascular decompensation, symptoms that indicate that the heart can’t support proper circulation.
Because cardiac disease plays a significant part in adverse outcomes, I think there should be a more concerted and stringent screening process as part of prenatal and postpartum care. We really need to do the research to see whether rigorous screening would improve outcomes.
Setting up more programmes similar to A Mother’s Heart, especially in US rural areas where there’s a predominance of under-served women of colour, can help not only Black and brown women but all pregnant people to have better maternal-health outcomes.
We should also direct more research towards how using medical support staff — such as those who help people navigate the medical system, doulas and midwives — could improve Black maternal-health outcomes.
‘Fourth’ trimester care
It’s also worth looking at parts of the world that have better maternal-health outcomes and learning from them. In contrast to people in many countries, a lot of people in the United States do not have access to low-cost health care during the postpartum period. Nearly half of US births are covered by Medicaid, which offers free or low-cost health care for low-income people, which only covers mothers’ care for the first 60 days after birth. Researchers say that, to catch more medical problems earlier, Medicaid should provide financial cover through at least the ‘fourth trimester’, or the first three months of the baby’s life, and ideally up to a full year after birth. (In 2021, the US Congress approved a Medicaid extension for 12 months after birth and 27 states have adopted such plans so far.) Each state has different policies on health-insurance coverage for fourth-trimester care, which leaves many people vulnerable.
Another important aspect is that we need to train physicians, starting in medical school, to unlearn biases and to centre the experiences of Black people during health care. US universities could create a curriculum through all four years of study dedicated to teaching medical students to be more aware of the impacts of bias and racism in health care. This training could continue and be built into the process of licence renewal, so combating racism and bias stay at the forefront of doctors’ minds.
The truth is, it’s difficult to change people’s hearts, especially when it comes to changing how they think about certain groups. Compensating or disciplining physicians financially for the health outcomes of Black patients could be an excellent way to keep them mindful of how racism and bias lead to poor results.
In general, we need more physicians and researchers who look like us. According to data from the Association of American Medical Colleges, as of July 2019, only 5% of US doctors identified as Black or African American.
Data show that Black patients fare better when they have Black doctors taking care of them. Unfortunately, research shows that about 53% of Black Americans struggle to find a doctor who identifies as Black where they live1.
And from the research perspective, if you are familiar with a particular set of issues because you are from the same background as the participants, then you can address nuances in your research more readily and build rapport and trust.
doi: https://doi.org/10.1038/d41586-022-04409-6
This interview has been edited for length and clarity.
References
1.Lyn, D. P. J. Gen. Intern. Med. 37, 1310–1312 (2022).