Advocating for Patients of Color as a Labor and Delivery Nurse

On October 4th, 2022, Governor Gavin Newsom of California endorsed SB 65, known as the California Momnibus Act. This legislation aims to enhance research and data collection related to racial and socio-economic disparities, specifically addressing the elevated rates of maternal and fetal mortality in communities of color.
In the previous month, Governor Newsom also signed AB 1356 and AB 1184. AB 1356 is centered around improving access to reproductive health, while AB 1184 focuses on safeguarding the privacy of both patients seeking reproductive care and their healthcare providers.

The Black Maternal Health Momnibus Act of 2021 is a comprehensive bill addressing all aspects contributing to the current maternal health crisis in the United States.

Introduction: Labor and Delivery Nurse advocacy role for Patients of Color

Maternal mortality rates among Black pregnant individuals in the U.S. are significantly higher compared to non-Hispanic white pregnant individuals. The United States has a maternal mortality rate higher than any other developed nation, and numerous of these deaths could have been prevented.

A study in the American Journal of Public Health re-evaluated maternal deaths among non-Hispanic Black women during 2016 and 2017. The findings highlighted that Black women are 3.5 times more likely to die from pregnancy-related complications than white women. This stark reality underscores the profound racial disparities in healthcare that persist in the U.S. healthcare system.

The question arises: why are Black pregnant individuals experiencing higher mortality rates? Factors such as chronic health conditions, limited access to health insurance and postpartum care, and systemic racism all contribute significantly.

This article delves into the risks of maternal death in non-Hispanic Black women, how labor and delivery (L&D) nurses can be advocates for patients of color, and strategies to eliminate maternal mortality within communities of color, emphasizing maternal mortality prevention.

Understanding Maternal Health Disparities

The incidence of maternal death in non-Hispanic Black women within the United States has been on the rise. The Pregnancy Mortality Surveillance System (PMSS) of the Centers for Disease Control and Prevention (CDC) has been tracking pregnancy-related deaths since 1987. Pregnancy-related death encompasses the passing of a woman during pregnancy or within a year after childbirth.

According to PMSS data from 2014-2017, non-Hispanic Black women experienced the highest maternal mortality rate among all races, with 41.7 deaths per 100,000 live births. Non-Hispanic American Indian or Alaska Native women ranked second at 21.8 deaths per 100,000 live births, followed by non-Hispanic Asian or Pacific Islander women at 13.8 deaths per 100,000 live births.

Race-based risk of death is attributable to preventable factors, including:

• Chronic diseases
• Limited access to quality care
• Systemic racism and implicit bias in healthcare

Risks of Maternal Death Among Non-Hispanic Black Women

Chronic Diseases

Cardiovascular disease, including conditions such as hypertension, diabetes, chronic heart disease, and strokes, is the leading cause of maternal death among non-Hispanic Black women. Cardiovascular issues account for over half of all maternal deaths.

Postponing pregnancy can exacerbate risks for those dealing with chronic diseases, making them more susceptible to maternal mortality. The American College of Obstetricians and Gynecologists identifies additional risk factors:

• Black ethnicity
• Age over 40
• Hypertensive disorders
• Obesity

Limited Access to Care

Insufficient access to healthcare in the U.S. disproportionately affects low-income women, minority populations, and rural areas. Access to healthcare plays a pivotal role in determining the number of pregnant individuals who succumb to childbirth and pregnancy-related complications. Evidence suggests that states with Medicaid expansion witness lower maternal mortality rates, while states without expansion experience an increase.

Medicaid expansion can offer benefits to racial and ethnic minority women. Non-Hispanic Black mothers experienced 16.27 fewer maternal deaths per 100,000 live births in states with expanded Medicaid. Conversely, states without Medicaid expansion continue to report higher mortality rates.

Limited Quality of Care

Maternal death, as defined by the CDC, includes fatalities during pregnancy and up to one year after childbirth. The maternal mortality rates have surged, primarily occurring after childbirth. This phase post-birth, often referred to as the “fourth trimester,” is marked by significant health risks. Many individuals fail to follow up with obstetricians or primary care providers due to various reasons, including lack of insurance, inadequate coordination of care, limited awareness, and insufficient information about postpartum care.

Systemic Racism and Implicit Bias

Racial and ethnic disparities persist even among women with higher education levels living in states with lower maternal mortality rates. Research reveals that Black women with higher incomes still face a higher likelihood of dying from pregnancy-related complications than white women. This suggests that systemic racism and implicit bias contribute to maternal mortality rates among non-Hispanic Black women.

Dr. Peggy Roberts, a certified women’s health nurse practitioner, asserts that maternal mortality is elevated among Black women because their symptoms often go unnoticed or disregarded. This bias, where healthcare providers do not take the concerns of Black women seriously, was exemplified by the health scare experienced by tennis champion Serena Williams after her pregnancy in 2017.

Addressing racial disparities requires the healthcare system to acknowledge their existence, provide mandatory implicit bias training for healthcare professionals, and establish advocacy committees within hospitals to address this epidemic.

The Role of Diversity in Labor and Delivery Nursing

The presence of diverse representation among L&D nurses is vital for the well-being of pregnant individuals of color. Studies demonstrate that patients receive superior care and experience better outcomes when their healthcare team is diverse.

Dr. Roberts emphasizes the significance of diversity in nursing due to the mistrust that people of color often harbor towards the healthcare system. Dr. Roberts asserts, “The healthcare team should mirror the diverse population they serve.”

Representation within healthcare providers has a life-saving impact. Data indicates that Black patients requested more preventive care when their physician shared their racial background. Additionally, Black newborns cared for by Black physicians exhibited a 40% lower mortality rate than Black infants under the care of white physicians, as indicated by a 2021 report from the National Academy of Sciences.

Advocacy Strategies for Labor and Delivery Nurses

L&D nurses occupy a unique position as the primary observers and caretakers of pregnant individuals. They are ideally situated to advocate for their patients, especially those belonging to marginalized communities. Ellie Beatus, a family nurse practitioner with over seven years of L&D nursing experience, describes L&D nurses as extensions of the pregnant individual. They provide continuous support during labor and guide individuals to ensure safe deliveries.

One effective method for L&D nurses to advocate for patients is to maintain open lines of communication, particularly with patients of color. Even though L&D nurses only interact with patients during and after labor, they can still educate patients about risk factors, particularly those relevant post-delivery.

Enhancing patient follow-up appointments is crucial. Currently, 40% of women do not attend postpartum appointments. By cultivating relationships with patients, L&D nurses can encourage more follow-up appointments, which are pivotal for preventing negative outcomes during the critical “fourth trimester.”

Caring for Pregnant Patients with Cardiovascular Risk Factors

The Preventive Cardiovascular Nurses Association highlights high blood pressure, obesity, and diabetes as risk factors for developing cardiovascular disease. L&D nurses can encourage patients fitting these criteria to:

• Advocate for a three-week postpartum appointment instead of the standard six-week period
• Collaborate with social workers to ensure that health insurance covers postpartum care during the “fourth trimester”
• Arrange a doctor’s visit within 12 weeks after birth if a three-week appointment is not possible
• Recognize signs and symptoms of high blood pressure and stroke
• Seek weight loss and substance use programs from their primary care providers

To be effective advocates, Beatus emphasizes that L&D nurses should fulfill patient wishes and monitor the safety of both the patient and the baby, ensuring a positive outcome for both.

Dr. Roberts underscores that L&D nurses can support patients by emphasizing collaboration, even when patients disagree with the recommended care plan from their doctors.

“The role of the L&D nurse is to act as a liaison between the patient and the healthcare team, ensuring the safest collaborative approach,” notes Dr. Roberts.

Empowering New Labor and Delivery Nurses

For new L&D graduates, the responsibility can be daunting. They not only care for pregnant patients but also safeguard the health of their unborn children. New L&D nurses should have the ability to advocate for and educate patients about the risk of maternal mortality among people of color.

Dr. Roberts advises staying informed about the current guidelines and recommendations established by the American College of Obstetricians and Gynecologists, as well as the specific practices of individual healthcare institutions.

“Ask questions,” urges Dr. Roberts. “Learn from adverse cases within your facility, understanding what happened and what could have been done differently.”

Beatus advises new nurses to conduct thorough patient histories during the first visit. As pregnancies progress, maintaining consistent contact with patients allows nurses to observe changes and take preventative measures against negative outcomes.

“Both the individual in front of you and their medical history hold significance,” Beatus emphasizes, noting that prior health history can shed light on areas that require more comprehensive monitoring throughout labor.

A Call to Action for Healthcare Providers

Both nursing organizations and hospitals have a responsibility to recruit diverse labor and delivery nurses to enhance representation in healthcare and support pregnant individuals of color. Legislative changes are also imperative to curb maternal mortality rates in the United States.

The Black Maternal Health Momnibus Act of 2021, co-sponsored by nurse and congresswoman Lauren Underwood, was signed into law on October 4th by Governor Gavin Newsom of California. Senate Bill 65, or the California Momnibus Act, builds upon existing legislation to comprehensively address every dimension of the maternal health crisis in America.

This act seeks to boost research and data collection related to racial disparities in healthcare, focusing on the elevated rates of maternal and fetal mortality within communities of color. It encompasses all factors influencing reproductive health access in the current maternal health crisis in the U.S.

In the preceding month, Governor Newsom also enacted Assembly Bill 1356 and Assembly Bill 1184. AB 1356 targets enhancing access to reproductive care for Californian women, while AB 1184 focuses on safeguarding the privacy of patients seeking reproductive care and their healthcare providers.

How Can Nurses and L&D Nurses Contribute?

• Reach out to members of Congress in both the House of Representatives and the Senate.
• Utilize social media to raise awareness.
• Engage with community-based organizations.
• Follow the Black Maternal Health Caucus on Twitter.

Given that healthcare expenditure in the U.S. amounts to $3.8 trillion, it is unacceptable that maternal mortality rates surpass those of other developed nations. Just as postpartum care is crucial, preconception check-ups and education should be promoted.

During preconception check-ups, providers and nurses can discuss conditions such as depression, high blood pressure, and obesity before pregnancy. Preconception check-ups provide another avenue for advocating for the care and safety of pregnant individuals of color.