The importance of diversity in obstetrics

This is part 1 of our 3 part series on diversity in obstetrics. Part 2 can be found here. Part 3 can be found here.

Katherine Bianco, MD

My name is Katherine Bianco, MD, I'm a high-risk obstetrician and a medical geneticist. I specialize in high-risk pregnancies. I work on the Department of OB/GYN at Stanford University and I’m in their division of maternal-fetal medicine and obstetric children's health.

Contemporary OB/GYN:

So how can racial and ethnic disparities be addressed in health care?

Bianco:

Well, that's a very interesting question and you could address it in many ways, I would start telling you that more and more evidence is showing that when we start addressing maternal background from race and ethnicity, we can understand better the, well, the disease if you will, but also understand better the care that needs to be provided to the patient. So here at Stanford Medicine and Children Health, we definitely look at a patient as an individual patient, we believe in precision medicine, and we believe every patient is unique. And with that, you really have to understand the cultures difference, the race and ethnicity of our patient. For example, when we take care of patients in my particular area of expertise that is high risk maternal complication, we do have to put into context for where is this patient cultural background is and where her racial ethnicity is, because we have learned that, for instance, certain races are more prone to certain diseases, as you realize where we are standing right now, in a crisis in the US for maternal mortality. We know this is increasing in African American/Black moms, and we've seen how exponential are the increased risks to have adverse perinatal outcomes and to have more human mortality when you compare it with the counterparts of all other ethnic groups. Also, Latinx and Hispanic groups are vulnerable to these. So, we have to ask the question, is there a social determinant of health that is actually leading to this difference, or is this a biological factor? And the discussion is in the literature right now, thinking about race, biological factor was such a construct, and that's one of the things I'm very intrigued and I mean, we are partnering here in children health, to understand better. So, we are all about having a very diverse population, but also understand what that diversity brings to the patient and the patient care. So, let's take one of the most common problems in pregnancy called hypertension disorders of pregnancy and can lead to very complex maternal manifestation and fetal implication. High blood pressures can bring the maternal stroke, cardiac infarct, renal dysfunction, all kinds of different things. And we can see that more often in our blood normals, and also can see in our non-white, Hispanic patients. And so, these bring to the table, is there a social component that might be leading this discrepancy when just utilizing for concepts and examples? So, that's what leads us to a time investigating how social determinants of health might modify this recipe. So, as you know, in California, there is a very active collaboration with the maternal quality and the pediatric quality health service, and during our audits and looking at maternal deaths in California, we have learned that one of the major implications to lead to these maternal deaths were due to hypertension disorders and cardiovascular affections. And going further, a lot of these deaths were deemed to be preventable. So, that took to the second major to understand better how they could have been preventable. So, we have doctors like Elia Maine, leading a lot of investigation to address social determinants of health and if it's really there is an impact on racism that would lead to an increase of these outcomes in this vulnerable population. So, it's very intriguing. Then we just survive a pandemic, and the pandemic was very clear to show the health disparity and has shed light on us in the work in this very critical population to see how we can address better these health disparities, we are actually actively investigating that.

Contemporary OB/GYN:

So, you went into it a little bit, but can you talk some more about how diversity in healthcare might help the patient population and care staff?

Bianco:

For sure, it's very well-known and documented, the more diverse your team, the better sites we create, either by basic science or by bedside. So, definitely at Stanford and Children's Health, we are a pioneer in that diversity and inclusion. I’m the director here at my department and I work hand to hand with the Office of the Dean. And we have many avenues, how we foster diversity at the bedside, and how we can not only guarantee that a patient will see a diverse team that understand their diverse background, but also, we are creating the future leaders in the field. So, for the School of Medicine, an example, we have a very diverse class, and we from the very first day of their location, we are working in creating that creative mind, that open mind approach to your patient, that diverse approach to your patient care. So, at a time these future medical providers are practicing in the wards, they already come into the table with that as an advantage, and those diversity lanes applied to the patient. We do a lot of training to our existing faculty and learners and to staff talking about inclusion bias and talking about older forms, that it can be intrinsic to our own bring up that we might bring it to the patient care and might modify our tech to the patient. So, when we look at health disparity, one of the key elements is to think about it how we are educating our team, and how that's going to translate in patient care. If we use again, California as an example, California in 2019, Pascal, painted a low where every single unit or labor unit or perinatal unit, meaning that provides maternal care and childcare should be trained in inclusion bias, and should be trained and in understanding how diversity impacts health disparities, and how that can decrease the gap that we have these days. So, we have at Children's Health, made sure that all our team under the Johnson Center that is a prenatal service, have received training through a health stream about inclusion bias, importance to recognize our intrinsic belief, and how we can translate that at the bedside with our patients.

Contemporary OB/GYN:

Thank you. Are there any other examples you might want to provide of how multimodal care can serve diverse populations?

Bianco:

For sure. So, let's talk about language. Language is very important. So, one of the things that we have is our patients can have a what we call and live a limited. I'm sorry, I'm blanking in the definition, but it's a limit and language prophecies. So, if we use our patient population here and children's health is strongly represented by Hispanic population, because you know, California has over 50% in population, Hispanics, our patients aren't representative. But we only have 6% in the entire country of physicians, primary cares medical doctors, people like me that speak Spanish. So, we have a gap. And we have recognized that, so in the School of Medicine here at Stanford, we are creating we are given medical school rotations, that allows them to get proficient and speak Spanish in a medical approach. That's one of the things that you can do to increase the diversity and other things. We made sure, at Children's Health, that we have in person just later 20 for server in our labor and delivery and our NICU and our pediatric works, meaning that patients have a person next to them that will be able to facilitate these very hard conversations. When we have an ill patient or ill baby in decisions have to be made and emergencies are happening. We guarantee in person translation, and we also have that for outpatient settings. So, we definitely recognize not having the ability to communicate the patient in her first language of preference can increase the gap of health disparities. So that is definitely something that we have advocated, and it's been supported here's a standard Stanford children's health. They think about more about social determinants of health, where the patients leave and how we can decrease the gap of them being able to not be in an area that perhaps is a desert area of medical care. We actually provide local housing for these patients. A lot of my mother's come from 200 Miles, 500 Miles away from the medical center and Children's Health haa the capacity to provide local housing for the mother and the family, which is wonderful because some of these mothers come in with a lot of stress either because they have a medical condition, or they're carrying a baby with a birth defect so they're able to really be relocated. We support social work with people that speak their language with the medical team, like us high-risk obstetric neonatologist, all have a very large and diverse healthcare team to guarantee follow up for her pregnancy and decrease adverse outcomes for her and her unborn child. So, we’re definitely understanding the background of the patient, from the language perspective, from the culture perspective, from the social determinants of health, and supporting any in need, trying to decrease that gap, you just laid in better care, and to manage health disparities. And I think we're doing very well, not only in California, but our staff for Children’s Health. In that regard, we're very lucky.

Contemporary OB/GYN:

Thank you. We're just about ready to wrap up. Is there anything you want to add first?

Bianco:

Um, no, I just want to say thank you and I really appreciate that you're getting this information out there for people to know.