Benefits of Understanding Systemic Racism in Forming Clinician-Patient Relationships to Reduce Black Infant Mortality

The United States began tracking infant death by race in 1850, when 217 of every 1 000 White babies and 340 of every 1 000 Black babies did not reach their first birthday.1 While the overall US infant mortality rate (IMR, the number of infant deaths per 1 000 live births, a leading indicator in the health of a community2) has dropped dramatically since then, we still lag far behind other wealthy nations (55th overall, with an IMR of 5.83). These national statistics belie deep geographic, health care access, and, especially, racial disparities: the gap between White and Black IMR is worse now than it was in 1850.1 Ohio’s 2018 IMR was 6.9, but for Black Ohioans was 13.9.4 And in Cuyahoga County, where the overall 2018 IMR was among Ohio’s worst at 8.7, the White IMR was 4.5 (up from 2017 due to the opioid epidemic), and the Black IMR was 14.9.5 While we are seeing progress, Black babies in Cuyahoga County are still dying at 3.3 times the rate of White babies. ABSTRACT


RESEARCH BRIEF
Scholar Dorothy Roberts has argued that the state has historically neglected Black infants via the socioeconomic status (SES) of their mothers through poverty, inadequate housing, poor nutrition, and lack of access to health care. 6 Dr. Roberts points, for example, to the harsh punishment of pregnant Black women who selfmedicate with illicit drugs versus the "temperate regulation" of pregnant middle-class women who use pharmaceuticals to treat their mental health, despite evidence that use of antidepressants and other prescribed medications during pregnancy may cause subtle neurological problems in newborns. 7 Such disparities in social treatment contribute to what public health researcher Arline Geronimus has termed "weathering," which she defines as the deterioration of Black women's health due to chronic stress. This stress is caused by the cumulative exposure of socioeconomic disadvantage in a society burdened by structural and systemic racism and has consistently been linked to preterm birth. 8 Multiple studies have reported associations between hormonal markers of chronic stress and preterm birth, showing disproportionate effects among Black women and women with low SES. 9 Preterm birth, the leading cause of infant death, has increased 31% in the United States since 1980, particularly among Black women, and risk identification, early detection, and pharmaceutical interventions have made no impact in reducing its occurrence. 9 In order to shed light on the marked racial disparities in infant mortality in Cuyahoga County, this study is exploring local clinicians' perceptions of and responses to these issues.

Setting
The target population was maternal health clinicians from 3 large Cuyahoga County, Ohio, hospitals that serve large numbers of Black women giving birth and large numbers of Medicaid-insured patients.

Design
This ongoing qualitative research study includes one-on-one semistructured interviews by telephone with maternal health care providers, focus groups with nurses and support staff who work with pregnant patients, and an interactive return of findings to participating hospitals to inform their future practice.

Participants
This portion of the study was open to physicians of any experience level who work with pregnant patients or patients seeking to become pregnant, at 3 Cuyahoga County hospitals. Before interviews were paused due to the COVID-19 pandemic, our 5 participants included 4 females and 1 male, ranging in experience level from resident to attending physician, with 4 White and 1 Asian participant (Table 1).

Procedures
All research methods were approved by the Case Western Reserve University Institutional Review Board (IRB). 10 Women's Health departments at 3 Cuyahoga County hospitals agreed to provide access to clinical staff for this study. Maternal health physicians at 3 Cuyahoga County hospitals were contacted via email to participate in this portion of the study; respondents were screened and gave verbal consent by phone, and all were provided with an electronic copy of the IRB-approved study information document. To provide opportunities for in-depth reflection on potentially sensitive topics (particularly infant mortality, systemic racism, and implicit bias in clinical care), individual interviews with maternal health clinicians were conducted. All 60 to 90 minute interviews were conducted via phone by the second author using a guided questionnaire, audio-recorded, and transcribed. Following 5 initial interviews, recruitment was paused due to the COVID-19 pandemic.

Measures/Outcomes
Participants provided basic demographic information, then were asked open-ended questions about: awareness and understanding of racial disparities in infant mortality at national and local levels (eg, What do you think the most important causes of these health disparities are?); the ways these understandings impacted interactions with Black pregnant patients (eg, How do you see these issues affecting your African American patients here? How have they affected how you interact with your patients?); and awareness and opinions about local efforts to mitigate disparities in infant mortality (including community birth workers and implicit bias training, eg, What do you think about these interventions? What recommendations might you have for your institution?).

Data Analysis
Research staff used an approach based in grounded theory, 11 with preliminary analyses informing successive interviews and analyses; themes, categories, and theoretical constructs emerged from qualitative coding and analysis. De-identified transcripts were uploaded to Dedoose (www.dedoose.com), a widely-used qualitative analysis software package. The first and third authors created a codebook using 1 interview; both then coded a second interview, resolved discrepancies by consensus, and revised the codebook. To maintain consistency, the first author coded all transcripts, including those used to create the codebook. A matrix was developed to surface major themes from the interviews.

RESULTS
We interviewed 5 prenatal health care physicians at Cuyahoga County hospitals ( Two interviewees described a deep awareness of racial disparities in maternal and infant mortality, both nationally and locally, and acknowledged their own biases. They also described independent information seeking on implicit bias and disparities in infant mortality. These 2 also recounted more positive and collaborative encounters with their patients than the other 3 participants: In contrast, the 3 clinicians who reported lower levels of awareness of the causes of infant mortality and were more likely to attribute disparities to lack of access, poverty, or obesity, also reported more difficulty in building trust and establishing rapport with their patients. These clinicians also described frustration with patients they viewed as "noncompliant" or unable to handle basic medical issues. These 3 clinicians reported patients who were skeptical of their recommendations and asked about what they may have seen on the internet or have heard from a family member. They also reported that when these conversations went awry, patients might not return for further appointments. Comparatively, the 2 clinicians who accepted this mistrust as historicallybased and increased their responsiveness to it, reported changing their practice patterns to better accommodate these types of questions and concerns:

RESEARCH BRIEF
In contrast, other clinicians in our study attributed racial disparities in infant mortality to poor behavior by pregnant women, suggesting that Black women have high-risk pregnancies because they are overweight, have hypertension, or because they are too young, too poor, or unmarried. The clinicians who attributed these disparities to poor behavior by pregnant women were less likely to associate these social determinants of health with systemic racism and were more likely to self-report lower levels of both acceptance in the concept of implicit bias and confidence in implicit bias training.

DISCUSSION
In these initial interviews with clinicians, an understanding of systemic racism as a cause of both chronic stress and poorer outcomes for Black mothers and babies was associated with an ability to communicate with Black patients in ways that fostered trust. These preliminary associations echo the findings of previous research on doctor-patient communication as a method of building trust with patients, which has found that the physician's approach to the medical encounter matters more than time spent. 12 Other studies have shown that communication and interpersonal skills, such as an ability to listen and repeat back what the patient has explained, help foster trust. 12 Clinicians' willingness to ask about health history and psychosocial concerns has been correlated with higher satisfaction among both patients and providers. 13 This preliminary data suggest that clinician-patient relationships may be influenced by clinicians' understanding of systemic racism and its impact on the social determinants of health. Throughout our interviews, clinicians who showed a higher awareness of systemic racism and accepted systemic racism as a primary factor in the social determinants of health also self-reported more positive and trusting relationships with their patients. In contrast, clinicians who viewed the social determinants of health as being more associated with personal choice and responsibility self-reported more negative and untrusting relationships with their patients.
Though our sample size in this analysis is small, a clear narrative of communication emerged from the interviews. Though communication was not a primary topic of our interview guide, interviewees returned to this theme repeatedly. Our findings suggest that doctor-patient communication may be a vehicle through which clinicians' awareness of systemic racism either improves or hinders their patient relationships, ultimately perhaps affecting their patients' birth outcomes.
We acknowledge that clinicians are often unfairly tasked with solving, or at least mitigating, harms inflicted on Black citizens by centuries of systemic discrimination both outside and inside the medical system. However, one of the tools in reducing infant mortality may be a positive and trusting relationship between the pregnant woman and her clinician, which is made easier when clinicians understand the historical forces facing Black women. This includes an awareness of their own implicit biases, the forces of structural racism in creating the social determinants that may be impacting their compliance, and the cultural norms that influence their behaviors and decisions. Whether that understanding comes from being able to better communicate with their patients-or if being able to better communicate with their patients comes from an initial understanding-is yet to be determined. It may be a mutually-reinforcing cycle, and here is where research with both patients and providers will provide greater understanding.
This study is limited by its small size, which was impacted by the COVID-19 pandemic. No Black clinicians were interviewed, and studies of racial concordance between patients and providers have shown improved outcomes for Black patients. 13,14 Further, the research only investigates the point of view of care providers, not patients. When research begins again, additional interviews and focus groups will enhance these initial findings. Further research will be needed to establish any clear correlations between positive communication and positive birth outcomes, both quantitatively and from a patient perspective.

PUBLIC HEALTH IMPLICATIONS
If additional research supports these preliminary findings, the findings could contribute to guidance for medical schools and hospitals to enhance communication skills among clinicians and other care providers. Trusting and supportive bonds between clinicians and Black pregnant patients could be one aspect of a societal approach to mitigate chronic stress, preterm birth, and infant mortality.