Rethinking cultural competency training for Black maternal health

AUSTIN (KXAN) — Klarque Denman, one of the doulas working with Black Mamas ATX or BMATX said assumptions and stereotypes are some of the major contributions to the standard of care shown to Black women.

“If we had a humanistic approach rather than a medical model approach, people would treat people like people,” Denman said. “Paying better attention to detail could make a world of difference.”

Research shows the need for cultural competency arises from the inherent power differential in the physician-patient relationship. Social issues such as stereotyping, institutionalized racism, and dominant-group privilege are as real in the examining room as they are in society at large.

Kelenne Blake-Fallon, executive director BMATX questions the efficacy of the concept since there’s been no improvements in mortality rates yet.

“Typical surface level cultural competency training will not be enough in the sense that cultural competency may not even be the ideal term or concept because you cannot be competent in someone else’s culture,” Blake-Fallon said. “Cultural sensitivity or humility are alternatives I’ve heard used.”

Nakeenya Wilson, a community advocate on the Maternal Mortality and Morbidity Review Committee believes institutional problems should be addressed at an institutional level.

“Cultural competency is not going to be a silver bullet. When we think about systems and how they were built in this country, they were not built equitably,” Wilson said. “Some of what we see has nothing to do with individual biases or racism, it has to deal with institutions and systems, and work must be done at the level of policy and practice.”

She added that cultural competency is about understanding that not everybody comes from the same place, not everybody has the same resources and ultimately, care needs to be centered and tailored around the individual.

While most hospitals have some training available, MMMRCs Chair, Dr. Carla Ortique said the actual, more intensive training that helps individuals recognize their bias is not always being done.

“The biggest piece that I want to convey is that we also need cultural humility, we have to acknowledge that no matter how many courses we take, no matter how intent we are, we will never be able to fully understand the reality of all people,” Ortique said. “But we can always be respectful and always attempt to create an environment that’s comfortable for the person sitting in front of us.”

Ortique said this will be one of the critical ways of improving or mending the trust gap; the mistrust that exists between communities that historically have been excluded from being able to achieve their full health.

Highlighting the MMMRCs recommendation to engage Black communities and those that support them in the development of maternal and women’s health programs, UT Arlington’s Maternal and Child Health Research Lab director, Kyrah Brown said there’s a level of detail and guidance that must come with that.

“If you’re partnering with Black led organizations who’ve been doing the work there’s a way in which you go about approaching those groups in a respectful way,” Brown said. “In a way that is consistent with you recognizing that they are the experts and you are there to follow and support.”

A 2019 amendment to Health & Safety Code 34.021 mandated the state to apply to the United States Department of Health and Human Services for grants under the federal Preventing Maternal Deaths Act. DSHS was awarded a CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant. One of the conditions of this grant was the investigation of discrimination as a contributing factor for severe maternal mortality.

“Even though we acknowledge that bias, discrimination, and racism played a role,” Ortique said. “This is the first time that we actually have a validated tool to use and a specific category that could be assigned.”

Efforts at diversity in healthcare – Medical Education & Scholarship

Three of the four mothers we spoke with have never seen a Black OB-GYN because of underrepresentation within the medical field. 

AAMC defines underrepresented in medicine as those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.

In the 2022 Physician Specialty Data Report, the Association of American Medical Colleges for the first time included race/ethnicity data. Only 5.7% identified as Black. This means one in every 17 doctors is Black. However, the report showed the number of Black first-year medical students increased 21% between 2020 and 2021.

In 2020, 6.3% of active physicians in Texas identified as Black, compared with 13.4% of the state population.

The Texas Medical Association created the diversity in medicine scholarship program in 1998 to help diversify the physician workforce to meet the health care needs of Texans. It is one of only a few available in Texas for underrepresented minority students seeking a career in medicine. Eligible applicants are Black, Hispanic/Latino and Native American.

Wilson has had three kids, but never had a Black OB-GYN. She now has a Black primary care doctor and her children see a Black pediatrician.

“Early on, I didn’t feel like I had a choice. Whether it was the fact that I had Medicaid or the fact that whatever insurance I had just kind of picked somebody who was closest and had good ratings, but what I’ve learned is that even when they have good ratings, doesn’t guarantee that I’m gonna have the same kind of experience,” Wilson said. “I’m a lot more intentional, but it’s hard because there’s not as many Black providers in the Austin area.”

Sabrina Ferguson is the only mother we spoke with who had a Black OB-GYN.

“I’m pregnant with twins, and my OB has been very intuitive and she listens, which is not something I expected from an OB. She’s also Black,” Ferguson said. “She has training in twin birth because with twins, the second baby, most of the time, is breech. So you have to have proper training in order to deliver without a C-section.”

Ferguson has opted to have a natural birth without any epidural, just like her prior two pregnancies.

“I think that birth should be simple, and it should be what the woman that is having the baby wants it to look like unless there’s a true medical emergency,” she said. “Other than that, I think women need to take their time and they need to be in a space where they feel safe.”

Alternative/Supportive Birthing Options

Denman enrolled for doula training after seeing some of singer-songwriter Erykah Badu’s birth advocacy work on home births. 

“I’ve been treated badly, and I get treated worse than the mother sometimes, but I just have to sit side by side with the mother and really advocate for her,” Denman said. “People like to treat Black people typically like we don’t have education, like we don’t know what we’re talking about. So I have to fight for that.”

Denman described a midwife as a holistic OB-GYN while a doula is someone who helps with education, advocacy and checks on the mother’s comfort levels.

“Working with a midwife out of hospital and working with a midwife or doctor in hospital is very different,” Denman said. “I’ve had some beautiful situations with doctors and midwives in hospital, but outside of the hospital with a midwife, it’s like water, it just flows.”

Research done by the American College of Obstetricians and Gynecologists found that in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.

The World Health Organization recommends midwives as an approach to reducing maternal mortality. Reviews found midwifery-led care for women with healthy pregnancies is comparable or preferable to physician-led care in terms of maternal outcomes, including lower maternal mortality and morbidity. In countries with low severe maternal mortality, midwives far greatly outnumber OB-GYNs.

“I absolutely believe there should be the option to have doula or some advocate at the time of delivery for all women and that it should not be dependent on ability to pay,” Ortique said. “That’s one of the recommendations in our report, to have doula care covered by public insurance.”

But Ortique said a possible problem might be finding doulas who are willing to accept Medicaid as a pay source. 

Rep. Shawn Theirry said the HB 465 (the ‘We Love Doulas’ bill) would solve the problem. This bill passed in the House last session but missed a Senate deadline.

“For a long time, a doula was something that pretty much women who were of the upper echelon of wealth had access to, these social determinants of health continue to play a role,” Thierry said. “But I’ve heard from numerous doulas across the state, and they’re really excited to have doula services covered by Medicaid.”

According to Thierry, there’s data showing that the number of C-sections goes down with women who have doula-assisted care, and hospital stays are shorter with less infections.

“So really, the purpose of this bill is to actually lower costs for our health care system,” Thierry said. 

Physicians gave testimony showing support for the bill at the House committee in March.

“They were happy to have that additional level of birth coaching and care,” Thierry said. “Ultimately, we all have the same goal to have healthy moms which equals healthy babies, which equals healthy families.”

Dominique Adeniyi, a student midwife and doula working with Giving Austin Labor Support or GALS moved to Austin from California, she said doulas weren’t easily accessible in California.

“So if you couldn’t afford a doula, you didn’t get a doula,” Adeniyi said. “Whereas here in Austin, if you can’t afford it, there’s other avenues right, especially if you’re Black.”

Given the increasing evidence of the positive impacts of midwifery care on maternal birth experience and delivery outcomes, the Texas Medicaid External Quality Review Organization conducted an analysis of encounter data associated with midwife attended deliveries among women in Texas Medicaid. 

According to their findings, midwifery-led care holds promise as a high-value investment of health care resources, and although the midwifery model of maternity care is associated with lower costs and positive pregnancy and birth outcomes, current literature suggests Medicaid members have limited access to and lower utilization of midwife services.

“It’s important to have midwives of color,” Adeniyi said. “Just because when there’s an issue, you want to know there’s someone who understands what you’re going through as a black woman.”