|
| A) | The goal annual reduction rate is 15% for every country. | ||
| B) | The location with the largest number of maternal deaths is southeast Asia. | ||
| C) | There was an overall global 34% increase in the maternal mortality rate between 2000 and 2020. | ||
| D) | The lowest rate of maternal mortality occurs in Sweden (with 4 maternal deaths per 100,000 live births). |
The United Nations International Children's Emergency Fund (UNICEF) reports an overall global 34% decline in the maternal mortality rate, from 342 maternal deaths per 100,000 live births in 2000 to 223 maternal deaths per 10,000 live births in 2020 [3]. This decrease is consistent with achieving the sustainable development goal of 70 maternal deaths per 100,000 live births by 2030. However, the maternal mortality rates plateaued in Western Europe and North America between 2016 and 2022, and Latin America and the Caribbean noted an increase over the same period. The goal annual reduction rate is 15% for every country [3].
The location with the largest number of maternal deaths is sub-Saharan Africa, where the rate is 545 maternal deaths per 100,000 live births. Countries with the lowest rates of maternal mortality include Australia and New Zealand (with 4 maternal deaths per 100,000 live births) [3]. Among regions, women in sub-Saharan Africa face the highest lifetime risk of maternal death (1 in 41), which is approximately 268 times higher than in Western Europe (1 in 11,000), the lowest-risk region [3].
| A) | 8% | ||
| B) | 20% | ||
| C) | 60% | ||
| D) | 80% |
In the United States, maternal deaths represent the largest disparity among all populations within perinatal health measures. The maternal mortality rate in the United States is unacceptably high and rising. In 2021, 1,205 women died of maternal causes in the United States, compared with 861 in 2020 and 754 in 2019 [4]. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. More than 80% of all pregnancy-related deaths that occur in the United States are considered preventable [5].
| A) | 1 | ||
| B) | 2.6 | ||
| C) | 5.8 | ||
| D) | 13 |
Maternal mortality rates in the United States are higher among American Indian, Alaskan Native, Pacific Islander/Native Hawaiian, and Black women than among Asian, Hispanic, or White populations [6]. In 1933, the first time all states reported maternal deaths, the maternal mortality rate for Black women (1,000 deaths per 100,000 births) was 1.8 times greater than the rate for White women (564 deaths per 100,000 births). As of 2021, maternal death rates among Black women (69.9 per 100,000 births) had risen to 2.6 times higher than the rate noted for White women (26.6 per 100,000 births) [7].
| A) | Age | ||
| B) | Skin tone | ||
| C) | English language proficiency and fluency | ||
| D) | All of the above |
Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessarily change in accordance with these outward expressions [18]. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [19]. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include [20]:
Age
Disability
Education
English language proficiency and fluency
Ethnicity
Health status
Disease/diagnosis (e.g., HIV/AIDS)
Insurance
Obesity
Race
Socioeconomic status
Sexual orientation, gender identity, or gender expression
Skin tone
Substance use
| A) | Location | ||
| B) | Leadership | ||
| C) | Internal politics | ||
| D) | Organizational history |
Larger organizational, institutional, societal, and cultural forces contribute, perpetuate, and reinforce implicit and explicit biases, racism, and discrimination. Psychological and neuroscientific approaches ultimately decontextualize racism [17,29]. Sources of bias in organizations include internal politics, culture, leadership, organizational history, and team-specific structures. Organizational bias reaches far beyond individuals themselves; the language used or tasks identified influence how the organization functions daily [30]. Bias within an organization can detour patients from visiting if they feel they are being viewed or cared for as a "lesser" patient. One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one's own position in this structure.
| A) | IAT | ||
| B) | SOAP | ||
| C) | STOP | ||
| D) | fMRI |
Harvard University sponsors Project Implicit, a research project which monitors implicit biases. Project Implicit houses the Implicit Association Test (IAT), which can be used as a metric to assess professionals' level of implicit bias on a variety of subjects, and this presupposes that implicit bias is a discrete phenomenon that can be measured quantitatively [32]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact. The IAT is available at https://implicit.harvard.edu/implicit, and anyone may complete an assessment.
| A) | Race | ||
| B) | Economic stability | ||
| C) | Health care access and quality | ||
| D) | Social and community context |
Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. For example, historical economic stresses and restrictions on housing, jobs, and education have resulted in health inequalities for racial and ethnic minority groups. Healthy People 2030 groups social determinants of health into five categories [38]:
Economic stability
Education access and quality
Health care access and quality
Social and community context
Neighborhood and built environment
| A) | is static and does not evolve over one's life. | ||
| B) | does not significantly impact how we respond to different situations. | ||
| C) | can influence the behaviors, professional decisions, interactions, and performance in health care. | ||
| D) | is defined as an attitude of humbleness, acknowledging one's limitations in the cultural knowledge of groups. |
Cultural identity is defined as the "shared characteristics of a group of people, which encompasses place of birth, religion, language, cuisine, social behaviors, art, literature, and music" [42]. Cultural identity is important as it influences how we respond to different situations. In health care, cultural identity can influence the behaviors one exhibits, the barriers upheld, and professional decisions, interactions, and performance. Cultural identity can evolve, and even if one does not consider their culture consciously, it is exhibited subconsciously [43]. It is important to remember that one's cultural identity should not impede the care provided to patients. For example, religion can influence one's practice but it should not determine how one practices or the type or quality of care given.
| A) | Spirituality | ||
| B) | Community | ||
| C) | Family/kinship | ||
| D) | All of the above |
Historical adversity and institutional racism contribute to health disparities in this group. For the Black population, patient assessment and treatment planning should be framed in a context that recognizes the totality of life experiences faced by patients. In many cases, particularly in the provision of mental health care, equality is sought in the provider-patient relationship, with less distance and more disclosure. Practitioners should assess whether their practices connect with core values of Black culture, such as family, kinship, community, and spirituality. Generalized or Eurocentric treatment approaches may not easily align with these components of the Black community [47]. Providers should also consider the impact of racial discrimination on health and mental health among Black patients. Reports indicate that expressions of emotion by Black patients tend to be negatively misunderstood or dismissed; this reflects implicit or explicit biases.
| A) | Strength | ||
| B) | Flexibility | ||
| C) | Machismo | ||
| D) | Perseverance |
When involved in the care of Latinx/Hispanic individuals, practitioners should strive to employ personalismo (warm, genuine communication) and recognize the importance of familismo (the centrality of the family). More flexible scheduling strategies may be more successful with this group, if possible, and some patients may benefit from culturally specific treatment and ethnic and gender matching with providers. Aspects of Latino culture can be assets in treatment: strength, perseverance, flexibility, and an ability to survive.
| A) | Listening is an important aspect of rapport building with Native American patients. | ||
| B) | Interruptions and in-depth questioning establish familiarity and are recommended, if possible. | ||
| C) | Practitioners should ask about family or personal matters unrelated to presenting issues as early as possible. | ||
| D) | Native American patients respond best when they are given directions rather than suggestions and options. |
Listening is an important aspect of rapport building with Native American patients, and practitioners should use active listening and reflective responses. Assessments and histories may include information regarding patients' stories, experiences, dreams, and rituals and their relevance. Interruptions and excessive questioning should be avoided if possible. Extended periods of silence may occur, and time should be allowed for patients to adjust and process information. Practitioners should avoid asking about family or personal matters unrelated to presenting issues without first asking permission to inquire about these areas. Native American patients often respond best when they are given suggestions and options rather than directions.
| A) | It is illegal in all states to refuse to provide services even if doing so would violate one's religious beliefs. | ||
| B) | Failure to treat patients because of moral objections particularly affects those who are racial minorities and men. | ||
| C) | Providers are obligated to act within their profession's code of ethics and to ensure all patients receive the best possible care. | ||
| D) | Encountering discrimination when seeking health or mental health services is not a significant barrier to optimal care and generally does not contribute to poorer outcomes in under-represented groups. |
Encountering discrimination when seeking health or mental health services is a barrier to optimal care and contributor to poorer outcomes in under-represented groups. Some providers will not treat patients because of moral objections, which can affect all groups, but particularly those who are gender and/or sexual minorities, religious minorities, and/or immigrants. In fact, in 2016, Mississippi and Tennessee passed laws allowing health providers to refuse to provide services if doing so would violate their religious beliefs [62]. However, it is important to remember that providers are obligated to act within their profession's code of ethics and to ensure all patients receive the best possible care.
| A) | Use of more informal language | ||
| B) | Speaking more and often raising one's voice | ||
| C) | Assumption that meanings are described explicitly | ||
| D) | Reliance on interpreting eye contact, gestures, and tone of voice |
Communicators from high-context cultures generally display the following characteristics [64,65,66,67]:
Use of indirect modes of communication
Use of vague descriptions
Less talk and less eye contact
Interpersonal sensitivity
Use of feelings to facilitate behavior
Assumed recollection of shared experiences
Reliance on nonverbal cues such as gestures, tone of voice, posture, voice level, rhythm of speaking, emotions, and pace and timing of speech
Assimilation of the "whole" picture, including visual and auditory cues
Emotional speech
Use of silence
Use of more formal language, emphasizing hierarchy between parties
| A) | participating in consciousness raising activities and committing funds to community programs. | ||
| B) | enacting policies guaranteeing a diverse workforce and the establishment of internal diversity committees. | ||
| C) | everyone getting the same opportunity and uniform approaches to care for all patients, regardless of race, color, or ethnicity. | ||
| D) | eliminating race-related health disparities, ensuring access and quality of care for minority groups, and improving quality of life for all persons, regardless of race, color, or ethnicity. |
Race Forward defines racial justice as "a vision and transformation of society to eliminate racial hierarchies and advance collective liberation, where Black, Indigenous, Latinx, Asian Americans, Native Hawaiians, and Pacific Islanders, in particular, have the dignity, resources, power, and self-determination to fully thrive" [70]. In the context of health care, this concept is related to eliminating race-related health disparities, ensuring access and quality of care for minority groups, and improving quality of life for all persons, regardless of race, color, or ethnicity. This requires that practitioners take a perspective of cultural humility and proactively move to dismantle harmful stereotypes and practices.
| A) | provide access to interpreter services for all patient interactions when patient language is not the clinicians' language. | ||
| B) | refer patients to social services to help improve patients' abilities to fulfill their needs and overcome barriers to care. | ||
| C) | inquire about and document social and structural determinants of health that may influence a patient's health and use of health care. | ||
| D) | All of the above |
The American College of Obstetricians and Gynecologists makes the following recommendations for obstetrician/gynecologists and other healthcare providers to improve patient-centered care and decrease inequities in reproductive health care by [71]:
Inquiring about and documenting social and structural determinants of health that may influence a patient's health and use of health care
Maximizing referrals to social services to help improve patients' abilities to fulfill these needs
Providing access to interpreter services for all patient interactions when patient language is not the clinicians' language
Recognizing that stereotyping patients using presumed cultural beliefs can negatively affect patient interactions, especially when patients' behaviors are attributed solely to individual choices without recognizing the role of social and structural factors
| A) | are also the largest source of maternal health care for White patients. | ||
| B) | generally have the best scores in terms of maternal mortality and morbidity. | ||
| C) | have higher rates of severe maternal morbidity rates for Black patients but not White patients. | ||
| D) | have higher risk-adjusted severe maternal morbidity rates, regardless of the patient's race/ethnicity, than the national average. |
Adherence to guideline-endorsed practice may also help to reduce health disparities. In a Ghanaian study, provider adherence to antenatal care guidelines beginning in the first visit improved delivery and neonatal outcomes [89]. In addition, racial and ethnic disparities in severe maternal morbidity and mortality may be at least partially explained by variation in hospital quality. The majority of Black women who deliver in the United States (75%) do so in only 25% of hospitals; only 18% of White women deliver in those same hospitals [1]. The hospitals more likely to serve Black communities have higher risk-adjusted severe maternal morbidity rates, regardless of the patient's race/ethnicity, than the national average. Improving access to high-quality maternal health care and adherence to antenatal and postpartum guidelines may thus effectively reduce racial disparities in maternal morbidity and mortality.
| A) | Priming | ||
| B) | Attunement | ||
| C) | Control strategies | ||
| D) | Perspective taking |
Perspective taking is a strategy of taking on a first-person perspective of a person in order to control one's automatic response toward individuals with certain social characteristics that might trigger implicit biases [73]. The goal is to increase psychological closeness, empathy, and connection with members of the group [39]. Engaging with media that presents a perspective (e.g., watching documentaries, reading an autobiography) can help promote better understanding of the specific group's lives, experiences, and viewpoints. In one study, participants who adopted the first-person perspectives of Black Americans had more positive automatic evaluations of the targeted group [74].
| A) | STOPP | ||
| B) | Priming | ||
| C) | Power-sharing | ||
| D) | Individuation |
Individuation is an implicit bias reduction intervention that involves obtaining specific information about the individual and relying on personal characteristics instead of stereotypes of the group to which he or she belongs [39,73]. The key is to concentrate on the person's specific experiences, achievements, personality traits, qualifications, and other personal attributes rather than focusing on gender, race, ethnicity, age, ability, and other social attributes, all of which can activate implicit biases. When providers lack relevant information, they are more likely to fill in data with stereotypes, in some cases unconsciously. Time constraints and job stress increase the likelihood of this occurring [78].
| A) | still, time, open, prayer, and pulse. | ||
| B) | stand, tilt, observation, prudent, and philosophy. | ||
| C) | stop, take a breath, observe, pull back, and practice. | ||
| D) | sacred, top-down, one moment, push through, and priority. |
Mindfulness approaches include yoga, meditation, and guided imagery. One approach to mindfulness using the acronym STOPP has been developed as a practical exercise to engage in mindfulness in any moment. STOPP is an acronym for [81]:
Stop
Take a breath
Observe
Pull back
Practice
| A) | promoting positive emotions such as empathy and compassion to help reduce implicit biases. | ||
| B) | presenting an image, idea, or construct that is counter to the oversimplified stereotypes typically held regarding members of a specific group. | ||
| C) | obtaining specific information about the individual and relying on personal characteristics instead of stereotypes of the group to which he or she belongs. | ||
| D) | stopping oneself and deliberately emptying one's mind of distractions or allowing distractions to drift through one's mind unimpeded, focusing only on the moment. |
Counter-stereotypical imaging approaches involve presenting an image, idea, or construct that is counter to the oversimplified stereotypes typically held regarding members of a specific group. In one study, participants were asked to imagine either a strong woman (the experimental condition) or a gender-neutral event (the control condition) [84]. Researchers found that participants in the experimental condition exhibited lower levels of implicit gender bias. Similarly, exposure to female leaders was found to reduce implicit gender bias [85]. Whether via increased contact with stigmatized groups to contradict prevailing stereotypes or simply exposure to counter-stereotypical imaging, it is possible to unlearn associations underlying various implicit biases. If the social environment is important in priming positive evaluations, having more positive visual images of members in stigmatized groups can help reduce implicit biases. Some have suggested that even just hanging photos and having computer screensavers reflecting positive images of various social groups could help to reduce negative associations [86].