While I was on call in the neonatal intensive care unit the other day, a baby born prematurely at 24 weeks died in his mother’s arms. Having seen this tragic outcome many times in my career, I reflexively knew what to do next: call the chaplain and the photographer, bring out the memory-making kits, and sign the death certificate.
Without needing to think about it, I listed the cause of death: prematurity. Because I work in a large university hospital in urban Chicago, it is common that I list African-American for race/ethnicity.
It doesn’t shock me anymore to write prematurity as the cause of death for babies. But it should.
Despite advances in obstetric and perinatal medicine, the U.S. has plummeted from 17th to 47th in global infant mortality in the past 50 years, and now lags far behind countries such as Iceland, Japan, and the Czech Republic. It’s even worse for African-American infants, who are more than twice as likely to die in the first year of life as white infants.
Over the years, researchers have studied the role of individual risk factors, such as education and poor prenatal care, as well as community factors such as neighborhood income, urban violence, and residential segregation. These do not fully explain the racial differences in prematurity or infant mortality rates.
A recent study from Stanford University evaluated the care provided to premature infants in neonatal intensive care units across California. Composite scores that included nine measures of quality neonatal care, such as timeliness of eye examinations, speed of weight gain, and death during hospitalization, were lower among African-American infants than among white infants.
Like many of my colleagues, I was outraged by these results, which suggested that implicit bias — unconscious preference for a specific class or racial/ethnic group — might be at work. Then I realized that I have sometimes treated babies and their parents differently because of their race or ethnicity. I’m not proud to admit that, but I can recall occasions when it happened. I wish I could take them back.
I have clumsily retreated from a family when I saw a portable video interpreter next to their baby’s bedside, saying to the nurses, “I’ll be back to update …” and not rushing back to do so.
I have spent 45 minutes during morning rounds chatting with mothers who visit their babies early every morning and stay all day. Then there are parents who miss my daily rounds because parking downtown is expensive and they must park during off hours to get a discount who I don’t take the time to call every day.
Since I have recognized this unintentional but nonetheless deplorable behavior in myself, I am making an effort to adjust my actions so my biases don’t affect the babies under my care and their parents.
This shouldn’t be so difficult as I am Japanese, a minority group in the countries I have lived in. I have been stared at, pointed at, and had my hopes denied because of how I look.
If a physician like me — one who took an oath to do no harm, who dedicated herself to giving every baby a chance, who knows what it’s like to be discriminated against, and whose research focuses on disparities in neonatal care — can unintentionally practice medicine with implicit bias, then anyone could be doing it.
I am now consciously on the lookout for ways to provide concrete support to families who are at a disadvantage, in tandem with the multidisciplinary team of social workers and discharge planners I work with. I ask families with transportation difficulties whether they would prefer having their baby transferred to a hospital closer to them. I block out times in my day, or my night, for family meetings with an interpreter in person.
Equally important, I talk about bias with my colleagues, even though some squirm in discomfort at the very idea of it.
The days of overt racial or ethnic discrimination in medicine are, I hope, coming to an end. I don’t believe that treatments are being withheld from African-American babies, but instead that the unintentional behaviors of health care providers, like my own examples of poor communication, will be what perpetuate health disparities like the racial gap in infant mortality.
Implicit bias has been described in medicine and among surgeons, nurses, and medical students. The Stanford study is the first to suggest the possible role of bias in quality of care against the tiniest and most vulnerable patients.
Closing the racial gap in infant mortality must be a health care and policy priority. Neonatologists must challenge themselves when yet another death of a premature African-American baby occurs without questioning how we could have done better.
I know I am starting with me.
Nana Matoba, M.D., is an assistant professor of pediatrics in the Division of Neonatology at Northwestern University’s Feinberg School of Medicine and a Public Voices Fellow through The OpEd Project.