Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO.
St. Louis Integrated Health Network, St. Louis, MO.
Am J Obstet Gynecol. 2021 Apr;224(4):359-361. doi: 10.1016/j.ajog.2020.11.040. Epub 2020 Dec 9.
Health inequities are not caused by personal failings or shortcomings within disadvantaged groups, which can be erased with behavioral interventions. The scope of the problem is much greater and will only fully be addressed with the examination of the systems, structures, and policies that perpetuate racism, classism, and an economic, class, race, or gender divide between patients and the people who care for them. Solution-oriented strategies to achieve health equity will remain elusive if researchers continue to focus on behavior modification in patients while failing to do harder work that includes focusing on the institutions, community, and societal contexts in which pregnant women are living; addressing social determinants of health; considering racism in study design, analysis, and reporting; valuing the voices of patients, practitioners, and researchers from historically disadvantaged groups; disseminating research findings back to the community; and developing policy and reimbursement structures to support care delivery change that advances equitable outcomes. A case study shows us how group prenatal care may be one viable vehicle through which to affect this change. Group prenatal care is one of the few interventions shown to improve pregnancy outcomes for black women. Studies of group prenatal care have predominantly focused on the patient, but here we propose that the intervention may exert its greatest impact on clinicians and the systems in which they work. The underlying mechanism through which group prenatal care works may be through increased quantity and quality of patient and practitioner time together and communication. We hypothesize that this, in turn, fosters greater opportunity for cross-cultural exposure and decreases clinician implicit bias, explicit bias, and racism, thus increasing the likelihood that practitioners advocate for systems-level changes that directly benefit patients and improve perinatal outcomes.
健康不平等不是弱势群体个人失败或缺点造成的，通过行为干预可以消除这些问题。问题的范围要大得多，只有通过检查使种族主义、阶级主义以及患者和医护人员之间的经济、阶级、种族或性别鸿沟永久存在的制度、结构和政策，才能充分解决这些问题。如果研究人员继续专注于改变患者的行为，而不努力关注孕妇所处的机构、社区和社会环境；解决健康的社会决定因素；在研究设计、分析和报告中考虑种族主义；重视来自历史上处于不利地位群体的患者、从业者和研究人员的意见；将研究结果传播回社区；并制定政策和报销结构，以支持提供能够改善公平结果的护理服务，那么以实现健康公平为导向的策略仍将难以实现。一个案例研究向我们展示了群体产前护理如何成为影响这种变化的可行手段之一。群体产前护理是少数被证明可以改善黑人女性妊娠结局的干预措施之一。群体产前护理的研究主要集中在患者身上，但在这里我们提出，该干预措施可能对临床医生及其工作的系统产生最大影响。群体产前护理发挥作用的潜在机制可能是增加了患者和从业者在一起的时间以及沟通的数量和质量。我们假设，这反过来又为跨文化接触提供了更多机会，并减少了临床医生的隐性偏见、显性偏见和种族主义，从而增加了从业者倡导系统层面的变革的可能性，这些变革直接使患者受益并改善围产期结局。
