Rubashkin Nicholas, Asiodu Ifeyinwa V, Vedam Saraswathi, Sufrin Carolyn, Kuppermann Miriam, Adams Vincanne
Department of Obstetrics, & Reproductive Sciences, University of California at San Francisco, 490 Illinois St, GynecologySan Francisco, CA, 1025594158, USA.
Institute for Global Health Sciences, University of California at San Francisco, San Francisco, CA, USA.
J Racial Ethn Health Disparities. 2024 Dec 14. doi: 10.1007/s40615-024-02233-4.
The clinical application of race-adjusted algorithms may perpetuate health inequities. We assessed the impact of the vaginal birth after cesarean (VBAC) calculator, which was revised in 2021 to address concerns about equity. The original algorithm factored race and ethnicity and gave lower VBAC probabilities to Black and Hispanic patients.
From 2019 to 2020, we conducted a multi-site, ethnographic study consisting of interviews and audio recordings of 14 prenatal visits. We used grounded theory to describe the social processes of racialization.
Across 4 sites, 12 obstetricians, 5 midwives, and 31 pregnant/postpartum patients participated. Seventy-four percent (N = 23) of the pregnant/postpartum individuals identified as racially minoritized, and the remaining 24% (N = 8) identified as White. We identified four processes that facilitated the "automation" of racism: adhering to strict cutoffs; the routine adoption of calculators; obfuscating the calculator; and the reflexive categorization of race and ethnicity. When clinicians adhered to strict cutoffs, they steered low-scoring Black and Hispanic patients toward repeat cesareans. If clinicians obfuscated the calculator, Black and Hispanic patients had to work to decode the role of race and ethnicity in their probabilities in order to pursue a VBAC. By reflexively categorizing race and ethnicity, the use of the calculator forced patients to choose a singular identity, even if it obscured the truth about their multi-faceted race or ethnicity.
The VBAC calculator's inclusion of race and ethnicity helped to automate racism by coding race into institutional practices and care interactions. This resulted in some clinicians discouraging or prohibiting Black and Hispanic patients from attempting a VBAC.
To date, no empiric study has examined whether the VBAC calculator produced inequities in access to VBAC services and reproduced racism in care. The VBAC calculator resulted in fewer VBAC attempts among racially minoritized patients, denying them the opportunity to undergo labor and a vaginal birthing experience.
种族调整算法的临床应用可能会使健康不平等现象长期存在。我们评估了2021年修订的剖宫产术后阴道分娩（VBAC）计算器的影响，该修订旨在解决对公平性的担忧。原始算法将种族和族裔因素考虑在内，给予黑人和西班牙裔患者较低的VBAC概率。
2019年至2020年，我们开展了一项多地点的人种志研究，包括对14次产前检查进行访谈和录音。我们运用扎根理论来描述种族化的社会过程。
在4个地点，12名产科医生、5名助产士和31名怀孕/产后患者参与了研究。74%（N = 23）的怀孕/产后个体被认定为少数族裔，其余24%（N = 8）被认定为白人。我们确定了促成种族主义“自动化”的四个过程：坚持严格的临界值；常规使用计算器；对计算器进行模糊处理；以及对种族和族裔进行反射性分类。当临床医生坚持严格的临界值时，他们会引导得分较低的黑人和西班牙裔患者选择再次剖宫产。如果临床医生对计算器进行模糊处理，黑人和西班牙裔患者必须努力解读种族和族裔在其VBAC概率中的作用，以便寻求VBAC。通过对种族和族裔进行反射性分类，计算器的使用迫使患者选择单一身份，即使这掩盖了他们多方面种族或族裔的真相。
VBAC计算器纳入种族和族裔因素，通过将种族编码到机构实践和护理互动中，有助于使种族主义自动化。这导致一些临床医生劝阻或禁止黑人和西班牙裔患者尝试VBAC。
迄今为止，尚无实证研究考察VBAC计算器是否在VBAC服务获取方面产生不平等现象，以及在护理中再现种族主义。VBAC计算器导致少数族裔患者尝试VBAC的次数减少，剥夺了他们经历分娩和阴道分娩体验的机会。
