“If you ask how many Black women are dying in Canada, we don’t have that,” said Dr. Tunde Byass, an obstetrics and gynecology specialist and president of Black Physicians Canada, speaking about recording incidence of maternal mortality.
Recently, reachers in the U.S. and U.K. have sought to shed light on health disparities facing Black women when it comes to labour and delivery. In June 2020, the U.K. government announced it would fund a study into factors associated with the higher risk of maternal death for Black and South Asian women. The announcement came after a government-sponsored petition received nearly 200,000 signatures following a report that showed Black women were five times more likely to die during childbirth compared to their white counterparts.
In April 2021, U.S. President Joe Biden established the first Black Maternal Health Week and announced the investment of $200 million to implement implicit bias training for healthcare providers; create state pregnancy medical home programs; bolster Maternal Mortality Review Committees; and expand the Rural Maternity and Obstetrics Management Strategies (RMOMS) program.
However in Canada, there remains a lack of data when it comes to maternal health and mortality as relates to race. Indeed, to inform care in Canada, the nation’s physicians are borrowing data from the U.K. and U.S. in order to better understand these disparities, said Dr. Byass.
This gap, she said, is potentially harmful to Black expectant mothers. “We need to . . . understand that if we don't talk about it, we cannot disrupt or respond to racism.”
What stats do exist and why aren’t there more?
In a key 2016 study informing the issue, researchers from McGill University found that 8.9% of Black women gave birth to pre-term babies, compared to 5.9% of their white peers, examining singleton live births for 2004 through 2006.
But there is little Canadian national data on Black maternal mortality and other birth-related adverse outcomes.
One reason for these limited statistics is that data collection of this kind simply isn’t routine practice in a clinical setting, said Liz Darling, director and assistant dean of McMaster’s Midwifery program.
As well, there are concerns around the sharing of such sensitive data. “[The fact that] people desire to make sure that if the data is collected, that it's collected appropriately and that it's used appropriately has been used as a barrier,” said Darling. “And essentially, until very recently, people haven't been willing to prioritize all the work that would be needed to figure out how to collect this data . . ..”
Pain of Black childbirth and beyond
In anarticle published by the New England Journal of Medicine, “Taking Black Pain Seriously” Dr. Oluwafunmilayo Akinlade explained how the lack of Black physicians and the misrepresentation of Black people in the media are factors contributing to biased decision making in relation to pain management for Black patients.
“Myths, disparities and pervasive systemic inequities in healthcare have fostered bias and distorted perceptions of Black people’s pain, leading to catastrophic outcomes,” Dr. Akinlade wrote.
In the world of obstetrics and gynecology specifically, this phenomenon has been observed in postpartum care. A retrospective cohort study including 9,900 women published in Obstetrics & Gynecologyin 2019 found Hispanic and non-Hispanic Black women more frequently reported pain scores of five or higher, were less likely to be prescribed opioids at discharge from hospital and got fewer morphine milligram equivalents per day as inpatients.
Representation in care
Meanwhile, the University of Toronto’s Temetry Faculty of Medicine is looking to address issues of bias in medical education, outlining mentoring and support programs in a recent accountability report. On March 23, 2020 the faculty held a conference Dismantling Anti-Black Racism in Medical Education. The report that followed found that only 6% of all medical students at the University of Toronto and 3% of those in residency identified as Black.
This lack of representation limits a pregnant Black woman’s ability to receive care from a practitioner who is also racialized. “Many Black women carry their lived experiences of racism into their medical appointments,” said Dr. Byass. As a result, even if non-Black practitioners are more aware of the biases that have been traditionally at play, it may not be enough to make some Black women entirely comfortable.
Websites such as Mommy Monitor, a database of all Black maternal healthcare providers in Ontario seeks to raise awareness and provide resources for expectant mothers before, during and after the gestational period. Such activist-based websites allow Black women to advocate for themselves and feel more comfortable with their chosen healthcare provider.
“The whole way that midwifery is built, is a relationship of trust—to provide time to develop a relationship, where the care provider can get to know the client that they're caring for and make sure that they're providing care that really, truly meets their needs,” said Darling.
Hunting and gathering
Today, various groups are taking steps to expand data collection among Black communities. The Black Health Equity Working Group together with academics, Black community members and public health professionals, is developing a framework on how race-based data collection can help bridge the gap in health disparities in Canada.
The working group is taking the equality, governance, access and protection (EGAP) approach—modeled after the First Nations principles of ownership, control, access and possession (OCAP). The OCAP principles are used and taught by the First Nations Information Governance Centre, which sought to design a health survey in response to the exclusion of Indigenous people living on reserves in three major censuses carried out by the Canadian government. The centre has been collecting data and promoting Indigenous ownership of that data since 2010.
The Black Equity Working Group’s framework places importance on dismantling anti-Black racism in public health by:
- uncovering inequities;
- developing policy and practice to tackle these inequities;
- monitoring and evaluating the effectiveness of interventions, by holding authorities accountable for improving outcomes; and ultimately
- eliminating structural racism from systems.
But, groups tackling this data collection have some serious work ahead of them. Dr. Byass suggests a national strategy is needed to overcome the barriers inherent to the varied provincial regulations on data collection. “There are so many barriers from different territories. . .. And that's the biggest issue. . ..That is why the number of deaths is grossly underestimated.”