Volume 68, Issue 4 | Page 19

ing or simply never having acknowledged that privilege comes with assumptions and biases that must be looked for consciously. For example, blaming a pregnant woman for gaining too much weight assumes that she has access to affordable healthy foods, time to prepare them and a safe place to exercise. Black women who are working long hours for low pay may barely be able to make it to the appointment, and need support, not blame. The insensitive, unaware type doctors might launch into a lecture and then feel aggrieved that patients “don’t listen” instead of seeing everything, first and foremost, from the patient’s reality - not their own. Research has proven that pain is undertreated in Black women compared to others. White doctors have been known to order more tests on white women than others. White doctors may speak differently to Black women, as described by the National Institutes of Health. These effects of bias are not lost on the Black patient, who recognizes the implicit bias and backs away from care by the offending provider. That can lead to failure to follow standard medical care with the result being an increased potential for medical injury. Nationally, the maternal mortality rate for women of color is twice that of white women. Reviewing two women may put life into these concepts. We may be treating patient Cierra, a 25-year-old Black woman from a largely non-white neighborhood. Even before COVID-19 struck, she had difficulty getting to a doctor in the suburbs and felt that the closest clinic treated her as a number. Cierra shares an apartment with her children, her parents and one other sibling. She cannot find anyone to watch her own children when she has to take two buses to get to her medical appointments, so she misses many of them. She is suspicious that the doctor makes money by just checking her in and is not really concerned with her health. Cierra is not able to follow the recommendations on diet or obtain prenatal vitamins—she has bigger issues to deal with in her environment. So it is not surprising that she develops hypertension in the pregnancy with renal injury. The obstetrician recommends early delivery as she is becoming pre-eclamptic. Cierra delivers prematurely at 31 weeks gestation; and because of her pre-eclampsia, is at risk for future hypertension. Kentucky has a large rural population. While only 8% of its population is Black, the Commonwealth has a large white population with a different set of problems. Nationally, women in rural areas MOTHERS IN MEDICINE Source: https://www.courier-journal.com/in-depth/news/investigations/2018/09/20/maternal-death-rate-state-medical-deadly-deliveries/1352054002/ (last accessed Aug. 9, 2020) face greater issues with adequate access to proper prenatal care both because of the distances to hospitals, and also because there are fewer obstetricians or maternal-fetal medicine doctors in the rural areas. The overall perinatal mortality rate is higher in the rural areas. All of this makes for higher-risk patients during the COVID-19 crisis. The impact on the rural areas is huge. But for our rural patient, Casey, who had a traumatic injury several years before her current pregnancy, she began taking Vicodin for that injury and is now finding OxyContin either in doctors’ offices or through friends. She has been unable to find work since her job at the Dollar General Store was eliminated with the coronavirus pandemic. She has trouble making her appointments because she is either high or her boyfriend doesn’t have gas money. She develops hypertension in pregnancy and has to have an early delivery. The (continued on page 18) SEPTEMBER 2020 17