Where do we stand in nursing and midwifery, in relationship to the patients we care for? At the bedside, you might say-a simple expression that acknowledges the importance these roles place on direct, hands-on caregiving. In support of birthing autonomy, some will say, or in contrast, committed to avoiding any possible risk in support of a healthy outcome. Along with acknowledging a spectrum of approaches to the clinical content of care, some more equitable than others, it is more than time to understand that there is also a spectrum of equity for all patients. Focusing on equity can lead clinicians to patterns of care that not only are more satisfying for the birthing patient but also lead to less disparate clinical outcomes.

Nursing, with the sheer volume of needed clinicians, must address the issues surrounding equitable care for all birthing families in many ways. Cultural concordance between provider and patient is one factor that has been recognized as supporting better outcomes.1 Providing culturally concordant nursing care is unlikely to be possible in most settings. While race or ethnicity is the most common cultural relationship discussed, gender and sexual identity or religious faith can also play a role. A more nuanced view can come from the social justice movement, using the concepts of positionality and intersectionality-the multiple factors that identify each individual and place him or her in a web of relationships. We are only experts for our own identity. Only when we truly see and listen to the patients we provide care for, and accept that each person carries the experiences of his or her own lives and community, can we honor their experience and support their needs. In other words, we must start with the woman where she is, and not demand that she meet our expectations in order to receive respectful care.

How clinicians provide information and the options offered affect the experience of birth. Structural racism within healthcare and personal bias contribute to negative experiences.2 One example of the work that needs to be done comes from Boston, where community organizers working to establish a birth center supported a study about what quality care means to people of color. Participants used the term "being known" to describe maternity providers who saw them as individuals and did not make judgments about their needs or condition based on race.3 Similarly, a qualitative study by Altman et al4 found that when providers invested quality time with patients and worked to build connections that led to individualized care, the experience of birth improved. Participants also identified implicit bias training and changing the healthcare system to reduce stereotyping and discrimination as important.4

To get to the possibility of seeing each person as a whole and worthy individual, nursing and midwifery need to take several actions. First, we must step back and explore how to achieve equity for students, which may challenge faculty perceptions of our own actions. Then we must actively explore how to teach our students attitudes and skills that will help them act to reduce racism and "othering" of challenging patients with stigmatizing conditions such as substance use, certain infections, or poverty.

Equity in professional education is not as simple as simply accepting more diverse students. Before nursing and midwifery students can feel safe, their faculty and staff-and clinical preceptors-need to address internal biases and presumptions about students from underrepresented communities. A simple video with checklist quiz is not adequate. Neither is hiring a single faculty member of color and expecting him or her to carry the load of expertise. Our ideas are long-standing; the work to change our awareness of how we interrelate with a complex community will take time and commitment. We cannot teach our students how to act as self-aware, equity-seeking clinicians unless we adopt the cultural humility necessary to learn for ourselves.5

As students learn material that puts forward concepts of inclusion and equity, explores the effects of systemic racism, and ensures an accurate representation of clinical aspects of care (eg, identifying lesions on highly pigmented skin) cannot be pushed aside into a single course or addressed as alternatives. To use the pigmentation example, if the illustrations and descriptions of dermatologic conditions are based on White skin, and examples as they appear in Black skin are separated out or presented as differences from that White baseline, then students of color have been told they are not the norm. A clinical assumption might be that Black teens are less likely to breastfeed, so there is no need to focus on supporting them. One resource that offers a road map for achieving a maternity workforce that better represents populations is the Equity Agenda Guideline and the Web site on Equity in Midwifery Education.5

The clinical setting in which students learn may also place them at risk of racist behaviors from their preceptors and future colleagues. Canty et al wrote that "racism in nursing is essentially a taboo topic."6⁽²⁶⁾ The issue is that if we cannot identify, speak out about, and work to change microaggressions, outright prejudice, and incorrect assumptions, we cannot change the environment. If we cannot change the clinical environment, we risk continuing to graduate young clinicians into a hostile workspace. As clinical units begin to work on anti-racist initiatives, the White participants will find themselves uncomfortable, and that is all right.

In summary, choosing an equitable future for our professions and equitable care for all our patients is hard work and multifaceted. It begins with looking at ourselves and listening to others. Surely we can do that much.

-Jan M. Kriebs, MSN, CNM, FACNM

Adjunct Professor

Midwifery Institute at Jefferson University

Philadelphia, Pennsylvania

References