Color lines: Disparities in pharmacy treatment, education, and practice

Abstract

The murder of George Floyd occurred at a time in history when the world had slowed down due to the pandemic and many citizens had time to watch and process racial injustices that had previously been lost in the frantic buzz of everyday life. This catapulted racial injustice to center stage and brought about what many call a “racial reckoning.”1Roberts JD Pandemics and protests: America has experienced racism like this before. Brookings, 2021www.brookings.edu/blog/how-we-rise/2021/06/09/pandemics-and-protests-america-has-experienced-racism-like-this-before/Google Scholar, 2Menendian S Gambhir S Gailes A The Roots of Structural Racism Project: Twenty-first century racial residential segregation in the United States. Othering & Belonging Institute, 2021belonging.berkeley.edu/roots-structural-racismGoogle Scholar Across the country, many organizations have implemented Diversity, Equity, and Inclusion (DEI) initiatives, created task forces, brought in speakers, and hosted workshops in order to foster these important conversations.3Stahl A What's to come in 2021 for diversity, equity and inclusion in the workplace. Forbes, 2021www.forbes.com/sites/ashleystahl/2021/04/14/whats-to-come-in-2021-for-diversity-equity-and-inclusion-in-the-workplace/?sh=3b955d157f26Google Scholar In the 2019 National Pharmacist Workforce Study, it was noted that the field of pharmacy is becoming more diverse.4American Association of Colleges of Pharmacy Pharmacy profession becoming increasingly diverse and trending younger, survey shows. American Association of Colleges of Pharmacy, 2021www.aacp.org/article/pharmacy-profession-becoming-increasingly-diverse-and-trending-younger-survey-showsGoogle Scholar From 2014–2019, the percentage of non-white licensed pharmacists increased from 14.9% to 21.8% and the percentage of Black pharmacists doubled from 2.3% to 4.9%.4American Association of Colleges of Pharmacy Pharmacy profession becoming increasingly diverse and trending younger, survey shows. American Association of Colleges of Pharmacy, 2021www.aacp.org/article/pharmacy-profession-becoming-increasingly-diverse-and-trending-younger-survey-showsGoogle Scholar While these statistics have shown a shift in demographics and increase in diversity, 31% of pharmacists reported they had experienced discrimination in the workplace, and harassment related to race/ethnicity was the most common and made up 15.7% of all reported incidents.4American Association of Colleges of Pharmacy Pharmacy profession becoming increasingly diverse and trending younger, survey shows. American Association of Colleges of Pharmacy, 2021www.aacp.org/article/pharmacy-profession-becoming-increasingly-diverse-and-trending-younger-survey-showsGoogle Scholar Hospitals and health systems are also focusing on this important issue in order to address health inequities and reduce disparities that impact the communities that they serve.5American Hospital Association Health equity, diversity & inclusion measures for hospitals and health system dashboards.ifdhe.aha.org/system/files/media/file/2020/12/ifdhe_inclusion_dashboard.pdfDate: 2020Google Scholar Pharmacists in the community setting play a key role as an intermediary between the patient and their provider(s) and contribute to patient care via counseling, contacting prescribers with drug therapy issues, and facilitating the safe and effective use of medications.6Barber N Smith F Anderson S Improving quality of health care: the role of pharmacists.Qual Health Care. 1994; 3: 153-158Crossref PubMed Google Scholar Issues of discrimination and bias can be felt directly by patients. In a study of bias and the impact on patient care, Black patients felt less respected, felt that there was less collaboration with their providers, and noted more verbal dominance.7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar This can have a negative impact on patient-provider communication and patient health outcomes.7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar With patient-centered care, communication, and collaboration at the core of the Pharmacists’ Patient Care Process,8Joint Commission of Pharmacy Practitioners Pharmacists’ Patient Care Process (PPCP).jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdfDate: 2014Google Scholar it is essential for pharmacists to learn how to combat these issues so that their patients feel respected and heard. As pharmacists, it is essential to understand how systematic racism impacts our patients of Black or African descent in terms of quality of care and susceptibility to diseases. We must also acknowledge how racism and discrimination impact our fellow pharmacists throughout pharmacy school, postgraduate training, and practice. According to CDC, African Americans are more likely to die at early ages from all causes in comparison to non-Hispanic and Hispanic whites, and they have a lower life expectancy overall.9CDC African American health: Creating equal opportunities for health. CDC: Center for Disease Control and Prevention, 2017www.cdc.gov/vitalsigns/aahealth/index.htmlGoogle Scholar, 10HHS Office of Minority Health Profile: Black/African Americans.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61Date: 2021Google Scholar While this may be partially accounted for due to a higher rate of chronic diseases such as diabetes and cardiovascular disease,11HHS Office of Minority Health Diabetes and African Americans.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18Date: 2021Google Scholar, 12HHS Office of Minority Health Heart disease and African Americans.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19Date: 2021Google Scholar that does not tell the entire story. Health disparities and social determinants of health (SDOH) play an important role in health outcomes and the role of racism and discrimination in perpetuating these disparities must be addressed.13Williams D Rucker T Understanding and addressing racial disparities in health care.Health Care Financ Rev. 2000; 21: 75-90PubMed Google Scholar According to Healthy People 2030, SDOH are conditions in the places where people live, work, learn, worship, play, and age that affect health outcomes, health risks, and quality of life.14Healthy People 2030 Social determinants of health. U.S. Department of Health and Human Services..health.gov/healthypeople/objectives-and-data/social-determinants-healthGoogle Scholar This includes the areas of economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (Figure 1).14Healthy People 2030 Social determinants of health. U.S. Department of Health and Human Services..health.gov/healthypeople/objectives-and-data/social-determinants-healthGoogle Scholar SDOH contribute to health disparities, and addressing them is an important aspect of achieving health equity. This means removing obstacles to health such as racism, discrimination, and lack of education so that everyone has a fair opportunity to be as healthy as possible.15CDC Frequently asked questions. CDC: Center for Disease Control and Prevention, 2019www.cdc.gov/nchhstp/socialdeterminants/faq.htmlGoogle Scholar, 16Braveman P Arkin E Orleans T et al.What is health equity?. Robert Wood Johnson Foundation, 2017www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.htmlGoogle Scholar Racism is defined as “an organized system, [sic] rooted in an ideology of inferiority that categorizes, ranks[,] and differentially allocates societal resources to human population groups.”13Williams D Rucker T Understanding and addressing racial disparities in health care.Health Care Financ Rev. 2000; 21: 75-90PubMed Google Scholar Health disparities such as low birth weight, higher rates of hypertension, poorer health status, and higher rates of maternal mortality and morbidity can all be linked to racism.17Healthy People 2030 Discrimination. U.S. Department of Health and Human Services, 2021health.gov/healthypeople/objectives-and-data/social-determinants-health/literature-summaries/discriminationGoogle Scholar According to the American Public Health Association, 37 states have passed declarations stating that racism is a public health crisis.18American Public Health Association Analysis: Declarations of racism as a public health crisis.www.apha.org/-/media/Files/PDF/topics/racism/Racism_Declarations_Analysis.ashxDate: 2021Google Scholar While these declarations are not legally enforceable, they represent an important acknowledgment by state and local entities that racism is detrimental to the health of people of color.18American Public Health Association Analysis: Declarations of racism as a public health crisis.www.apha.org/-/media/Files/PDF/topics/racism/Racism_Declarations_Analysis.ashxDate: 2021Google Scholar There are various types of racism that can impact the health status of African Americans. Environmental racism is defined as the disproportionate impact of environmental hazards on people of color.19Beech P What is environmental racism and how can we fight it?. World Economic Forum, 2020www.weforum.org/agenda/2020/07/what-is-environmental-racism-pollution-covid-systemic/Google Scholar A prime example of this was the Flint water crisis, when primarily African American residents in Flint, MI were exposed to contaminated water due to a switch in water drinking supply by the local government.20Denchak M Flint water crisis: Everything you need to know. Natural Resources Defense Council, 2018www.nrdc.org/stories/flint-water-crisis-everything-you-need-knowGoogle Scholar Initial complaints were not addressed, and after the issue was investigated it was found that lead exposure rates in children had doubled and in some cases tripled.20Denchak M Flint water crisis: Everything you need to know. Natural Resources Defense Council, 2018www.nrdc.org/stories/flint-water-crisis-everything-you-need-knowGoogle Scholar In a paper by Tessum and colleagues, it was determined that Black Americans were exposed to 56% more pollution than they produced, while white Americans were exposed to 17% less pollution than they produced.22Tessum CW Apte JS Goodkind AL et al.Inequity in consumption of goods and services adds to racial-ethnic disparities in air pollution exposure.Proc Natl Acad Sci U S A. 2019; 116: 6001-6006Crossref PubMed Scopus (169) Google Scholar This is especially concerning because particulate matter, a type of air pollution, has been named as a contributor to lung disease, heart attacks, arrhythmias, and aggravated asthma by the Environmental Protection Agency.23United States Environmental Protection Agency Health and environmental effects of particulate matter (PM). United States Environmental Protection Agency, 2021www.epa.gov/pm-pollution/health-and-environmental-effects-particulate-matter-pmGoogle Scholar Redlining, a form of lending discrimination, is the practice of denying applicants mortgages based on racial bias.24The United States Department of Justice Justice Department announces new initiative to combat redlining: DOJ, CFPB and OCC announce resolution of lending discrimination claims against Trustmark National Bank. The United States Department of Justice, 2021www.justice.gov/opa/pr/justice-department-announces-new-initiative-combat-redliningGoogle Scholar While the practice of redlining was outlawed in 1968 with the Fair Housing Act, it still occurs today.24The United States Department of Justice Justice Department announces new initiative to combat redlining: DOJ, CFPB and OCC announce resolution of lending discrimination claims against Trustmark National Bank. The United States Department of Justice, 2021www.justice.gov/opa/pr/justice-department-announces-new-initiative-combat-redliningGoogle Scholar A recent report from UC Berkeley's Othering & Belonging Institute analyzed the demographics of major metropolitan areas across the United States and found that 81% of those regions were more segregated today than they were in 1990 (Figure 2).2Menendian S Gambhir S Gailes A The Roots of Structural Racism Project: Twenty-first century racial residential segregation in the United States. Othering & Belonging Institute, 2021belonging.berkeley.edu/roots-structural-racismGoogle Scholar Redlining has contributed to environmental racism by forcing African American families into less desirable areas that were at a greater risk of environmental exposures.25Center for Urban Population Health Equity. CUPH, 2021www.cuph.org/health-equity.htmlGoogle Scholar As homeownership is a cornerstone of wealth building in this country, redlining can lead to greater poverty rates.25Center for Urban Population Health Equity. CUPH, 2021www.cuph.org/health-equity.htmlGoogle Scholar It is also correlated with lower life expectancies; higher rates of chronic diseases and increased exposure to environmental risks and hazards such as lead in paint and the water supply.25Center for Urban Population Health Equity. CUPH, 2021www.cuph.org/health-equity.htmlGoogle Scholar, 26Richardson J Mitchell BC Meier HCS et al.Redlining and neighborhood health. National Community Reinvestment Coalition, 2021ncrc.org/holc-health/Google Scholar These exposures can have permanent and wide-reaching consequences, as lead poisoning can cause kidney and brain damage (Table 1);21The National Institute for Occupational Safety and Health Lead: Health Problems Caused by Lead. Centers for Disease Control and Prevention.www.cdc.gov/niosh/topics/lead/health.htmlDate accessed: December 21, 2021Google Scholar, 27Healthy People 2030 Reduce exposure to lead—EH-08. U.S. Department of Health and Human Services, 2021health.gov/healthypeople/objectives-and-data/browse-objectives/environmental-health/reduce-exposure-lead-eh-08Google Scholar, 28Healthy People 2030 Reduce blood lead levels in children aged 1 to 5 years—EH-04. U.S. Department of Health and Human Services, 2021health.gov/healthypeople/objectives-and-data/browse-objectives/housing-and-homes/reduce-blood-lead-levels-children-aged-1-5-years-eh-04Google Scholar additionally, mounting evidence has found that there was a statistically significant correlation between higher blood-lead levels and higher levels violent crime (e.g., gun crimes, assaults, robberies, and homicides).29Boutwell BB Nelson EJ Qian Z et al.Aggregate-level lead exposure, gun violence, homicide, and rape.PLoS One. 2017; 12e0187953 Crossref PubMed Scopus (10) Google ScholarTable 1Adverse effects of lead exposure21The National Institute for Occupational Safety and Health Lead: Health Problems Caused by Lead. Centers for Disease Control and Prevention.www.cdc.gov/niosh/topics/lead/health.htmlDate accessed: December 21, 2021Google ScholarMemory lossPain or tingling in hands and/or feetWeaknessAbdominal painHeadacheConstipationAnemiaKidney damageBrain damage (affects behavior and intelligence in children)Miscarriage, stillbirth, infertility Open table in a new tab Although the research is newly emerging, residential segregation also seems to have an impact on access to pharmacies. A study published in 2021 analyzed 42 million residents across the 30 most populous cities in the United States—79% of which were segregated by race/ethnicity—to determine the prevalence of pharmacy deserts, defined as a neighborhood with low access to pharmacies.30Guadamuz JS Wilder JR Mouslim MC et al.Fewer pharmacies In Black And Hispanic/Latino neighborhoods compared with white or diverse neighborhoods, 2007–15.Health Aff (Millwood). 2021; 40: 802-811Crossref PubMed Scopus (10) Google Scholar During the 2007–2015 study, there were fewer pharmacies in Black and Hispanic/Latino neighborhoods when compared to white or diverse neighborhoods.30Guadamuz JS Wilder JR Mouslim MC et al.Fewer pharmacies In Black And Hispanic/Latino neighborhoods compared with white or diverse neighborhoods, 2007–15.Health Aff (Millwood). 2021; 40: 802-811Crossref PubMed Scopus (10) Google Scholar This difference was statistically significant. Additionally, fewer pharmacies opened—and more closed—in Black and Hispanic/Latino neighborhoods.30Guadamuz JS Wilder JR Mouslim MC et al.Fewer pharmacies In Black And Hispanic/Latino neighborhoods compared with white or diverse neighborhoods, 2007–15.Health Aff (Millwood). 2021; 40: 802-811Crossref PubMed Scopus (10) Google Scholar Without adequate access to pharmacies, patients will have challenges with adherence to their medication regimens and difficulties managing chronic diseases. They also lose access to additional services—such as naloxone, contraception, COVID-19 testing, and vaccinations—which serve to further impact health outcomes.30Guadamuz JS Wilder JR Mouslim MC et al.Fewer pharmacies In Black And Hispanic/Latino neighborhoods compared with white or diverse neighborhoods, 2007–15.Health Aff (Millwood). 2021; 40: 802-811Crossref PubMed Scopus (10) Google Scholar In 2015, almost 15 million people were impacted by pharmacy desserts, which were in one-third of all neighborhoods in the largest cities in the United States.30Guadamuz JS Wilder JR Mouslim MC et al.Fewer pharmacies In Black And Hispanic/Latino neighborhoods compared with white or diverse neighborhoods, 2007–15.Health Aff (Millwood). 2021; 40: 802-811Crossref PubMed Scopus (10) Google Scholar Implicit attitudes are ones that exist outside of our conscious awareness and can conflict with how a person believes that they view the world.7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar According to evolutionary psychologists, they stem from the human brain's attempts to quickly find patterns in small amounts of information and may have been developed as a protective mechanism.31American College of Cardiology Cover story: Implicit bias: Recognizing the unconscious barriers to quality care and diversity in medicine. American College of Cardiology, 2020www.acc.org/latest-in-cardiology/articles/2020/01/01/24/42/cover-story-implicit-bias-recognizing-the-unconscious-barriers-to-quality-care-and-diversity-in-medicineGoogle Scholar They also form at a young age and can be continuously reinforced over time.31American College of Cardiology Cover story: Implicit bias: Recognizing the unconscious barriers to quality care and diversity in medicine. American College of Cardiology, 2020www.acc.org/latest-in-cardiology/articles/2020/01/01/24/42/cover-story-implicit-bias-recognizing-the-unconscious-barriers-to-quality-care-and-diversity-in-medicineGoogle Scholar While they may have helped humans rapidly identify a threat in an encounter—for example, with a wild animal—implicit biases can have a direct, negative impact on patient care by affecting provider-patient interactions and relationships and by contributing to health disparities.31American College of Cardiology Cover story: Implicit bias: Recognizing the unconscious barriers to quality care and diversity in medicine. American College of Cardiology, 2020www.acc.org/latest-in-cardiology/articles/2020/01/01/24/42/cover-story-implicit-bias-recognizing-the-unconscious-barriers-to-quality-care-and-diversity-in-medicineGoogle Scholar, 32Edgoose J Quiogue M Sidhar K How to identify, understand, and unlearn implicit bias in patient care.Fam Pract Manag. 2019; 26: 29-33PubMed Google Scholar Explicit biases—such as viewing Black patients as less intelligent, less adherent, and more likely to engage in risky behaviors in comparison to white patients—may be maintained by some health care professionals.7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar However, even if these explicit biases are addressed, implicit biases may still remain and continue to affect the medical care provided to Black patients.7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar In a systematic review of implicit bias among health care professionals, Black patients perceived lower levels of patient-centeredness and provider communication from providers that demonstrated implicit bias based on the Implicit Association Test (IAT).7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google Scholar Treatment recommendations and patient health outcomes were also affected (Table 2).7Hall WJ Chapman MV Lee KM et al.Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (777) Google ScholarTable 2Effects of implicit bias in patient care31American College of Cardiology Cover story: Implicit bias: Recognizing the unconscious barriers to quality care and diversity in medicine. American College of Cardiology, 2020www.acc.org/latest-in-cardiology/articles/2020/01/01/24/42/cover-story-implicit-bias-recognizing-the-unconscious-barriers-to-quality-care-and-diversity-in-medicineGoogle Scholar, 33The Joint Commission Quick safety 23: Implicit bias in health care. The Joint Commission, 2016www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/implicit-bias-in-health-care/Google ScholarBlack and Hispanic patients are less likely than whites to receive pain medications. When they do, the doses are lower than those prescribed to white patients.Black patients are less likely to receive evidence-based care for stroke, myocardial infarction, and heart failure in comparison to white patients.Black women are more likely to die after a breast cancer diagnosis.Black men are less likely to receive chemotherapy and radiation to treat prostate cancer and are more likely to have testicles removed. Open table in a new tab The Black maternal health crisis is at the intersection of health disparities, health inequity, and implicit bias. Overall maternal mortality rates have decreased worldwide with better access to prenatal care, healthier living conditions, safer procedures, and antibiotics;34Declercq E Zephyrin L Maternal mortality in the United States: A primer. The Commonwealth Fund, 2020www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primerGoogle Scholar however, in the United States, maternal mortality rates have increased by 26.6% from 2000 to 2014.35MacDorman MF Declercq E Cabral H et al.Is the United States maternal mortality rate increasing? Disentangling trends from measurement issues.Obstet Gynecol. 2016; 128: 447-455Crossref PubMed Scopus (254) Google Scholar Approximately 700 women die annually due to pregnancy or delivery complications;36CDC Infographic: Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. CDC: Centers for Disease Control and Prevention, 2020www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/infographic.htmlGoogle Scholar up to 60% of these deaths may be preventable and are affected by racial disparities.37Omeish Y Kiernan S Targeting bias to improve maternal care and outcomes for Black women in the USA.EClinicalMedicine. 2020; 27100568 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The maternal mortality rate for Black mothers was 2.5 times higher than that for white mothers according to a 2018 dataset from CDC; this was higher than in 1915, when Black maternal mortality was 1.8 times greater than white maternal mortality.34Declercq E Zephyrin L Maternal mortality in the United States: A primer. The Commonwealth Fund, 2020www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primerGoogle Scholar When looking at education levels specifically, African American women with a college degree or higher were 5 times more likely to suffer a pregnancy-related death in comparison to a white woman with similar education (Figure 3).36CDC Infographic: Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. CDC: Centers for Disease Control and Prevention, 2020www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/infographic.htmlGoogle Scholar Socioeconomic status, access to good quality care, and insurance coverage are important to address for both mortality and morbidity rates, but there are additional factors at play given that completing higher education is not protective for African American mothers.34Declercq E Zephyrin L Maternal mortality in the United States: A primer. The Commonwealth Fund, 2020www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primerGoogle Scholar, 37Omeish Y Kiernan S Targeting bias to improve maternal care and outcomes for Black women in the USA.EClinicalMedicine. 2020; 27100568 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Patient-provider communication can be poor and there is the potential for false preconceived beliefs that Black patients have higher pain thresholds.38Green T Zapatas J Brown H et al.Rethinking bias to achieve maternal health equity changing organizations, not just individuals.Obstet Gynecol. 2021; 137: 935-940Crossref PubMed Scopus (2) Google Scholar African American women are less likely to receive epidurals for pain management and are more likely to undergo cesarean sections.38Green T Zapatas J Brown H et al.Rethinking bias to achieve maternal health equity changing organizations, not just individuals.Obstet Gynecol. 2021; 137: 935-940Crossref PubMed Scopus (2) Google Scholar, 39Saluja B Bryant Z How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States.J Womens Health (Larchmt). 2021; 30: 270-273Crossref PubMed Scopus (18) Google Scholar This may be partially responsible for the increase in maternal death rates, as hemorrhage, anesthesia complications, and infection are associated with cesarean sections and are 3 of the top leading causes of maternal mortality.39Saluja B Bryant Z How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States.J Womens Health (Larchmt). 2021; 30: 270-273Crossref PubMed Scopus (18) Google Scholar There are also systematic issues impacting this issue. In the Vaginal Birth After Cesarean (VBAC) Calculator, ethnicity in addition to age, BMI, and obstetrics history is taken into account to calculate the probability of a successful vaginal birth due to observational data that found that women who identified as nonHispanic white were more likely to achieve VBAC.38Green T Zapatas J Brown H et al.Rethinking bias to achieve maternal health equity changing organizations, not just individuals.Obstet Gynecol. 2021; 137: 935-940Crossref PubMed Scopus (2) Google Scholar Even with all other characteristics being the same, a provider attempting to practice evidence-based medicine may make different recommendations to their African American patients in comparison to their white patients due to this calculator.38Green T Zapatas J Brown H et al.Rethinking bias to achieve maternal health equity changing organizations, not just individuals.Obstet Gynecol. 2021; 137: 935-940Crossref PubMed Scopus (2) Google Scholar These differences are not just exclusive to white and Black pregnancies. In 2017–2019, the cesarean rate across all ethnic groups was 31.8%; African Americans had a rate of 35.5%, Asian/Pacific Islanders had a rate of 32.5%, and whites had a rate of 31%.40March of Dimes Foundation Total cesarean deliveries by race: United States, 2017-2019 average. March of Dimes, 2021www.marchofdimes.org/Peristats/ViewSubtopic.aspx?lev=1&obj=1&reg=99&slev=1&stop=355&top=8Google Scholar Additionally, according to the Listen to Mothers III survey, approximately 1 in 5 Black or Hispanic women experienced mistreatment from health care providers based in hospitals.39Saluja B Bryant Z How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States.J Womens Health (Larchmt). 2021; 30: 270-273Crossref PubMed Scopus (18) Google Scholar Addressing the lack of diversity in medical education is a key step that would lead to a more racially and socioeconomically diverse physician workforce equipped to address health disparities and holistically care for the populations they serve.38Green T Zapatas J Brown H et al.Rethinking bias to achieve maternal health equity changing organizations, not just individuals.Obstet Gynecol. 2021; 137: 935-940Crossref PubMed Scopus (2) Google Scholar The Black Maternal Momnibus Act of 2021 would help address this issue by providing funding f