Jenné Johns, MPH, Emilia Garcia, DNP, RNC-NIC

Nationally, August marks Breastfeeding Awareness Month, a time dedicated to advancing advocacy, protection, and promotion of breastfeeding to ensure that all families have the opportunity to breastfeed. August 25-31^st is also declared Black Breastfeeding Awareness Week to support Black women and families through lactation, cultural empowerment, and ensuring racial equity. As we celebrate and lift up stories across the spectrum of breastfeeding women, let us remember the unique needs of premature babies and their families’ joys, struggles, trials, and triumphs with feeding while in the NICU.

In this month’s Health Equity Column, I am honored to introduce Dr. Emilia Garcia, Neonatal Program Manager at Covenant Children’s Hospital, who is on a double mission – to improve health and racial equity institutionally and to replicate her success with eliminating breastfeeding disparity with Black women in her NICU.

Dr. Garcia was one of the first NICUs to require the completion of the Once Upon A Preemie Academy e-Learning courses with all NICU staff and specialists. In this column, you will learn the trans- formational power of implicit bias training personally and within a large hospital system and how these lessons positively impact all NICU families, specifically Black NICU families. As you read this column, I encourage you to reflect on your institutional challenges, gaps, and opportunities for improvement to eliminate disparities based on race, culture, and socioeconomic status in perinatal and neonatal care.

What is your definition of health equity?

I think it’s important that everyone recognizes the difference between equality and equity. Equality means that everybody gets the same thing. That seems fair, right? But in reality, every patient and every family has different needs. Those specific needs should be addressed. Health equity means the opportunity to reach our own highest potential of health. As healthcare givers, we should be aware of the individualized care that each person needs. The needs can range from language translation, transportation issues, spiritual care, mental health care, or food insecurity. The best way to know the needs of our patients is in the art and service of listening. There is quite a bit of focus on communicating with patients. In general, we think and act on communication through talking. I think we don’t take the time to listen, really listen to our patient’s stories.

And to make matters worse, the nursing shortage encourages task-oriented care. Nurses are incredibly busy trying to complete the nursing tasked care that it can be difficult to take the time necessary to listen. Being heard is an innate need for everyone; everybody wants to be heard because it makes us feel valued. It shows other people that you have time for them, and it demonstrates respect. I think listening demonstrates that the person/patient being heard matters.

What are your organizational priorities for addressing health and racial equity in perinatal and neonatal care? 

Our organization is committed to addressing health and racial equity. One of the first and critical barriers I have encountered is prioritizing demographic data collection to always include race, ethnicity, and language data (REaL data). We do a good job at data collection during inpatient registration, but sometimes some patients fall through the cracks. For example, there are multiple instances when a neonatal or a maternal transport arrives at our organization, and we do not collect their REaL data demographics. As we all know, data out is only as good as data in. When REaL data is available, patient outcomes can be stratified by race and ethnicity to determine if an area of disparate care is identified. If any area of disparate care is identified, we can acknowledge and act upon that information. 

It is also critical to maintain any improvement in patient outcomes through the development of a sustainability plan that may include education, dissemination of information through various platforms, administrative changes, and behavioral changes. When neonatal or perinatal patient outcomes are improved, it’s assuring to know there’s a that’s a plan in place, so all our efforts are not in vain and not short-lived. We want to make sure that everything we’re doing is sustainable over time and not just because DEI has become more recognized. Health and racial equity without organizational and executive leadership support is only optics. We need to have organizational strategies and funds for DEI to ensure that we are not just providing the appearance of DEI advocacy. Health and racial equity are seen in patient outcomes, not just the paper and print of a DEI commitment statement. 

One last thing I think it’s extremely critical to report our quality outcomes. We do a great job with and have a fantastic committee that reports all our quality outcomes throughout our organization, but I think it’s important to report those outcomes through an equity lens. A goal I have is to report neonatal and perinatal outcomes through an equity dashboard. I think this will give our staff and leadership some really great visual information that will help leverage some of the projects and changes that we want to make. 

What personal and professional experiences led you to focus on health equity in perinatal and neonatal care? 

For me, it was some of the experiences during the time I was a bedside nurse and charge nurse in the NICU. I would notice that some of our families were allowed to hold their babies sooner than other families, or some families were allowed extra family members at the bedside pre-COVID times. Looking back, I was guilty of these acts as well – particularly, I’d find myself engaging in providing privileged care to families that were higher socioeconomic status in the community or even privileged care to our staff who had their own infant in the NICU. Now I understand more about implicit bias and that we all have them. What’s important is self-reflection and recognizing when an implicit bias is swaying our decision(s) as a healthcare giver. 

During my doctoral program, we completed a statistics project, and we found some racial and ethnic disparities as outcomes in our project. It was really eye-opening to me and made me wonder what stratified data in our NICU would look like. One of my responsibilities is the oversight of our Nicu’s VON data. I was able to look at our overall outcomes, and then I stratified by race and ethnicity. The findings for our NICU showed disparate outcomes, which led to a health equity project in our NICU with a focus on breastfeeding at discharge. Through our partnership with Once A Preemie Academy and the incorporation of their health equity training courses, we have made statistically significant improvements in our breastfeeding at discharge rates for our Black infants. Breastfeeding rates at discharge for our Black infants was 40% for 2021 and have increased to 75% in 2022, 1st quarter. I am so proud of the improvements thus far! I am hoping to continue to build on the success of the health equity training and to further disseminate the health equity trainings to our newborn nursery and perinatal areas. 

What is your call to action for the industry as we seek to eliminate health and racial inequities in perinatal and neonatal care? 

During this time that I’ve developed a passion for equity, I think the big thing is that we need to acknowledge and act. We need to acknowledge our own biases and be mindful about when they occur, and then act to ensure that those biases don’t negatively affect the care of our patients. Then we need to acknowledge that racial and ethnic disparities and racism do exist within our organizations and that’s sometimes a hard pill to swallow. I think that once we can acknowledge that disparities and racism do exist within our own walls, then we can act. And we can act by making health equity an organizational strategic priority starting with executive leadership. Also, we need to speak up when we see inequities or acts of racism in our organization. Sometimes that’s hard to do, but by doing that, we help increase the health of our moms and our babies. Healthier moms mean healthier babies, and when you have healthier moms and babies, then you have healthier communities. I would go as far as to say, this, in turn, would result in a healthier world. 

As healthcare providers, we’re in a unique position to make a difference in the lives of our patients, and that has the potential to affect generations. My advisor said, “If you only help one person, that’s huge.” In terms of the ripple effect, so many things in our lives are generational, so if we can start with one mom and one baby, that can change generations. I think we need to do a better job about educating our mothers about the health of their bodies and their babies. They need the support and extra time to make sure that they understand the benefits of things like a healthy diet and the benefits of breastfeeding for both the mom and the baby. Sometimes they just don’t know. It’s our job to listen to their needs, barriers, and desires. What do they want? What are their goals for themselves and their babies? We can help provide them resources that they need to be healthy and stay healthy. I think it takes vulnerability for our moms to say, “Hey, I don’t understand what you’re saying,” or “I don’t understand what that means.” No one likes to be the one that has the question or to seem like they don’t know, but if we can create safe spaces and build trust, our families can feel comfortable asking questions and can feel okay being vulnerable. It takes lots of vulnerability and courage to ask questions, especially with the lack of provider concordance. 

I know that my own mother and father feel more comfortable with a Hispanic doctor or nurse because they feel they will be better understood from a shared culture experience. Sometimes there’s a bit of mistrust when a provider does not look like you. But it is possible to create trust with our patients by showing cultural humility and genuine desire to help meet their needs – equity. Respectful dialogue (listening) elevates the family to their rightful role as the primary caregiver. And it also helps us encourage family-centered care. 

I love the mission statement of Providence St. Joseph Health because I think it really wraps it all up perfectly. The mission statement is: “Know me, care for me, and ease my way.” I think that hits every part of what I’ve been talking about. 

Disclosure: The authors have no disclosures.