Recognizing Our Biases, Understanding the Evidence, and Responding Equitably

Application of the Socioecological Model to Reduce Racial Disparities in the NICU

Abstract

Background: 

Implicit bias permeates beliefs and actions both personally and professionally and results in negative health outcomes for people of color—even in the neonatal intensive care unit (NICU). NICU clinicians may naïvely and incorrectly assume that NICU families receive unbiased care. Existing evidence establishing associations between sex, race, and neonatal outcomes may perpetuate the tendency to deny racial bias in NICU practice.

Evidence Acquisition: 

Using the socioecological model as a framework, this article outlines evidence for racial health disparities in the NICU on multiple levels—societal, community, institutional, interpersonal, and individual. Using current evidence and recommendations from the National Association of Neonatal Nurses Position Statement on “Racial Bias in the NICU,” appropriate interventions and equitable responses of the NICU clinician are explored.

Results: 

Based on current evidence, clinicians should reject the notion that the social construct of race is the root cause for certain neonatal morbidities. Instead, clinicians should focus on the confluence of medical and social factors contributing to each individual infant's progress. This critical distinction is not only important for clinicians employing life-saving interventions, but also for those who provide routine care, developmental care, and family education—as these biases can and do shape clinical interactions.

Implications for Practice and Research: 

Healthcare practitioners have an ethical and moral responsibility to maintain up-to-date knowledge of new evidence that impacts our clinical practice. The evidence demonstrates the importance of recognizing the enduring role of racism in the health and well-being of people of color and the need to adjust care accordingly.

Implicit biases reflect unconscious attitudes or stereotypes toward an individual or group of individuals based on their social group membership, categories, or traits.¹ These biases are often difficult to recognize in oneself because they develop based on how memories are formed by our culture and history, and then how assumptions are retained from that history. Individuals come from various backgrounds and social structures and are therefore shaped by these varied experiences—in ways that are often outside of one's control. Implicit biases may be either positive or negative and can unconsciously impact one's actions and decision-making processes.¹ Clinician bias has the potential to be especially harmful in healthcare where patients are already vulnerable given their state of illness or injury.² Healthcare practitioners have an ethical and moral responsibility to maintain up-to-date knowledge of new evidence about the effectiveness of interventions employed and make necessary adjustments, as new evidence comes to light. The same must be true for implicit bias. Self-reflection around both prejudices and affinities that impact daily practice, making necessary adjustments, and seeking out evidence-based strategies are critical to improving patient care.

Over the many years I have worked as a physical therapist in the neonatal intensive care unit (NICU), I have often heard the term “wimpy White boy” casually applied to neonates who slowly develop independent respiratory and feeding skills,³ ultimately, requiring more attention from their caregivers. In opposition, infants making steady progress, often Black girls, were described as “feisty.”

While these terms seemed to be quite harmless initially, about 5 years ago, I gained new perspective in reading an online article by Tyrese Coleman titled “‘Wimpy White Boy Syndrome’: How Racial Bias Creeps Into Neonatal Care.”⁴ It was jarring to see the term “wimpy white boy syndrome” (WWBS) in print as an example of racial bias, mostly because my most recent framework for conceptualizing racial bias was in the form of reading about or watching police brutality and other violent acts of racial injustice displayed in the media. The author of the piece, a Black mother of extremely preterm twins, presented historical and research evidence indicating that the biases we harbor, unconscious or otherwise, can and do make their way into medical spaces—even while caring for the tiniest infants. “The question,” she says, “is whether WWBS is a legitimate medical concern or a form of justified bias that ensures White infants get different care.”⁴

While reflecting on this article, I identified ways that my own unconscious affinity bias toward White middle-aged mothers of preterm infants could be contributing to asymmetries in my patient care delivery. I found the article and the studies it cited enlightening—especially as I continued to seek helpful ways to recognize and respond to racial bias and how it permeates personal, professional, and community life. I quickly clicked “share” on my social media page, hoping some of my colleagues would find it helpful too. I did not expect what happened next.

BS

I can't believe people actually believe this stuff.

This is so offensive and far from the truth. Whoever wrote this article should be ashamed!

Anyone who had any real experience in a NICU will never believe any of this crap.

This has gone too far.

And those were just a few of the comments.

At first I was startled at the defensive responses from my friends and colleagues on social media, but now understand this reaction is not unique. Dr Joan Rikli, President of the National Association of Neonatal Nurses (NANN) described our “naïve and incorrect” tendency to “believe we are unbiased” in our care for infants in the NICU.⁵ Nearly 5 years ago, I was not fully aware of racial health disparities, much less what contributed to them and how to respond clinically and professionally. My colleagues' reactions over social media indicated to me that current evidence about these disparities should be disseminated more widely, as well as examined more carefully in several key places.

Using the socioecological model (SEM) as a framework, the purpose of this article is to outline evidence for racial health disparities in the NICU on multiple levels of influence—societal, community, institutional, interpersonal, and individual. Then appropriate interventions and equitable responses of the NICU clinician will be applied in the context of current evidence and recommendations from the NANN Position Statement on “Racial Bias in the NICU.”

PRETERM INFANT OUTCOMES BY RACE AND SEX

Since the early 20th century, racial disparities in pregnancy outcomes have been well documented. Black mothers are not only 3 times more likely to die from a pregnancy-related cause than White mothers,⁶ but they also have a 4.5-fold higher risk of extremely preterm delivery (24-27 weeks' gestation) and have more than 3 times the likelihood of preterm birth-related infant mortality.⁷ Racial disparities in pregnancy morbidity and mortality have largely been attributed to social determinants of health (SDOH) or, “the conditions in which we are born, live, learn, work, play, worship, and age.”⁸ Some SDOH likely to contribute to disparate pregnancy outcomes include racism, income, insurance, housing, immigration status, social support, geography, and neighborhood, all of which contribute to variable quality in healthcare, limited access to early and regular prenatal visits, and higher rates of chronic health conditions in pregnant women of color.⁶ Similar outcomes are observed in newborns born to women of color. For example, Black infants born prematurely have higher rates of comorbidities such as long-term respiratory complications,⁹ necrotizing enterocolitis,¹⁰ and intraventricular hemorrhage.¹¹

A “familiar pattern”¹² emerges when comparing survival rates of Black and White infants by gestational age and birth weight. For decades neonatal clinicians have learned that Black infants have higher survival rates at very early gestational ages (<32 weeks) and very low birth weights (<1500 grams) as compared with White infants.^12–14 Similar results have been reproduced in more recent studies.^15–18 The cause of this higher survival rate in Black infants in early gestation is unknown, but it is hypothesized that this “may reflect ‘survival of the fittest’ from an unfavorable uterine environment.”¹⁵ While this hypothesis requires further investigation into maternal indications for preterm delivery, this unsettling hypothesis would align with previous evidence outlining the negative impact that SDOH can have on women of color before, during, and after their pregnancies.⁸

Sex differences in preterm infant outcomes have been widely supported in the literature, and as such, neonatal clinicians expect that female infants will survive and thrive developmentally at higher rates than their male counterparts. Female survival in extremely preterm infants has been shown to be 1.7 times the odds of male survival,¹³ mostly as a result of worse respiratory function in males. Despite advances in medical care including use of steroids and postnatal surfactant,¹⁹ male preterm infants require mechanical ventilation for longer periods and are more likely than females to develop chronic lung disease—2 factors that are associated with worse neurodevelopmental outcomes in childhood.¹⁶ While it is hypothesized that the combination of poorer respiratory and neurological function contributes to an overall worse neonatal profile in males, researchers have found there to be “separate male vulnerability” that is not yet fully understood.¹⁹ In fact, the explanations for both sex and race-related disparities in infants are complicated and do not tell a straightforward story.

When examining outcomes of extremely low birth-weight infants at the intersection of sex and race, Morse et al¹³ found that Black females had 2.1 times the odds of survival as compared with White males. In fact, odds of survival from greatest to least were as follows: Black females, White females, Black males, and White males, reinforcing the “wimpy white boy syndrome” mentality among neonatal clinicians. However, results consistently report that with increasing gestational age and birth weight, the risk of mortality increases for Black infants, contributing to an overall infant mortality rate that is more than double the rate for White infants (5.9 per 1000 live births as compared with 2.4 per 1000 live births, respectively).¹⁵ Despite controlling for factors like gestational maturity, comorbidities, and social determinants like parent's education level, the higher rate of Black infant mortality persists.¹² Regarding ethnicity, rates of Hispanic infant mortality has been comparable to that of White infants, but disparate outcomes in comorbidity are prevalent in this group. For example, Hispanic infants have 0.67 times the odds of developing respiratory distress syndrome and a 70% increase in retinopathy of prematurity as compared with White infants.²⁰

Because race, and to a greater degree sex, plays an important role in estimating survival rates, it is certainly plausible that this knowledge impacts treatment decisions such as escalating care for White infants more readily or frequently. Current data noting that Black and Hispanic infants received fewer antenatal steroid treatments¹⁸ and surfactant administration²¹ than White infants would suggest that clinician bias influences patient care, especially since care practices for these same interventions are similar when comparing preterm infants by sex alone.²²

Therefore, it is important to consider how this existing evidence establishing associations between sex, race, and neonatal outcomes may perpetuate the tendency to deny racial disparities in NICU practice. This biased approach to caring for neonates is critical to understand and address. While certain biological factors may, in fact, disadvantage male preterm infants from thriving in comparable ways to their female counterparts, clinicians should reject the notion that the social construct of race is the root cause for certain neonatal comorbidities. Instead, clinicians should focus on the confluence of medical and social factors contributing to each individual infant's progress.²³ This critical distinction is not only important for those neonatal practitioners employing life-saving interventions, but also for those who provide routine care, therapeutic and developmental care, and family education—as these biases can and do shape clinical interactions.

THE EVIDENCE DEMANDS ACTION

Whether or not a NICU clinician agrees with the potential implications of the problematic use of terms like WWBS, the most up-to-date evidence determines that racial health disparities are widespread and complex, both in greater society and in NICUs. While a great deal of previously published literature examining racial disparities has examined race as a biological determinant, there is a critical need for further investigation into social determinants contributing to racial disparities to mitigate negative consequences for infants and families of color. More specifically, documentation and assessment of biological determinants of health as well as the social determinants of health are necessary to better understand associations between plan of care delivery and persistent racial health disparities.

Within the SEM, Bronfenbrenner outlined 5 levels of social influence that can impact health: societal, community, institutional, interpersonal, and individual.²⁴ To truly appreciate how deeply racial bias is embedded in the NICU, one must recognize how factors at each of these levels have permeated the experience of infants and parents of color in the particular spaces, institutions, and communities we inhabit. Because racial disparities are experienced across and within multiple levels of influence, it is necessary to identify solutions in clinical practice approaches as well as in NICU procedures and policies.

In June 2020, just weeks after the murder of George Floyd and at the height of the racial reckoning in the United States, NANN released a “Racial Disparity in the NICU” Position Statement²⁵ to provide a background of supporting evidence as well as recommendations for healthcare practitioners (Table 1). The following section will align NANN's Position Statement Recommendations at the intersections of the 5 levels of the SEM (Figure 1). This approach is outlined not only to describe the deeply embedded nature of racism in our healthcare context, but also to provide guidance to the NICU care providers seeking ways to mitigate its negative consequences in practice (Table 2). The term “we” in what follows refers to White healthcare practitioners—nurses, physicians, and therapists (physical, occupational, speech, and developmental) alike—but may also be of use to healthcare workers who are people of color working to advocate for change in their particular units.

TABLE 1. - NANN's Racial Disparity in the NICU Position Statement Recommendations^a

Elevate awareness of racial disparities, inclusion, and cultural sensitivity by providing education in cultural competence, presenting published research on the issues, and having open discussions about the topics.

Encourage diversity in the workforce.

Examine personal bias and beliefs, some of which may be unconscious. Be self-aware and open to feedback and observations from others.

Examine individual NICU statistics to evaluate significant trends in gestational age, race, and patient outcomes.

Invite families to participate in the culture of the NICU by involving a diverse team of parents on committees, such as a quality improvement committee.

Regularly use interpreters when caring for families who do not speak English. Relying on other family members to interpret for parents may contribute to misinformation and a lack of appropriate education.

Provide written and electronic information in multiple languages whenever possible.

Consider all discharge requirements and available resources to transition families to the home environment.

Advocate for racial awareness and equality in your hospital and community. Connect with hospital administrators, community leaders, and elected officials to discuss health outcomes of racial disparities, and advocate for resources that positively impact the social determinants of health affecting maternal and infant health.

Abbreviation: NICU, neonatal intensive care unit.

^aFrom Townsel et al.¹⁸

FIGURE 1: NANN racial disparity recommendations²⁵ within levels of the socioecological model.

TABLE 2. - Evidence and Recommendations by SEM Level

SEM Level	Supporting Evidence	Recommendations
Societal	Gadson et al8	Screen patients for SDOH at point of entry Systematically align research agendas, quality metrics, care models, and policy
	Chen et al15	Analyze the indications for preterm birth in maternal populations Implement multilevel interventions to improve the postnatal neonatal environment
Community	Chung et al26	Prompt referral to resources, social work, and community agencies Ongoing screening families for SDOH
	Hebert et al27	Further research should examine influence of insurance on mother's prenatal choices Improve quality of care at low-performing hospitals
Institutional	van Veenendaal et al28	Institutions should collect infant and parent outcomes—including measures of parent mental health based on single family room placement vs open-bay units Research should determine whether benefits can be achieved with other family-centered approaches when single family rooms are not possible (family-centered rounds, increased support and communication with parents, parent education, family-integrated care models)
	Riley et al29	Future research should examine how geography and transportation mediate mother's provision of human milk
Interpersonal	Hall et al30	Interventions decrease bias should consider multiple experience levels (ie, primary prevention for health profession students, practitioners, and systemic interventions in the institutional setting), recognizing that biases may be perpetuated with clinician experience
	Hendricks-Muñoz et al31	Training for clinicians to increase awareness of self-imposed culture-based perceptions Provision of culturally competent education for parents
Individual	Hall and Fields32	Individual bias is strongly associated with group membership; therefore, individuals should examine various aspects of their identities in order to increase awareness of implicit bias
	Devine et al33	Identify “trigger populations” that active bias Actively perform stereotype replacement and counter stereotype imaging by bringing forth a positive image of someone who belongs to “trigger populations” for whom you have more positive feelings Think of each of your patients and family members as individuals and attempt to see things from their perspectives Have meaningful, high-quality contact with people who belong to “trigger populations”

Abbreviation: SDOH, social determinants of health.

SOCIETAL LEVEL

Supporting Black infants and families at each level of the SEM aligns with NANN's recommendation to “[a]dvocate for racial awareness and equality in your hospital and community.”²⁵ As healthcare providers, we have the responsibility to be sufficiently aware of systemic structures, political legislation, history, and policies of the past and present that afford or limit access to quality medical care. Reich et al³⁴ call this concept “structural competency,” and define it as “the capability of clinicians to address social and institutional determinants of their patients' health.” Our focus cannot only include improving medical care and technologies solely, as these advances often widen the racial disparity gaps.^34,35 This widening racial disparity gap is the result of many potential factors. For example, because researched populations are often made up of majority White participants, we have less understanding about the impact on participants of color.³⁶ Additionally, Black and Hispanic patients receive subspecialty referrals at lower rates than White patients, and their access to certain interventions may be further challenged by insurance status.³⁶ Therefore, while delivering high-quality care within our capabilities, we must also work to identify the systematic barriers impacting SDOH within and beyond the walls of our NICUs. Beck et al state that “[a]ll infants and their families will not realize the full benefit of the dramatic technical advances in perinatal and neonatal care that will occur in the 21^st century unless we accept our responsibility for addressing the full range of determinants of health that ultimately shape long-term outcomes.”³⁷ Once determinants disproportionately impacting Black communities are fully identified, we can contribute to change on the societal level by seeking and supporting necessary policy changes designed to reduce disparities and by engaging our legislative representatives to garner attention to issues underpinning disparity.³⁵

COMMUNITY LEVEL

The communities and physical environments in which we live, including neighborhoods, homes, and outdoor spaces, have direct effects on health.²⁴ Both physical environmental exposures, such as lead and phthalates, and social environmental exposures, such as violent crime, can negatively impact birth outcomes.³⁵ Furthermore, poverty and unstable housing, which disproportionately impact children of color, are associated with malnutrition, growth stunting,²⁶ and increased incidences of asthma, acute otitis media, and mental health conditions.^26,38 Neighborhood geography also plays a role in health outcomes. Hebert et al²⁷ found that not only were Black women less likely to deliver at top-tier hospitals, but those top hospitals were less likely to be in Black neighborhoods. NANN recommends making a difference through “connect[ing] with hospital administrators, community leaders, and elected officials to discuss health outcomes of racial disparities, and advocate for resources that positively impact the SDOH.”²⁵ NANN also encourages diversifying the healthcare workforce to better reflect the rapidly changing US demographics.²⁵ Diversity in the healthcare workforce should reflect increasing diversity at all levels—including leadership and administration. Healthcare workers can support diverse workforce development in their communities through contributing to minority scholarship programs, establishing mentoring relationships with students of color, and volunteering for career training programs and outreach initiatives in local schools, community colleges, and historically Black colleges and universities.³⁹

INSTITUTIONAL LEVEL

Within the hospitals and units where we work, we submit to policies and procedures designed to streamline processes, reduce safety hazards, and contribute to the overall well-being of patients and employees. However, we may fail to recognize and prevent barriers that these policies and procedures create for some families. For example, because the majority of NICUs are designed to house multiple infants in large rooms, nursing efficiency has historically been prioritized over family members' ability to stay for extended periods at the infant's bedside²⁸—a convenience that would benefit families without access to reliable transportation. Riley et al²⁹ found that Black mothers, especially those without access to a car, were less likely to still be providing human milk to their infants at NICU discharge than White mothers.

It is important then, for clinicians and researchers alike, to evaluate whether the NICU policies, procedures, and physical environments have disparate impacts on the ability of families of color to engage in developmentally supportive practices. NANN recommends that individual NICUs “[e]xamine ... statistics to evaluate significant trends in gestational age, race, and patient outcomes ... [and] invite families to participate in the culture of the NICU by involving a diverse team of parents on committees, such as a quality improvement committee.”²⁵ In this way, NICUs can establish an evolving and iterative process of receiving feedback from varied perspectives, implementing new care practices, and evaluating the impact on families as needs change. These practices can illuminate potential areas for improvement in medical practices, protocols, resource provision, and work climate.

INTERPERSONAL LEVEL

Medical care in the NICU requires practitioners and families to communicate verbally and nonverbally, step into personal spaces, touch, educate, and collaborate effectively. While overt discrimination toward people of color may have seen decline in the past few decades, implicit or unconscious biases continue to negatively impact interactions between the healthcare practitioner and the family.³⁰ A systematic review concluded that clinicians across settings and disciplines consistently demonstrate low to moderate levels of implicit bias toward people of color, and that this had a significant influence on patient health outcomes and treatment regimens.³⁰ Because of the unconscious and pervasive way that biases shape behavior, White healthcare practitioners can perpetuate racial discrimination in their interactions with families despite their intent to do good.³²

Examples of interpersonal biases in the literature include a study by Hendricks-Muñoz et al³¹ that surveyed NICU mothers and found that more mothers of color were discouraged from performing kangaroo (skin-to-skin) care by their NICU nurses than white mothers. Another study examining parent satisfaction in the NICU found that Black parents were more likely to have overall negative comments about their NICU experience and, in particular, were most dissatisfied by lack of compassionate nursing support, while White parents expressed the most frustration around inconsistent nursing assignments and lack of education about their infant.⁴⁰ More specifically, Black parents felt their infants received less attention from the nurse than other infants under the same nurse's care and expressed disrespectful exchanges with the nursing staff.

NANN recommends practices such as regular use of interpreters for non-English-speaking families, providing a variety of education strategies based on individual learning preferences (eg, written, pictorial, video, and hands-on), as well as establishing comprehensive discharge services and resources early in the NICU stay.²⁵ Beyond these concrete recommendations, how might we become more aware of the ways racism shapes our conversations and interactions with all families? Can we speak up when colleagues, either knowingly or unknowingly, create unwelcoming environments to parents of color? Can we identify accountability partners jointly committed to eradicating bias?

INDIVIDUAL LEVEL

Author, professor, and advocate Ibram X. Kendi wrote that “denial is the heartbeat of racism.”⁴¹ Unless we can come to terms with the existence of racism in our NICUs and our part in it, we contribute to the racial disparities our infants and families experience. Yet, as my experience on social media shows, the urge to defend the individual or the individual's intent is strong, while ignoring multifaceted ways that bias creeps into the NICU. Furthermore, research indicates that a person's self-reported explicit attitudes about race are often not consistent with implicit preferences revealed through clinical observation or implicit bias testing.⁴²

There are actions we can take. NANN recommends that we “[e]xamine personal bias and beliefs, some of which may be unconscious” and to “[b]e self-aware and open to feedback and observations from others.”²⁵ First steps in this process might include finding tools to generate self-reflection like Harvard's Implicit Association Test⁴³ and discussing the results with a trusted friend. Set an intentional goal to approach each family and each interaction with fairness. If opportunities to interact with people of color are limited, begin by reading the works of Black authors, and then commit to expanding social networks. If opportunities and resources to promote self-reflection and inclusivity are not available in your place of work, then hold leadership accountable to create an environment conducive to collaboration and personal growth.³³

The final NANN recommendation is to “[e]levate awareness of racial disparities, inclusion, and cultural sensitivity by providing education in cultural competence, presenting published research on the issues, and having open discussions about the topics.”²⁵ This comprehensive recommendation spans all levels of the SEM—societal, community, institutional, interpersonal, and individual—and encapsulates the necessary commitment from each healthcare professional seeking equitable healthcare for everyone and, in particular, supporting Black lives in the NICU setting and beyond.

CONCLUSION

As healthcare practitioners, it is our ethical and moral responsibility to maintain up-to-date knowledge of new evidence that impacts clinical practice. The evidence demonstrates the importance of recognizing the enduring role of racism in the health and well-being of people of color and the need to adjust care accordingly. It was unacceptable for clinicians to refuse to accept that racial disparities and bias in the NICU are a problem 5 years ago, and it is unacceptable today.

While the problem of racial disparities may seem overwhelming—especially when considering the problem at all levels of the SEM—we do not have the luxury of being paralyzed by its complexity. Instead, we can seek to better understand the multilevel causes of the problem in our local context, always seeking to pair concrete action with our insight into the issue. As healthcare professionals, we are called to a higher standard than the status quo. We must reject the use of racially descriptive terms and assumptions as well as actions and inactions that perpetuate racism in our NICUs. We may not be able to respond to all 5 levels of SEM influence at once, but we can pursue the possibilities available to us, be open to feedback, celebrate those making progress in these areas, and seek to work together to overcome racial disparities in the NICU.

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What we know:	The most up-to-date evidence suggests that racial health disparities are widespread and complex, both in our greater society and in our local NICU contexts.
What needs to be studied:	There is a critical need for further investigation into the underlying mechanisms resulting in these differences to develop effective interventions to mitigate negative consequences for infants and families of color. Documentation and assessment of biological determinants of health as well as the social determinants of health are necessary to better understand associations between plan of care delivery and persistent racial health disparities.
What we can do today:	To truly appreciate how deeply racial bias is embedded in the NICU, we must recognize how factors at each level of the socioecological model have permeated the experience of infants and parents of color in the particular spaces, institutions, and communities we inhabit. Because racial disparities are experienced across and within multiple levels of influence, it is necessary to identify solutions in clinical practice approaches as well as in NICU procedures and policies.