Strengthening equity and anti-racism in women's care: a quality improvement initiative reducing institutional maternal mortality in Brazil.

Abstract

Background: Circumstances that lead to maternal death are complex and multifactorial, including inequity and racism issues. Quality improvement (QI) strategies have demonstrated success in improving maternal outcomes. The Collaborative Abraço de Mãe (CAM) reduced the institutional maternal mortality rate (iMMR) by 34.2% from the baseline rate in 19 Brazilian maternity hospitals.

Objective: To present the integration of anti-racism and equity strategies implemented during the CAM.

Methods: A QI report assessing the CAM focused on strengthening the awareness of obstetric teams about ethnic-racial inequalities and institutional racism as social determinants of maternal outcomes. A mixed methods approach was used to understand the overall impact of the intervention. Measures included the Anti-Racist Leadership Survey and interviews (individual and grouped). Qualitative and quantitative data were applied simultaneously but independently, followed by a triangulated comparison to define convergences.

Results: The domain with the highest average score was emotional resources and communication; the lowest was fundamental knowledge and translation of the knowledge in action. Interviews evidenced three categories: (A) equity and anti-racism training contributed to a more profound recognition of race and racism awareness, leading to a change in culture; (B) Priority change ideas and actions focusing on anti-racism and equity were demonstrated in several ways among the leaders; and (C) Challenges when equity is centralised in the care model. Triangulations revealed two convergences: (i) Evidence of a better understanding of ethnic-racial inequalities, institutional racism, and racism recognition by the leaders and participating institutions, and (ii) Resistance when trying to bring new content to the clinical staff, as well as a lack of tools when dealing with the emotional resources needed to confront interpersonal racism.

Conclusion: With a significant reduction in iMMR, the CAM reveals that a QI intervention addressing inequities and racism issues is a feasible and promising approach to improve maternal outcomes within an equity-oriented model of care.