Achieving equity in reproductive care and birth outcomes for Black people in Canada
===================================================================================

* Cynthia Maxwell
* Modupe Tunde-Byass
* Karline Wilson-Mitchell

KEY POINTS
*   Canada has been slow to collect the robust race-based maternal–newborn data that could allow study of racial inequity in maternal morbidity and mortality at the population level.

*   Peer countries such as the United Kingdom and United States have recently adopted systematic approaches to reducing racial inequities in reproductive and birthing care informed by race-based data collection.

*   Substantive policy changes will be required to address the harms of health inequity in reproductive care faced by Black people in Canada, and race-based perinatal data collection according to best practice guidelines is foundational.

High-income countries, such as the United States and United Kingdom, systematically collect race-based pregnancy outcome data to inform policies and address racial disparity in reproductive health rooted in systemic racism.1,2 The US federal government recently announced strategies to increase access, improve outcomes, and educate providers about implicit bias. In the UK, a Maternity Transformation Programme, through Better Births and the National Health Service Long-Term Plan, is taking a systematic approach to reducing health inequities and variation in care targeting Black, Asian, and minority ethnic women and people from the country’s most deprived areas, through increasing numbers of maternity care providers, pregnancy grants, early years education and child care, and Universal Credit.1 Furthermore, discovery of racial disparities in perinatal outcomes, as well as evaluation of the UK policies, is informed by race-based data collection and audits.3 Similar actions in Canada could address the social determinants of health underpinning disparate birth outcomes and inform how Canada’s provincial policies are implemented.

A limited sample analysis of race-based data related to birth outcomes in Canada from 2004 to 2006 showed that 8.9% of Black women gave birth to preterm babies, whereas 5.9% of White women did.4 In 2021, more than 1.5 million people in Canada self-identified as Black on the federal Census, a sizable proportion of whom are likely to seek reproductive care.5 The COVID-19 pandemic highlighted the importance of collecting race-based data.5,6 More comprehensive race-based data collection is key to understanding and addressing inequities and eliminating structural racism in services that deliver care to pregnant patients. Best practice guidelines indicate that self-identified race should be routinely collected by hospitals at admission, community clinics, and perinatal providers on antenatal history forms, and in electronic records to facilitate quantitative analysis of big data.6

Evidence from high-resourced countries collecting comprehensive ethnoracial data indicates that ethnoracial disparities exist in maternal mortality and morbidity.2,7 Rather than genetic causes or lack of responsible self-care practices, differences are likely due to epigenetics, biological weathering, biases that drive systemic barriers, and social determinants that cause harm.8,9 In the US, the maternal mortality rate rose at the end of the last decade, and data indicate that rates were higher for Black women (37.3, 44, and 55.3 per 100 000 live births for 2018, 2019, and 2020, respectively) than for non-Hispanic White women (14.9, 17.9, and 19.1 per 100 000 live births in the same years, respectively).10 Before this, it was assumed that the maternal mortality rate was underestimated between 2003 and 2017 until the addition of a standardized pregnancy checkbox in certificates. In both the UK and the US, Black people are 3–4 times more likely to die in pregnancy and childbirth than White people.11,12 Similar disparities are likely to exist in Canada, despite publicly funded pregnancy and birthing care in Canadian jurisdictions, as suggested by the limited data available5 and considering that race-based data collected during the COVID-19 pandemic showed that Black people in Canada were disproportionately affected in terms of poor disease outcomes.8,13 Government-funded health care clearly does not prevent inequitable outcomes given the disparate reproductive outcomes observed in the UK, where reproductive health is similarly publicly funded.3

A 2023 study found representation of Black health care providers to be associated with improved population health.14 Implicit and explicit bias within the health care system limits Black people’s access to reproductive health care, leading to substandard care.15,16 Bias must be actively addressed at the systems level to deconstruct and correct disparities and support equitable access to high quality care for Black antenatal and birthing patients.15 Sovereignty and engagement are essential components of deconstructing socially determined harms on Black families.11,12 Using both the recommendations of the Alliance for Healthier Communities6 and the Canadian Institute for Health Information (CIHI),17 organizations, researchers, policy-makers, and clinicians who plan studies or clinical guidelines affecting Black people must, at minimum, include Black researchers, clinicians, learners, leaders, and community representatives on research teams, in the codesign, execution, and culturally appropriate translation of research that will affect Black communities. Toronto hospital health equity teams recommend that ethnoracial identity be derived from voluntary self-identification and equity-based questionnaires be offered to every patient at admission by trained support staff.6,17,18 Additionally, learners and clinicians require training on the impact of anti-Black racism on health care outcomes and strategies that engender trust before collecting race-based information from the community.11,12 The actions and guidelines provided by the CIHI are accompanied by compelling evidence of the ethical soundness of collecting raced-based and Indigenous data.

The Society of Obstetricians and Gynaecologists of Canada is currently working with knowledge advisors in addressing the gaps in maternal mortality in Canada.13 Race-based data should be foundational to this work, and the guidelines offered by the Alliance for Healthier Communities and the CIHI Guidance on the Use of Standards for Race-Based and Indigenous Identity Data Collection and Health Reporting in Canada16 must be embedded in how those data are collected, interpreted, and used by engaging with leaders from diverse Black communities to co-create initiatives that will address racial inequity in maternal mortality and morbidity.6

Canada has been slow to collect the robust race-based maternal–newborn data that could allow study of racial inequity in maternal morbidity and mortality at the population level.18 Substantive policy changes will be required to address the harms of health inequity in reproductive care faced by Black people in Canada. As health care providers serving the Black reproductive community in Canada, we challenge colleagues, leaders, reproductive health organizations, interested parties, and governments to address reproductive health disparities systematically to ensure the delivery of safe, accessible, and equitable care for all people in Canada.

## Acknowledgements

The following individuals provided contributions by conducting research, and writing and editing the manuscript as members of the Black Reproductive Working Group: Remi Ejiwunmi, Feben Aseffa, Colette Rutherford, Shani Robertson, Lara Gotha, Tumushabe Mutungi, Marjorie Dixon, Janelle Griffith, Amoy Jacques, Placide Rubabaza, Elsie Amoako, and Jordyn Gibson.

## Footnotes

*   Competing interests: Modupe Tunde-Byass reports research grants from Ferring Pharmaceuticals, North York General Hospital-Shoppers Drug Mart Women’s Health Initiative, and North York General Hospital Exploration Fund. Dr. Tunde-Byass also reports speaking honoraria from Women’s College Hospital for the Black Health Summit, Microsoft, Society of Obstetricians and Gynecologists of Canada, University of Manitoba, Saskatchewan Medical Association, Vancouver Coastal Health, University of Alberta, Federation of Medical Women of Canada, Canadian Medical Association, and Public Sector Executive Institute. She has received payment for expert testimony, and support for attending meetings from the Royal College of Physicians and Surgeons of Canada, Association of Faculty of Medicine of Canada, Federation of Medical Regulatory Authorities of Canada, Federation of Medical Women of Canada, and Society of Obstetricians and Gynaecologists of Canada. Dr. Tunde-Byass is president of Black Physicians of Canada; cofounder of Women’s Education Made Simple; co-chair of Black Health Education Collaborative, North York Hospital; and vice-chair of Maternal Newborn Outcome Committee, Better Outcome Registry Network. No other competing interests were declared.

*   This article has been peer reviewed.

*   Contributors: All of the authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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