By Stacey Tuck, Director of Programs, Association of Maternal & Child Health Programs (AMCHP)
In the United States, birth experiences and their related maternal and infant health outcomes are troubling for all races and ethnicities. However, the outcomes for Black families are far worse than for White families and signal a clarion call for change. The latest published infant mortality rate (IMR) in the United States for non-Hispanic Black infants was 10.6 deaths per 1,000 live births. By comparison, the overall IMR was 5.4 infant deaths per 1,000 live births (Centers for Disease Control and Prevention, 2022).
Maternal health outcomes are even more alarming. According to the latest officially released figures, 1,205 women in the United States died due to pregnancy-related issues, and our country has experienced an 89 percent increase in the maternal mortality rate since 2018 (March of Dimes, 2023). Black women giving birth fare even worse than their babies do. The 2021 maternal mortality rate for non-Hispanic Black women was 2.6 times greater than that of non-Hispanic White women (Hoyert, 2023). Systemic and structural racism is a contributing factor in these disparities, as demonstrated by the data showing that Black women with advanced education and socioeconomic status still have worse birth outcomes than White women with high school diplomas (Smith et al., 2018).
These inequities continue to persist despite the committed efforts of those in health care, public health, and social services. Having served in the maternal and child health (MCH) field for more than 25 years, I sometimes get frustrated and question the work we are doing. However, I realize that feeling stuck due to despair about the data does not help matters. My omnipresent (but sometimes dimmed) hope is stoked when I see public health agencies collaborating with the people in their community and when I ask these key questions that might empower a call to action:
- What shifts can the MCH field, partners, and stakeholders make to contradict the systematized oppression that has contributed to the longstanding maternal and infant mortality crisis in the United States?
- What can we do differently?
- How can we in public health approach our work anew?
Cultural Humility and Cultural Competency
I suggest that one shift that will help close the gaps in maternal and infant mortality rates is evolving from employing cultural competency to embodying cultural humility.
Cultural competency emphasizes learned knowledge and the skillsets needed to manage cross-cultural relationships. The motivation to employ cultural competency practices stems from a desire to improve an individual or an organization’s understanding of an issue and is based on finite mastery (Mosley, 2017). Those operating from a culturally competent standpoint rely on books, learned knowledge, and training as key sources of information.
Founded in 1998 by Doctors Melanie Tervalon and Jann Murray-Garcia, the concept of cultural humility leaves space for continued evolution. Cultural humility requires individuals and organizations to remain teachable and to operate from a place of deference. Mosley (2017) asserts that being culturally humble requires the ability to bow to another’s culture, persona, and position. Cultural humility is propelled by partnerships, welcomes advice and input from people with lived experience and from community-rooted organizations, and it requires institutional accountability (Tervalon and Murray-García, 1998). Power dynamics among all stakeholders are acknowledged, and actions are taken to intentionally level the playing field to promote shared power. A cultural humility approach requires individuals or a health agency to continually demonstrate self-awareness and reflection that is also informed by community feedback. Furthermore, cultural humility is seen as an ongoing process rather than a destination fueled by mastery.
Putting Cultural Competence and Cultural Humility into Practice
Public health agencies seek to improve health outcomes regardless of whether they employ cultural competence or cultural humility; however, the most palpable difference is in the approach.
A public health provider who approaches an issue from a cultural competency standpoint is likely to say: “I am here to assess your problem and to prescribe a method to you to fix it.” The practitioner’s attitude or mental model behind the way they approach a client is that the practitioner has studied the cultural contributors to the health problem and is a qualified expert to recommend a solution oftentimes without input from the client.
In contrast, a public health provider who operates from a cultural humility stance is likely to say:
“Let’s discuss the issues you feel are important and you see as problematic and develop a plan together to address them.” The practitioner shows curiosity and emphasizes that the individual participating in health care has agency.
Let’s say a health agency decides to host a community town hall. Using a cultural competency approach, a health agency may opt to hold the town hall in an area with the highest rates of a certain negative health outcome in a space frequented often by community members. During the town hall, health department representatives may deliver a well-prepared presentation that highlights relevant data and services offered by the agency and then field questions from the audience. The representatives will do their best to answer the issues raised by the community on the spot. They likely will provide a way to follow up with the individuals who have questions. The community may view the town hall as more of a “one-off” event with this type of approach.
By contrast, agency representatives using a cultural humility approach engage with organizations and community champions within the community to co-plan and host the town hall together. They gather input from the community prior to the event. They include trusted organizational and community representatives on the panel. Any prepared presentation takes a backseat to bi-directional conversation under the direction of the community. A cultural humility approach includes a well-established feedback loop between the community and the health agency. The community is invited to co-create solutions, and resources are available to both the community organizations, individuals, and health agency.
As AMCHP seeks to promote equity in all that we do, we consciously strive to incorporate cultural humility into our own work and to broadly promote its advantages. We are consistently examining our internal culture and the way that we operationalize our goals to make sure we are actively listening to our staff, members, and community organizations and moving forward as a learning organization. We acknowledge that, by definition, incorporating cultural humility requires us to be on a continuously evolving journey and embrace growing edges for our organization and for our staff members. We are intentionally increasing inclusivity and championing community-based leadership and engagement. In addition, we developed and are using standardized policies across our organization to ensure people with lived experience are well compensated for their contributions as expeditiously as possible.
This work is exciting, and AMCHP is poised to continue it; to offer technical assistance to our members; and to seek opportunities that enable us to connect community-rooted organizations to resources and to co-lead efforts with them. Cultural humility can be part of the solution for MCH staff to apply within themselves and in working within the communities we serve to improve the health of all birthing persons and babies. Cultural humility is part of the toolkit to improve longstanding health inequities that have persistently been fueled by racism manifesting itself on structural and interpersonal levels.
Centers for Disease Control and Prevention. (2022, June 22). Infant mortality. Centers for Disease Control and Prevention https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
Hoyert D. L. (2023). Maternal mortality rates in the United States, 2021. National Center for Health Statistics, Health E-Stats. https://dx.doi.org/10.15620/cdc:124678
March of Dimes. (2023, March 16). M-BAN unites to address alarming maternal mortality data. Mom and Baby Action Network. Retrieved April 17, 2023, from https://pages.marchofdimes.org/index.php/email/emailWebview?mkt_tok=ODY3LVBLUi01NzEAAAGKilans82GImYufijoSk5ywwNhaGlRVWOCiuZVcazGPwEJPN-2IIUMxDN4ZX4_3ppSu2lw3FJ0QFqFrlFAyNt9VsUdiA1YICVBiklRokSDiWEm&md_id=32545
Mosley, J. (2017, December 1). Cultural humility. tedxwestchester. YouTube. Retrieved April 17, 2023, from https://www.youtube.com/watch?v=Ww_ml21L7Ns
Smith, I. Z., Bentley-Edwards, K. L., El-Amin, S., & Darity, W. (2018). (rep.). Fighting at birth: Eradicating the Black-White infant mortality gap. Oakland, CA
Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi-org.proxy-ms.researchport.umd.edu/10.1353/hpu.2010.0233