Addressing Health Equity During the COVID-19 Pandemic

May 11, 2020

Scope of the Issue

Current data indicate disproportionate rates of COVID-19 infection, severe morbidity, and mortality in communities of color, particularly among Black, Latinx, and Native American people. The American College of Obstetricians and Gynecologists (ACOG) is committed to eliminating health disparities and providing ACOG members with the tools they need to implement change to improve health and wellbeing. Inequities that have already been identified in maternal morbidity and mortality have the potential to be exacerbated during the COVID-19 pandemic. Efforts to eliminate preventable morbidity and mortality, with a focus on eliminating racial inequities in maternal health access, quality of care, and health outcomes, need to be expanded during the pandemic.

Social determinants of health, current and historic inequities in access to health care and other resources, and structural racism contribute to these disparate outcomes. These factors also contribute to disproportionate rates of comorbidities in communities of color, which place individuals at higher risk of severe illness from COVID-19. Access to preventive strategies, COVID-19 testing, and health care resources for those affected may also be limited in some communities. Additional data are needed to understand the full extent of these inequities and to guide equitable allocation of health care resources and other public health interventions.

Obstetrician–gynecologists and other health care practitioners should recognize and examine the ways in which health care systems perpetuate unacceptable inequities in access to care and outcomes. This includes recognizing that bias plays a role in health inequities. Racism and implicit bias in the health care system, including among clinicians, may negatively influence access to prevention, testing, and treatment, particularly when there are shortages in medical supplies, equipment, and staff.

In addition, many people may be experiencing new or exacerbated challenges during this pandemic, such as loss of employment and insurance coverage, food insecurity, difficulty accessing needed supplies, and intimate partner violence. Rural areas, tribal lands, and low-income communities may have limited access to internet and cell service, and hospitals in such areas may have unreliable landline service and limited cell and internet access, making it difficult to access. Some individuals with physical or mental disabilities or those who are hard of hearing also may have difficulty using telehealth services. Additionally, coverage for telehealth services is variable.

Given these limitations, telehealth services should be planned and implemented with these challenges in mind, understanding that telephone visits may require more time than in-person visits or video-based telehealth encounters and that in-person services should remain available for those who cannot utilize telehealth effectively. Existing mistrust of health care systems may make relationship building via telehealth more difficult. However, achieving a therapeutic relationship is critical to providing high-quality, ethical care.

Below are examples of how health care institutions, obstetrician–gynecologists, and other health care practitioners can work to address these issues

Data Collection

Local, statewide, and national data regarding COVID-19 testing and outcomes, stratified by race/ethnicity, socioeconomic status and language ability, are critical to ensure accurate documentation of disproportionate effects and to ensure that resources are equitably distributed. These data should be reliably and consistently reported and available to health care systems, state and local health departments, government agencies, and the public, in order to coordinate and direct resources to those at highest risk and most affected by COVID-19 infection. Support for and participation in registries and data collection efforts to facilitate collection and analysis of comprehensive and accurate data is imperative to understand the full impact of the pandemic.

Health Care Systems

Ensuring that protocols and policies for testing, visitation, triage, treatment, and resource allocation are intentionally reaching and meeting the needs of the communities clinicians serve will be a significant component to equitable care and access. For example, testing sites can improve accessibility by operating outside of normal business hours to accommodate all frontline workers, and mobile units can be used to help make testing more available to those without transportation. It is important to collaborate with community leaders, patient advocates, and other relevant stakeholders in the development of response protocols to assist in designing strategies that meet community needs. Beyond health care systems, expansion of public health resources that may be outside of the traditional health care system are critical as demonstrated by COVID-19 and other natural disasters, such as hurricane responses.

Recognizing and acknowledging the history of discrimination and exploitation of communities of color and the resultant distrust of the medical system, including the field of obstetrics and gynecology, are important to making a positive impact. Efforts to build trust and improve clinical outcomes must continue to be prioritized during the pandemic. Policies and processes designed to mitigate virus transmission should be closely evaluated to ensure that their implementation does not worsen inequities.

Health Care Professionals

Obstetrician–gynecologists and other health care professionals have the potential to:

• Evaluate crisis response efforts to prioritize ensuring that existing inequities are not worsened, nor are new inequities created, while attempting to reduce risk of exposure. For example, there is variation in resources and the ability of individuals to follow public health recommendations to shelter in place, self-isolate, telework, or purchase and use masks.
• Screen for and document social determinants that may influence an individual’s health and use of health care, such as access to stable and safe housing; access to clean water, food, other supplies, and translation services; and employment status. Social determinants screening instruments are available and can be incorporated into electronic health records. Clinical decision support systems can prompt practitioners to take action when screens are positive, such as facilitation of referrals to institutional and community support services.
• Remain cognizant of increased stressors during this pandemic and ensure screening for mental health is included with all visits. Provide referrals for mental health services as indicated.
• Deliver clinical and public health messaging in the preferred language of each patient; use trained medical interpreters for any clinical encounters with patients of limited English proficiency.
• Maintain active, respectful, culturally responsive, and patient-centered communication with patients to encourage ongoing care and to assess if health care needs are being met.
• Advocate at the institutional, local, state, and federal levels for policies that support patient autonomy, promote the provision of culturally congruent care, and advance health equity.

ACOG Resources

Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. ACOG Committee Opinion No. 729. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e43-8.

Health disparities in rural women. ACOG Committee Opinion No. 586. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:384-8. 

American College of Obstetrics and Gynecologists. Our commitment to changing the culture of medicine - resources. Available at: https://www.acog.org/about/our-commitment-to-changing-the-culture-of-medicine-and-eliminating-racial-disparities-in-womens-health-outcomes/our-commitment-to-changing-the-culture-of-medicine-resources. Retrieved May 7, 2020.

American College of Obstetricians and Gynecologists. Code of professional ethics of the American College of Obstetricians and Gynecologists. Washington, DC: ACOG; 2018. Available at: https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/acog-policies/code-of-professional-ethics-of-the-american-college-of-obstetricians-and-gynecologists.pdf. Retrieved May 7, 2020.

American College of Obstetricians and Gynecologists. Racial bias. ACOG Statement of Policy. Washington, DC: ACOG; 2017. Available at: https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2017/racial-bias. Retrieved May 7, 2020.

Additional Resources on COVID-19 and Social Determinants of Health from Other Organizations

(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists)

Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people who are at higher risk Atlanta, GA: CDC; 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html. Retrieved May 7, 2020.

National Medical Association. Rainbow PUSH Coalition and National Medical Association joint statement on the response to the coronavirus/COVID-19 pandemic: a public health manifesto April 15, 2020 Silver Spring, MD: NMA; 2020. Available at: https://www.nmanet.org/news/503170/Joint-Statement-on-the-Response-to-the-CoronavirusCOVID-19-Pandemic.htm. Retrieved May 7, 2020.

American Academy of Family Physicians. Social determinants of health guide to social needs screening. Leawood, KS: AAFP; 2019. Available at: https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/hops19-physician-guide-sdoh.pdf. Retrieved May 7, 2020.

American Medical Association. COVID-19 FAQs: health equity in a pandemic. Chicago, IL: AMA; 2020. Available at: https://www.ama-assn.org/delivering-care/health-equity/covid-19-faqs-health-equity-pandemic. Retrieved May 7, 2020.

American Medical Association. COVID-19 health equity resources. Chicago, IL: AMA; 2020. Available at: https://www.ama-assn.org/delivering-care/health-equity/covid-19-health-equity-resources. Retrieved May 7, 2020.

Centers for Medicare and Medicaid Services. The Accountable Health Communities health-related social needs screening tool. Baltimore, MD: CMS; 2018. Available at: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf. Retrieved May 7, 2020.

Henry J. Kaiser Family Foundation. Communities of color at higher risk for health and economic challenges due to COVID-19. Menlo, CA: KFF; 2020. Available at: https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Retrieved May 7, 2020.

Koma W, Artiga S, Neuman T, Claxton G, Rae M, Kates J, et al. Low-income and communities of color at higher risk of serious illness if infected with coronavirus. Menlo, CA: Henry J. Kaiser Family Foundation; 2020. Available at: https://www.kff.org/disparities-policy/issue-brief/low-income-and-communities-of-color-at-higher-risk-of-serious-illness-if-infected-with-coronavirus. Retrieved May 7, 2020.

National Association for the Advancement of Colored People. Ten equity implications of the coronavirus COVID-19 outbreak in the United States. The imperative for civil rights advocacy, monitoring, and enforcement. Baltimore, MD: NAACP; 2020. Available at: https://naacp.org/wp-content/uploads/2020/03/Ten-Equity-Considerations-of-the-Coronavirus-COVID-19-Outbreak-in-the-United-States_Version-2.pdf. Retrieved May 7, 2020.

University of California San Francisco. PRIORITY: pregnancy coronavirus outcomes registry. Available at: https://priority.ucsf.edu/. Retrieved May 7, 2020.