University of Maryland Medicine Eliminates Race in Birthing Decisions

Health enterprise change to a national medical standard will drive greater equity in Cesarean births among African American and Hispanic American women. This is the latest in UMMS' far-reaching commitment to improve health equity.

University of Maryland Medicine, comprised of the University of Maryland Medical System (UMMS) and the University of Maryland School of Medicine (UMSOM), announced it has officially eliminated race as a factor in birthing decisions, which had become a national standard. The tool, called the Vaginal Birth After Cesarean (VBAC) calculator, included a modifier that assigned a higher risk of a complicated vaginal delivery to African American or Hispanic American women with previous surgical Cesarean section (C-section) compared to other women. This has led doctors, particularly at many community hospitals across the country, to be more likely to recommend a C-section to African American or Hispanic American women who had a previous one compared to women of other races or ethnicities.

The VBAC calculator was not frequently used at the University of Maryland Medical Center (UMMC), the System's flagship academic medical center, or at the System's hospitals in communities throughout the state. However, UM Medicine wanted to eliminate its use completely to ensure a race-free standard among physicians practicing in all UMMS hospitals.

As of May 1, UM Medicine has replaced the VBAC calculator with an updated assessment tool that excludes race or ethnicity as a risk factor. This revised calculator, VBAC 2.0, is endorsed by the American College of Obstetricians and Gynecologists, and adds consideration for a history of hypertension. UMSOM and UMMS leaders say the shift, which has been implemented across its statewide health system, could influence decision-making for thousands of births each year and have significant, sustainable impact toward establishing equity in maternal health.

"Racial disparities persist in nearly every field of medicine including obstetrics," said E. Albert Reece, MD, PhD, MBA, Executive Vice President for Medical Affairs, University of Maryland, Baltimore, and the John Z. and Akiko K. Bowers Distinguished Professor, and Dean, UMSOM. "As an obstetrician/gynecologist and a maternal-fetal medicine physician-scientist, I am in full support of the commitment of UMSOM and UMMS to mitigate inequities, including greater scrutiny of protocols in clinical practice and medical training. I am encouraged, not only by the immediate impact, but by the influence on the next generation of physicians."

This latest change continues UM Medicine's efforts to eliminate race-based clinical norms across its more than 150 UMMS locations as part of a broader commitment to reduce health disparities in the communities it serves. In January, UM Medicine transitioned to a race-free algorithm used to evaluate kidney function, increasing access to specialty care or transplantation for thousands of African American people living with advanced kidney disease.

"Reducing health disparity outcomes, especially those rooted in the inappropriate use of race or ethnicity as proxies for perceived biologic differences, is a principal priority for UMMS," said the System's Chief Diversity, Equity and Inclusion Officer, Roderick K. King, MD, MPH. "It starts with building stronger consciousness and working collectively to reinforce the vital importance of science and integrity in unraveling the structural and systemic inequities that have contributed to pervasive disparities in care and outcomes."

Originally published in 2007, the VBAC calculator identified age, body mass index, history of vaginal delivery, or prior cesarean, along with race and ethnicity as key predictors. Rates of VBAC for African American and Hispanic American women have historically lagged somewhat behind those of white women or any other ethnic group according to the Centers for Disease Control and Prevention. This matters, because while an elective C-section may be the safer option for many mothers, experts agree that the risk of complications is higher with repeat cesarean births as compared to a successful VBAC. These include excessive bleeding, infection or blood clotting issues. Such complications often come with longer, costlier recovery times or even potential complications in future pregnancies, including a need for repeat cesarean section for subsequent deliveries.

"It should never be a given that a woman of any race should undergo a repeat C-section after a prior uncomplicated cesarean delivery," said May Hsieh Blanchard, MD, Associate Professor of Obstetrics, Gynecology and Reproductive Sciences at UMSOM, Chief of General Obstetrics and Gynecology at the University of Maryland Medical Center, and Chair of the UM Medicine Obstetric Patient Safety Committee. "Consideration of a trial of labor toward vaginal birth can and should be a part of an informed, patient-centered discussion and shared decision-making process. Taking race and ethnicity out of the decision-making equation is an important step toward eliminating racial and ethnic disparities in maternal health and I'm proud that UMMS and UMSOM are among the leading institutions to decisively take this action."

Assessment algorithms are just one tool physicians draw from for clinical decisions, but leaders in obstetrics and gynecology welcome the move to a more equitable standard for every practice across the system. They also note that comprehensive sustainability of the practice change requires ongoing education and advocacy – elements UMMS leaders say make the close partnership with UMSOM critical.

In recent years, progress has been made through widespread acceptance that the concept of race is a social construct, not based in biology. Leaders in the medical field, however, concede that well-established standards that are deeply ingrained in medical practice take time to unravel. UM Medicine is currently undergoing a systematic review of each of the race-corrected clinical algorithms cited in a highly referenced 2020 New England Journal of Medicine article. The process could lead to more changes down the road to reverse racial bias in medicine.

In addition to taking coordinated, evidence-based actions with real and immediate impact, UMMS continues to take a leadership position in this movement with an important viewpoint of its own. In a recent article published in Pediatric Research, Joseph L. Wright, MD, MPH, Vice President and Chief Health Equity Officer for the system, notes it is critically important to understand the genesis of race-based medicine in order to unwind its roots.

"Acknowledgement of the ill-advised actions that have characterized these race-based clinical algorithms requires purposeful analysis and dismantling of those that are not embedded in science," Dr. Wright said.

About the University of Maryland Medical System

The University of Maryland Medical System (UMMS) is a university-based regional health care system focused on serving the health care needs of Maryland, bringing innovation, discovery and research to the care we provide and educating the state's future physician and health care professionals through our partnership with the University of Maryland School of Medicine and University of Maryland, Baltimore professional schools (Nursing, Pharmacy, Social Work and Dentistry) in Baltimore. As one of the largest private employers in the State, the health system's more than 29,500 employees and 4,000 affiliated physicians provide primary and specialty care in more than 150 locations, including 12 hospitals and 9 University of Maryland Urgent Care centers. The UMMS flagship academic campus, the University of Maryland Medical Center in downtown Baltimore, is recognized regionally and nationally for excellence and innovation in specialized care. Our acute care and specialty rehabilitation hospitals serve urban, suburban and rural communities and are located in 13 counties across the State. For more information, visit www.umms.org.

About the University of Maryland School of Medicine

Now in its third century, the University of Maryland School of Medicine was chartered in 1807 as the first public medical school in the United States. It continues today as one of the fastest growing, top-tier biomedical research enterprises in the world -- with 46 academic departments, centers, institutes, and programs, and a faculty of more than 3,000 physicians, scientists, and allied health professionals, including members of the National Academy of Medicine and the National Academy of Sciences, and a distinguished two-time winner of the Albert E. Lasker Award in Medical Research. With an operating budget of more than $1.2 billion, the School of Medicine works closely in partnership with the University of Maryland Medical Center and Medical System to provide research-intensive, academic and clinically based care for nearly 2 million patients each year. The School of Medicine has nearly $600 million in extramural funding, with most of its academic departments highly ranked among all medical schools in the nation in research funding. As one of the seven professional schools that make up the University of Maryland, Baltimore campus, the School of Medicine has a total population of nearly 9,000 faculty and staff, including 2,500 students, trainees, residents, and fellows. The combined School of Medicine and Medical System ("University of Maryland Medicine") has an annual budget of over $6 billion and an economic impact of nearly $20 billion on the state and local community. The School of Medicine, which ranks as the 8th highest among public medical schools in research productivity (according to the Association of American Medical Colleges profile) is an innovator in translational medicine, with 606 active patents and 52 start-up companies. In the latest U.S. News & World Report ranking of the Best Medical Schools, published in 2021, the UM School of Medicine is ranked #9 among the 92 public medical schools in the U.S., and in the top 15 percent (#27) of all 192 public and private U.S. medical schools. The School of Medicine works locally, nationally, and globally, with research and treatment facilities in 36 countries around the world. Visit medschool.umaryland.edu.

About the University of Maryland Medical Center

The University of Maryland Medical Center (UMMC) is comprised of two hospital campuses in Baltimore: the 800-bed flagship institution of the 13-hospital University of Maryland Medical System (UMMS) and the 200-bed UMMC Midtown Campus. Both campuses are academic medical centers for training physicians and health professionals and for pursuing research and innovation to improve health. UMMC's downtown campus is a national and regional referral center for trauma, cancer care, neurosciences, advanced cardiovascular care, and women's and children's health, and has one of the largest solid organ transplant programs in the country. All physicians on staff at the downtown campus are clinical faculty physicians of the University of Maryland School of Medicine. The UMMC Midtown Campus medical staff is predominantly faculty physicians specializing in a wide spectrum of medical and surgical subspecialties, primary care for adults and children and behavioral health. UMMC Midtown has been a teaching hospital for 140 years and is located one mile away from the downtown campus. For more information, visit www.umm.edu.