The U.S. Has an Alarming Maternal Mortality Rate—Particularly for Black People. How Can We Change This Tragic Trajectory?

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The United States is a medical pioneer, offering some of the most advanced healthcare in the world and many of the top, leading-edge medical innovations. However, this country nonetheless has an alarming maternal mortality rate, with nearly 33 deaths per 100,000 births—a rate that has quadrupled in the last 30 years. Statistics from the Centers for Disease Control and Prevention indicate that 84 percent of these deaths are preventable. And, although fatalities are obviously the most heartbreaking, past data shows that for every death, there were at least 70 near-death experiences.

Black and brown birthing people face the brunt of these risks. Statistics show that in 2021 (the latest year for which data is available), the Black maternal death rate was 2.6 times higher than that of white people. This racial disparity has long been the case—even among patients with similar education and socioeconomic factors—and when the maternal mortality rate rose sharply in 2021 (partially due to COVID and its ripple effects on hospitals), the increases were especially prevalent among Black birthing people.

This begs the question: How do we fix this tragic trajectory?

There are several channels working in parallel path to strike positive, life-saving change. From maternal care in and out of the hospital, to research and better diversity education within medical schools, multiple channels are trying to improve the dire and completely lacking state of healthcare for Black birthing parents.

Midwives and doulas can bring a more holistic approach to maternal care

It is well-documented that doulas and midwives can positively impact birth outcomes for many, especially people of color who need advocates in the delivery room. While doulas can provide emotional support and assistance before, during, and after labor, midwives combine medical expertise with a patient-centered approach.

According to Saonjie Hamilton, CNM, the lead midwife for Oula Health, a New York City-based midwifery clinic, “Midwives are licensed medical professionals who take a more holistic approach to pregnancy, childbirth, and postpartum care.” Midwives don’t just focus on the labor, but the birthing person as a whole. Their work goes beyond test results: Midwifery often takes into account social determinants of health—like family support, access to nutrition, the stability of a patient's housing situation, implicit bias, and partner violence (homicide is the leading cause of death for pregnant people)—and they build relationships that aren’t often forged in a typical seven-minute obstetrics visit.

Midwifery can be a standalone practice, or part of interprofessional collaboration with physicians, nurses, dietitians, and even social workers. Though they can’t perform C-sections, midwives can collaborate with other physicians in hospital settings if complications arise.

Particularly in parts of the country that are considered “maternal-care deserts,” midwifery has been called the answer to offering more care for low-risk pregnancies. Counties classified as deserts are those that have zero birthing centers, obstetricians, or nurse midwife access. And they are unfortunately quite common. A 2022 March of Dimes report shows that 1,119 counties in the US are considered deserts, affecting 6.9 million women. These areas overlap with ones that are known for poor outcomes for birthing people and their babies.

For a little history: Prior to the 1920s, Black midwives were the standard for prenatal care throughout the South for Black pregnant people. When laws were enacted that prevented them from practicing without a license or medical education, obstetrics—mostly led by white men—became the norm. Today, only eight percent of births are overseen by midwives.

Medical schools are training providers more intentionally

According to 2018 data, 68 percent of OB/GYNs are white, and 43 percent are men. Even leadership roles in universities are more likely to be held by white physicians. This is why some universities are actively encouraging and fostering the careers of future doctors from diverse backgrounds.

Patients of color often feel better having practitioners who look like them, but studies also show that there are merits to racial concordance that extend to infant survival. Racism has been built into medical care, and many doctors still believe in biological differences between Black and white bodies. For instance, one 2016 study even showed that some doctors believe that Black people have thicker skin and feel less pain.

Of course, doctors don't necessarily need to be the same race as their patient to provide them with quality treatment. But more equitable care does require providers of all backgrounds to be aware of how implicit bias can show up in a doctor’s notes, tests ordered, and patient communication. This is why public health expert Tiffany Green, PhD, is launching a class at the University of Wisconsin-Madison that teaches medical school students about racial disparities in healthcare. “I can't tell you how many doctors, including obstetricians, are just now learning about reproductive health disparities,” she says. “So I'll be teaching what is probably one of the first, if not the first, medical school classes on race and obstetrics in American obstetrics and gynecology.”

Dr. Green emphasizes that surviving pregnancy and childbirth shouldn’t just be the responsibility of the pregnant person, and that often the disparities begin before conception. She explains that history is rife with examples of Black and brown, and even Irish, bodies being used solely for the advancement of gynecology: They were treated as test subjects instead of people, and often without anesthesia. “When we're talking about the solutions to this problem, and asking universities to be a part of promoting evidence-based solutions to this problem, start with a true acknowledgment of why this problem exists,” she says. Med students in her class will gain an understanding of this long history of doctors ignoring Black women's pain.

University-led research can highlight where interventions are needed

Last year, Tufts University launched The Center for Black Maternal Health and Reproductive Justice. This center is a part of its medical school, and as one of a handful of universities looking to close the maternal health gap, is focused on researching the racial disparities that continue to feed it. Similarly, health equity researcher Rachel Hardeman, PhD, founded the Center for Antiracism Research for Health Equity at the University of Minnesota. She has conducted extensive research on birth outcomes in heavily policed areas, and on racial concordance of doctors and birth outcomes for Black babies.

“By establishing and prioritizing centers for maternal and infant health research, policy, and birth equity, dedicated funding can help close the maternal and infant health mortality gap through targeted, evidence-based interventions,” says Quantrilla Ard, PhD, PMH, a maternal and infant health advocate, who adds that from education comes quality, empathetic care.

Government is aware, but legislation takes time

With a problem of this magnitude, you'd expect the government to get involved as well. And there are some strides being made. The Black Maternal Health Caucus in Congress is bringing the concerns of Black parents to the forefront and inspiring legislative action, like the recently reintroduced Momnibus Act, made up of 12 individual bills that target Black maternal health equity through efforts around affordable housing and transportation, mental health care, nutrition, and support for women in prison.

“Other proposed legislation such as the Build Back Better bill and Maternal Care Act all work together to build the infrastructure necessary to reduce and eliminate maternal and infant morbidity and mortality,” Dr. Ard says. She believes these strides will start to change the systems that put Black birthing people and their babies at risk.

Yet it's anyone's guess when this legislation might kick in, if it ever does. So in the meantime, nonprofit organizations like the Black Mamas Matter Alliance are shifting cultural understanding of the issue so that more Americans are aware of the problem and can start making noise about its dire consequences.

Altering the trajectory of the birthing experience will require changes in all areas of healthcare. Working together is imperative. Fixing health and, specifically, birth disparities, must touch every level of our society, from the government to the very classrooms where future frontline medical staff are trained.

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