Black women and their newborn babies are trapped in a public health crisis that is rooted in enslavement and perpetuated by systemic racism. Centuries of marginalization, exposure to environmental toxins, use of Black women’s bodies for scientific and pseudo-scientific experimentation, poor housing, substandard education, and the food apartheid that denies Black people self-determination in nutritional health have conspired over centuries to produce alarming health disparities and literally kill Black women and infants. These deaths are preventable, yet the numbers of the dead have risen. Looking forward, experts fear that the COVID-19 pandemic will only exacerbate racial disparities in maternal and infant health.
Across racial lines, the United States has the highest rates of maternal mortality than any other developed country in the world, with 17.4 deaths per 100,000 live births in 2018. According to the American Medical Association (AMA), this rate of maternal death was more than double the rates of maternal mortality in countries of comparable wealth. The following year, in 2019, the Centers for Disease Control and Prevention (CDC) found that the U.S. maternal mortality rate rose to 20.1 deaths per 100,000 live births.
Black maternal mortality ranks even worse. Maternal mortality rates for non-Hispanic African American women rose from 37.3 deaths per 100,000 live births in 2018 to 44.0 deaths per 100,000 live births in 2019. Black women’s maternal mortality exceeds that of other BIPOC women, including Latinx women, whose rates of maternal mortality (11.8 in 2018 and 12.6 in 2019) are lower than white women (17.4 in 2018 and 17.9 in 2019).
The CDC 2018 statistics on maternal mortality do not include data on Indigenous women, even though statistics on racial disparities were included in the report. (Indigenous women’s exclusion from the 2018 CDC report is consistent with their experience of marginalization in U.S. politics and policies, as well as silencing in the public discourse.) The CDC does have rates of maternal mortality for Indian and Alaska Native women for 2014-2017: 28.3 per 100,000 live births compared to 41.7 per 100,000 live births for African American women during that same period. During that period, white women and Asian and Pacific Islander women were statistically tied, at 13.4 per 100,000 live births and 13.8 per 100,000 live births respectively, while Latinx women had the lowest rates of maternal mortality, at 11.6 per 100,000 live births.
A History of Medical Apartheid
In a stunning 2018 New York Times article, Linda Villarosa, journalist-in-residence at the Craig Newmark Graduate School of Journalism at CUNY, identified the stress related to Black life in the U.S. as one cause of the racial disparities in Black maternal health. The impact of racism on maternal health has specific expressions on women of African descent when compared to other BIPOC women, including Latinx, Asian and Pacific Islander, and Indigenous women.
“The racial disparity in maternal and infant mortality between Black and white women is stark — but Black women have the worst outcomes in America because we have been the targets of harm for so long,” Villarosa told Truthout. “Institutional and structural racism have affected our communities for centuries, beginning with slavery and continuing with Jim Crow, segregation in housing and education, redlining and the poisoning of our neighborhoods with pollution. Our bodies have also been studied closely, at first because of the commodification tied to enslavement, later as test subjects.”
Black babies are also locked in this death grip. According to the CDC, in 2018, the infant mortality rate in this country was 5.7 deaths per 1,000 live births. However, the rate of Black infant mortality was, alarmingly, double that, at 10.8 deaths per 1,000 live births.
Higher socioeconomic status does not liberate African Americans from the risk of maternal or infant mortality, as Serena Williams’s experience after giving birth to her daughter Olympia made clear. While income inequality certainly impacts infant and maternal health, infant mortality rates are higher among babies born to well-educated, middle-class Black women than in babies whose mothers are low-income white women with only a high school education.
“What is interesting about this question regarding the impact of poor maternal health on Black communities is that, despite education, income and employment, we are still dying,” Simone Toomer, a certified birth and postpartum doula, childbirth educator and international board-certified lactation consultant, says. “This shows it is beyond us and our efforts, although being informed and advocating for ourselves does make a difference.” Toomer adds that these disparities, despite wealth and education, impact Black families in ways maternal and infant mortality rates do not quantify when mother and baby survive but do not thrive. “Poor maternal health care trickles down into poor breastfeeding rates amongst our infants, higher percentage of Black mothers being readmitted to the hospital after delivery and higher rates of PMADs [perinatal or postpartum mood and anxiety disorder].” These health outcomes have reverberating impacts on Black communities across income levels and through U.S. society more broadly.
Villarosa, who is author of the forthcoming book on race and public health titled, Under the Skin: Racism, Inequality and the Health of a Nation, does have numbers to place poor maternal and infant care in perspective: “Racial disparity in maternal and infant mortality has led to tens of thousands of lost lives. For every woman that dies as a result of pregnancy, childbirth and the months after a birth, nearly 100 women almost die. This is traumatizing for individuals and families.”
The reasons for these racial disparities and the overwhelming trauma they cause across income and education levels are vast and complex, according to Chi Chi Okwu, executive director of EverThrive Illinois, a social services agency dedicated to achieving health equity. “What we do know is that the combination and crushing weight of racism and sexism has a profound impact on the health of BIPOC women,” Okwu says. “This is a complex issue that requires us to look at the entire health ecosystem in addition to dismantling the racist and sexist institutions in our society.” In a state where, according to a 2016-2017 report from the Illinois Department of Public Health, Black women are three times likely to die from pregnancy-related medical conditions as white women, Okwu and her colleagues at EverThrive are focused on changing policy to improve birth outcomes. At the state level, these policies include expanding Medicaid to provide doula, lactation consulting and home-visiting services.
Black Women Are Doing the Work
To produce healthier outcomes, African American women are working to disrupt the policies, systems and the inherent bias among health care workers that harm vulnerable Black mothers and their babies. Policymakers in the Biden administration seeking to improve Black maternal and infant health should listen to these women.
In addition to policy, EverThrive Illinois also supports initiatives developed through strategic partnerships that center women and babies most impacted by racial and economic inequalities in health. The Family Connects Chicago program is one initiative Okwu’s organization supports to promote positive health outcomes for Black women and their newborns. In a city where Black unemployment far outpaced other racial groups well before COVID, Family Connects provides a visiting nurse for parents who are having difficulty getting to doctor’s appointments. Okwu says a home visitation nurse can work with the parents to identify the barriers to care and obtain the support they need to overcome them.
To afford a baby nurse that comes into the home to support mother and child, wealthy families in the Chicago area must pay salaries averaging in the high-five to low-six figures. The median baby nurse salary in Chicago is nearly $80,000. Through Family Connects, parents who can’t afford to pay more than they make themselves receive the same privilege of in-home care. “Home visiting provides an opportunity for parents to conveniently receive additional support in their own home. This is not a substitute to going to their OB-GYN or pediatrician,” Okwu explains. “Parents need all the support they can get after giving birth, and home visiting is just one part of the support network to ensure both the parent and child are getting all of the help they need in the postpartum period.”
Improving the relationship between health care systems and African American homes requires shifts in both policy and the public conversation in order to address racism in medical settings. The AMA and The American College of Obstetrics and Gynecologists (ACOG) have identified racism as a public health crisis. To dismantle racism in health care and improve outcomes in Black maternal and infant health, professionals must focus on policies and systems that directly impact Black families. “Dismantling racism in health care will take a multi-pronged systemic and localized approach. We need to ensure that all people have access to high-quality, comprehensive health care,” Okwu says. “We also need to ensure that the care being provided is culturally competent and patient-centered.”
Reducing racial health disparities requires such significant change, but Black women like Okwu are already producing outcomes that health care professionals in ACOG and the AMA, as well as policymakers in Biden administration, should consider. In Okwu’s state, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program had declined, reducing the opportunities for Black women and babies to benefit from the breastfeeding support and healthy food WIC provides. In response, EverThrive Illinois convened a group of partners — those who run WIC sites and WIC program participants — to form the Making WIC Work Coalition and, in 2019, published a landmark Making WIC Work Report. In response to the coalition’s advocacy, the State of Illinois has made significant improvements to the way it runs WIC, including eliminating a discriminatory coupon system which has limited access to food for mostly Black and Brown families in Chicago for more than 20 years; offering more choices so people shopping with WIC can redeem their benefits for a wider variety of foods; providing updated guidance so that all WIC sites provide consistent services and implement streamlined application procedures; and adapting quickly to provide flexibility in WIC enrollment and redemption of benefits so families can care for themselves during the COVID-19 pandemic.
Though the data is not yet available, certainly the global pandemic has exacerbated racial disparities in health outcomes for Black women and babies. The California Health Care Foundation has documented these complications, but the problems of Black women’s access to quality maternal and infant care through the pandemic are national in scope.
Black-led organizations lead the efforts to fill COVID-related gaps. The Social Science Research Council (SSRC) is studying the work done in Cleveland, Ohio, by Birthing Beautiful Communities (BBC), a Black-owned and run perinatal support agency. By studying service shifts caused by the COVID pandemic, including the use of technology in infant mortality prevention programming, SSRC expects “the findings to have implications for healthcare service delivery for Black women and their families.”
Black Women and Doulas
One successful program initiative at BBC is the community-based doula program, which provides overnight postpartum care. Doulas can fill wide gaps created by racism in health care. According to Toomer, “The data is limited on how doulas reduce the Black maternal and infant mortality; however, across the board, we know continuous doula support increases positive outcomes for both the birthing person and infant through emotional and physical support, advocacy and preparation.”
Toomer, who works at New York Presbyterian Methodist Hospital in Brooklyn as a doula and lactation consultant providing prenatal education and support in the clinic and on the Mother Baby Unit, and who also has a thriving private practice, explains that doulas provide multiple beams of support for families. Depending on their training, birth doulas support families through pregnancy, with some trained to support people as they undergo the assisted reproductive technology known as in vitro fertilization (IVF), in which eggs and sperm are combined in a laboratory. Toomer explains that “Doulas provide resources, educate and empower families around their birth options before the baby is here and in the laboring room. We assist within that first hour with latching baby and ensuring a smooth transition once home.” Consistent with the efforts of organizations like EverThrive Illinois and the BBC, doulas also provide critical care to support mothers and give infants a better chance at surviving the first year after birth. Toomer says, “Postpartum doulas come into the home to support newborn feeding, assessing for PMADS, the need for sleep and food, newborn education and ensuring everyone continues to transition smoothly.”
Toomer says that doulas fill gaps that are the standard in maternal care throughout in the medical community. “All parents have to bring their infant to the pediatrician in the first 24-28 hours after discharge; however, oftentimes, no one is checking in on the parents. Many things can happen in those six weeks but unfortunately that is the next time most birthing people are seeing their care providers after delivery.”
Toomer worked with the Healthy Start Brooklyn’s By My Side Support Program for four years. She says that, as a doula, “at every monthly meeting we would hear how our support prenatally, through delivery and postpartum, affirmed families, empowered them and provided that continuity of care that is lacking from the American health care system.”
Systemic Change Is Needed
From her vantage point on the front lines of the Black maternal and infant mortality crisis, Toomer hears “in many stories regarding Black maternal death, accountability is lacking. Accountability of these providers.” She insists that the work she does will never be enough to save Black women and their babies, and that this country’s health care system needs significant institutional change. “It is nice to be on the radar; however, it is beyond providing a doula for every Black mom. We are a small piece in the big puzzle.”
Change needs to start at the top with establishments such as hospitals, Toomer asserts. “Anti-racism health professionals need to continue training in cultural humility. Black women need to be heard and listened to. Biases need to be erased. We need to be looked at as human and respected as such.”
Villarosa says California is providing a template to address the needs that Black women like she and Toomer have identified. “Our country should follow the lead of California, which made implicit bias training mandatory for all health care providers who work with pregnant and birthing people,” Villarosa says. “During the pandemic, the state became the first to make implicit bias training mandatory for all providers, which will go in effect in January. The U.S. should do the same.”
The California Health Care Foundation says that exposing people to their unconscious bias and providing “a historical context for modern-day inequities in maternal health” can help professionals produce healthier outcomes as they “begin to understand how even well-meaning routine responses to patients can inadvertently cause harm and even death.”
Despite this promising commitment to dismantling racism in health care, Villarosa says that, in researching her book, the most surprising thing she discovered “is how well discrimination in our medical system has been documented — yet, there’s still a call for more ‘proof.’” This is more than unnerving as Black women and their babies continue to die at disproportionate rates, and experience poor health outcomes even when Black mothers survive the birthing process and Black babies survive the first year of life. These poor maternal and infant outcomes are the shame of a system that, as Toomer says, “is a broken system never meant to help us.”
Villarosa testifies to a consistent national truth: “Racial health disparities have been part of the American story since the founding of our country. Black mothers and babies should not be dying for reasons that are largely preventable. This isn’t how a just society treats a segment of its population.” The U.S. has the most advanced, expensive health care system in the world, she points out, “so why are we the only wealthy country where the overall rates of women dying or almost dying related to pregnancy are rising? And why do we have the highest rate of infant mortality of all the wealthy countries? These poor health outcomes are shameful, driven by the disproportionate death rates of Black mothers and babies, and are revealing that nation’s inequality.”