How Can We Solve the Black Maternal Health Crisis?
A special three-part series of Public Health On Call shines light on the heightened risks faced by Black birthing people in the U.S., the history and racism behind this crisis, and what can be done to address it—by policymakers, hospitals and practices, community advocates, and a new generation of medical trainees.
Dire statistics about maternal health outcomes for Black women in America have become front-page news in recent years, in part because of the high-profile deaths of new mothers like CDC scientist Shalon Irving, MPH ’09, as well as the deep racial health inequities laid bare by the COVID-19 pandemic.
But this problem isn’t new—in fact, it has roots in the very fabric of American society and health care, with structural and systemic racism at its core.
CDC data show that Black women are two to three times more likely to die from pregnancy-related complications than white women, with most of the maternal deaths being preventable. This heightened risk spans all income and education levels. According to the study from the National Bureau of Economic Research, the wealthiest Black woman in California is at a higher risk of maternal mortality than the least wealthy white woman.
Black birthing people are also more likely to experience life-threatening conditions like preeclampsia, postpartum hemorrhage, and blood clots, as well as increased incidence of other pregnancy-related complications like preterm birth and low birth weight.
Amid a national reckoning with the systemic racism underpinning American society and health care, advocates are pushing forward solutions from multiple angles, including reforming policy, health systems and medical education, and bolstering community-based organizations that advocate for better care and resources for Black moms.
Sixty-five percent of Black birthing people in the U.S. rely on Medicaid—the joint state and federal health care program for low-income Americans—for pregnancy and postpartum care, compared to 42% of all U.S. mothers overall.
With nearly half of maternal deaths happening within the first year postpartum, maternal health advocates have long advocated for expanding postpartum Medicaid benefits to a full year—rather than the 60 days required under federal law—to ensure women have access to adequate care as they navigate new motherhood.
And dozens of states have done so, in part thanks to the expansion of federal policies—originally put in place to help Americans recover from the COVID-19 pandemic—which made it more appealing for states to expand Medicaid. Those states have lower rates of maternal death, particularly for Black women. States with less generous benefits, on the other hand, have worse maternal health outcomes and higher uninsured rates for women of reproductive age—again, particularly for Black women.
But even with expanded Medicaid coverage, the prospect of being forced to return to work too soon after birth is a major strain on mothers. The U.S. is one of only a handful of countries that have no national policy guaranteeing paid leave to new parents.
Evidence shows that job-protected paid parental leave is essential for healthy moms, babies, and communities—and that Black women are less likely to have access to paid leave through their jobs than white women, adding to their risk of the worst maternal health outcomes.
Fortunately, efforts to provide paid family leave are garnering more support, and 13 states and the District of Columbia have passed their own paid family and medical leave laws.
Telehealth services are another way to foster healthy pregnancies—and their footprint is expanding, allowing more Americans to video conference with doctors, check test results online, and remotely monitor health conditions. One study found that implementing telehealth for postpartum care amid the pandemic was linked to decreased racial disparities in postpartum visit attendance.
Many telehealth policies were made official through the landmark COVID-19 relief bill known as the CARES Act. While they have yet to be codified into federal law, the 2022 Omnibus spending bill extended COVID-era rules that made it easier for many Americans to access telehealth services.
Expanding telehealth and many other policies have been written into the largest, most ambitious effort to confront the Black maternal health crisis from the federal level: The Black Maternal Health Momnibus Act of 2021.
Introduced by The Black Maternal Health Caucus, the package proposes big changes in maternal health through 12 standalone bills that address the full slate of socio-economic factors that impact a pregnancy, including investing in the social determinants of health, growing and diversifying the perinatal workforce, and improving data collection for maternal health.
“At the heart of these investments is the principle that in America every family has the right to thrive, a principle that begins with a safe and healthy pregnancy and birth,” said Illinois Representative Lauren Underwood, MSN/MPH ’09, a lead sponsor of the Momnibus.
So far only one element of the Momnibus has been signed into law—the Protecting Moms Who Served Act. If passed in full, the Momnibus package could make a major impact on maternal health outcomes.
Health Care System and Education Reform
Reforms to the way medicine is practiced and taught are also central to the effort to improve outcomes for Black moms. At the center of this work is a reckoning with systemic racism that is baked into the history of the American health system.
The 1910 Flexner Report—funded by the American Medical Association—laid the foundation for American medical education and led to the closure of all but two historically Black medical schools. This created severe shortages of Black health professionals that persist today, contributing to a lack of cultural humility when caring for Black patients.
At the same time, Black providers such as Granny midwives—who attended half of all births at the beginning of the 20th century—were increasingly undermined and discredited. By 1975, less than 1% of births were attended by midwives as hospital births became the health care standard.
Advocacy for reform in health systems and education seeks to unravel the legacy of these practices by reckoning directly with racism, seeking to diversify the health care workforce, and providing Black moms with culturally sensitive care.
That includes expanding access to midwives and doulas to assist Black mothers. People who receive care from midwives are less likely to have a preterm birth, less likely to have a C-section, and more likely to breastfeed. Doulas—non-clinical health care providers who offer physical, emotional, and informational support during pregnancy, labor, delivery, and postpartum—can play a critical role in reducing racial disparities in maternal health, and their services have been associated with fewer birth complications and a reduced risk of having a low birth weight infant. Some states cover these services under Medicaid, and advocates are pushing for expanded access to these services nationwide.
When it comes to clinical care, addressing biased care practices within clinical care is a top priority for physician advocates—and that includes calling out biased care practices, such as the excessive drug testing of Black women on labor and delivery wards. A recent study of Pennsylvania hospitals found that Black women were less likely to test positive for drugs than white women, despite being tested more.
A commitment to addressing discriminatory hospital policies has led many physicians to refocus their energy on advocacy, says Jamila Perritt, MD, MPH ’10, president and CEO of Physicians for Reproductive Health.
“These are policies that are deeply misinformed, misguided, not grounded in science or medical evidence, and in fact, are directly misaligned with principles of public health," says Perritt. “It’s recognition that [physicians] are not infallible. We will make mistakes and we will cause harm and the question becomes, what did we do after it?”
Meanwhile, a new generation of medical trainees is also putting equity front and center of their education, both by participating in the larger anti-racism movement through groups like White Coats for Black Lives and leading the charge to change their curricula, says Neel Shah, MD, assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.
“One of the things I've seen the last couple of years is that medical students themselves are driving the change,” Shah says. “They're the ones who are calling for implicit bias curricula or calling for health equity to be part of the curriculum.”
Bolstering Community Organizations
The movement for birth equity is also being led with growing momentum by community-based organizations (CBOs) focused on caring for Black moms and advocating for system change across policy and health systems.
“Health isn't produced in the four walls of the clinic,” says Shah. “It's produced in people's homes and their communities and their workplace. And you have to not only have the right technical expertise to serve someone; you have to have the right lived experience, particularly when it comes to childbirth.”
CBOs are often the vital intermediary between individuals and policymakers, working at both the grassroots level, empowering everyday people, and at the “grass tops” level, mobilizing political support and influence. They are particularly well-suited to address the unique needs of their communities, including the challenges faced by Black birthing people seeking quality care.
These organizations are critical partners in efforts to reduce disparities in maternal health outcomes. They collaborate with health care providers, policymakers, and other stakeholders to advocate for programs that target the issue at hand, and they step up to provide much-needed resources such as access to doulas, home visits, social services referrals, and education.
Supporting for the work already being done in Black communities has been written into policy efforts like the Momnibus and the proposals in the 2022 White House Blueprint for Addressing the Maternal Health Crisis.
As complex and deep-rooted as the Black maternal health crisis is, solutions are at play at all levels of society. There is promise in policy, potential in system change, and renewed energy with the next generation of medical trainees. Communities are using collective efforts to transform experiences. Families affected by the crisis are raising their voices.
But it’s not just policymakers, physicians, and Black birthing people who can help solve this problem by staying informed about the roots of the problem, and supporting the work being done to fight it.
If you’re interested in learning more about the Black maternal health crisis, the history of the issue, and solutions to it, check out the links and book recommendations below.
Organizations mentioned in the podcast series
- The Black Mamas Matter Alliance, founders of Black Maternal Health Week, advances Black maternal health, rights, and justice.
- National Birth Equity Collaborative works to optimize Black maternal, infant, sexual, and reproductive wellbeing.
- 4Kira4Moms is a nonprofit dedicated to eradicating maternal mortality.
- Dr. Shalon's Maternal Action Project is part of an advocacy collective focused on the postpartum period for BIPOC birthing people.
- Review to Action connects states to Maternal Mortality Review Committees.
- Physicians for Reproductive Health aims to ensure safe and compassionate access to care.
- Maven Clinic, a digital health platform focused on family care.
- The Century Foundation, a progressive, independent think tank that drives policy change for issues including for maternal health.
- The Bloom Collective focuses on providing a nurturing, supportive and empowering space for mothers, parents and families.
- Mamatoto Village creates career pathways for Black women in maternal health.
- Black Women’s Health Imperative, the first and only national non-profit solely dedicated to achieving health equity for Black women in America.
- National Black Doulas Association, connects Black birthing professionals and provides resources and support with families seeking doula service.
- National Black Midwives Alliance establishes a representative voice at the national level that organizes, advocates, and brings visibility to the issues impacting Black midwives and the communities they serve.
- SisterSong, created by the founders of the reproductive justice movement, is a national activist organization amplifying the collective voices of indigenous women and women of color to achieve reproductive justice.
- Under the Skin by Linda Villarosa
- Medical Apartheid by Harriet Washington
- Killing the Black Body by Dorothy Roberts
- Medical Bondage by Deirdre Cooper Owens
- Policing the Womb by Michele Goodwin
- Reproducing Race by Khiara Bridges
- Birthing Justice by Julia Chinyere Parah and Alicia Bonaparte
- Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society by Arline Geronimus
- The Philadelphia Negro by W.E.B. DuBois
- Film: Aftershock (2022)
Rachel Bervell, MD, is a physician and MPH candidate at the Bloomberg School, and co-founder of @TheBlackObGynProject. Her insights have been featured on Health Affairs, NPR, and more.
Annalies Winny is a producer of Public Health in the Field and Associate Editor of Global Health NOW at the Johns Hopkins Bloomberg School of Public Health.