This piece was originally printed Verily Magazine's Spring 2023 issue. This is not a public link, it is for portfolio use only.
How can we close the maternal health gap?
Mothers and their children deserve better.
Author’s Note: As a white maternal health care provider, I recognize that practicing my allyship and challenging my biases is an everyday practice. It's important to me to not only bring awareness to this issue, but to also ensure I'm amplifying diverse sources and voices.
Despite the fact that America spends $111 billion (yes, billion with a b) annually on maternal and newborn care--twice as much as other high income countries--we have the highest maternal death rate of the developed nations. Maternal death rates in the US have doubled over the last twenty years, despite newer technologies and increased health spending, while other affluent countries have reduced their rates.
What is more alarming is that when you look a little closer, these numbers correlate with racial and ethnic disparities. According to Dr. Elizabeth Howell, MD, MPP, of The Blavatnik Family Women’s Health Research Institute, Black women are fourfold more likely to die from pregnancy and birth related causes than white women. In the same 2019 paper, Howell showed that Native Americans, Asians, and Latinas also experience higher death rates than white women, though these numbers are not as drastic. The final gut punch? Sixty percent of these morbidities are thought to be preventable.
Race and disparities in maternal health care
What has caused such drastic disparities? It is both simple and complex. Main contributors are bias (whether implicit or outright) about non-white patients, structural racism in health care education and practices, historical and economic forces like financial barriers, and communication skills. Over the last couple of years particularly, many have had a lot of time to think about their role, whether passive or active, in racism in America. Important topics, such as the maternal health gap, have been fast-tracked to the top of the priority list.
Bias is one of the most influential players in causing such disparate care. While overt bias exists as a separate issue, implicit bias is sneaky, covert, and much more difficult to dismantle. Dr. Howell calls implicit biases “deeply rooted and deployed unconsciously.” She explains that implicit bias refers to behaviors in reaction to a patient’s characteristics like age, race, ethnicity, gender, sexual orientation, physicality, and disability that shape actions and inform clinical decisions.
An example of implicit bias of physicality might occur with a patient with a higher body mass index (BMI). A practitioner might assume that the patient is eating unhealthily (even though she might be eating a well-rounded diet). The problem? The practitioner might not even recognize the assumptions she is making. By assuming the patient is eating a poor diet, she might miss a diagnosis of something else. This is happening across the board with Black mothers and often with preventable conditions, such as heart complications, stroke, severe bleeding, amniotic fluid embolism, and cardiomyopathy.
Diagnosing risk categories
Structural racism in healthcare settings is equally as cunning. Black physicians make up a mere five percent of their profession. The reasons behind this are many and complicated, but nonetheless significant. For one thing, due to historical and economical factors like housing restrictions and job access, Blacks are less likely to be able to afford the upfront costs of medical school and residency.
Those same barriers play a role in health disparities, but don’t fully explain them. It is true that lower-income neighborhoods are less likely to have access to fresh food and safe parks, and their inhabitants are exposed to more toxins and are more likely to have chronic stress about basic needs being met. But in New York City even a Black woman with a college degree still falls into a higher risk category than a white woman with only a high school education.
Communication, or lack thereof, on both patients’ and practitioners’ ends also impedes proper care. This doesn’t only concern Black and non-white patients, but it certainly affects them as well, and perhaps in different ways due to biases. Historically, non-white patients have been targeted for medical experimentation, so (understandably) distrust is high. Patients have hesitations about speaking up, for they fear either judgment or being a burden.
Practitioners with high patient loads may have difficulty managing time during office visits. They may unintentionally rush a visit and miss key information that could have opened a conversation about symptoms. The system itself presents problems without implicit bias. But implicit bias increases the gap, which must be addressed.
Addressing the gap
How do we even begin to address these issues? For starters, we need to expand the model of care across the continuum of reproductive health, not pigeonholing care into the annual Pap smear and the six-week postpartum visit. Reproductive health gets cornered into what Dr. Howell calls “touch points” throughout a woman’s life. But these touch points may not be enough. Waiting until your next annual appointment or in between appointments throughout a pregnancy can worsen time-sensitive issues.
Watering down reproductive health to paltry categories like birth control, pregnancy, and birth is oversimplified at best. Period health, endocrine disorders, emotional and mental well-being, physical support during transitional phases like pregnancy and postpartum are all part of the complex and nuanced topic of “healthcare.” This is where allied health professionals like doulas and Fertility Awareness Educators can serve a vital role. A patient may have hesitations about bothering her obstetrician about an issue, like those pesky Braxton Hicks contractions, but a doula is educated enough to serve as a middle (wo)man, and oftentimes encourage the patient to address the concern with her provider.
The more supported moms feel between these touch points, the more likely it is that life-threatening conditions can be prevented, simply because women, especially those in minorities, feel they can bring issues up with their providers.
Contraception and race
Fertility Awareness Educators can help empower all women, but especially women of color, in understanding their bodies to make informed choices. Women of color are more likely to have contraception, specifically long-acting reversible contraception (LARCs), pushed on them right after birth. This is problematic, considering IUDs give patients the least amount of agency and come with side effects that are likely to be overlooked in the incredibly sensitive period, hormonally and otherwise, known as postpartum.
This is a two-pronged issue, as the history of birth control itself is steeped in racism and eugenics, which means people of color are less likely to take it. In fact more than forty percent of Black and Latina women think the government promotes birth control to limit births among communities of color. In the New York Times opinion piece, “The Dangerous Rise of the IUD as Poverty Cure,” Christine Dehlendorf and Kelsey Holt, researchers with the Person-Centered Reproductive Health Program at the University of California, San Francisco, explain, “Today, this age-old idea that reproduction is to blame for societal problems has seen a resurgence in the current enthusiasm around long-acting, reversible contraception.” Deirdre Cooper Owens outlines this complex history in Medical Bondage: Race, Gender, and the Origins of American Gynecology. Owens delves into the intergenerational trauma dating back to the origins of the US and slavery, from slave wet nurses who witnessed their own babies’ starvation while feeding their “master’s” white babies from their breasts to the eradication of midwifery in the early twentieth century, which put black women’s healthcare in the hands of white men--again.
Fertility Awareness Methods, by design, put the patient in the driver’s seat. Prioritizing Fertility Awareness Education for communities of color--and more importantly by women of color--can empower non-white moms and assuage their feelings of fear, unease, and pressure in their doctors’ offices, ultimately leading to more positive outcomes for mothers today and their children tomorrow.
Continuing to educate ourselves
Maternal care is sorely lacking for moms in America, and non-white moms bear much of the burden. The more we, as both providers and simply as fellow women, know about the situation, the better the help we can provide, the more effective the action we can take. A great podcast to listen to on this topic is, “Why do Black American women die having babies?” on Equal Time with Mary C. Curtis. Listening well is only the first step, but it’s one we all need to take and one we can start with right now.
The shift in healthcare systems from sterile doctors’ offices to more holistic views, including mental and emotional well-being, are signs of positive change. One organization working to lead the charge in this regard is 4Kira4Moms, which was founded with the mission to advocate for improved maternal health policies and regulations, to educate the public about the impact of maternal mortality in communities, to provide peer support to the victim's family and friends, and to promote the idea that maternal mortality should be viewed and discussed as a human rights issue.
The situation in which we find our nation is multi-layered and complex. With knowledge and proper motivation to improve the situation for ourselves and our sisters, change is possible and powerful.
Author’s Note: As a white maternal health care provider, I recognize that practicing my allyship and challenging my biases is an everyday practice. It's important to me to not only bring awareness to this issue, but to also ensure I'm amplifying diverse sources and voices.
Despite the fact that America spends $111 billion (yes, billion with a b) annually on maternal and newborn care--twice as much as other high income countries--we have the highest maternal death rate of the developed nations. Maternal death rates in the US have doubled over the last twenty years, despite newer technologies and increased health spending, while other affluent countries have reduced their rates.
What is more alarming is that when you look a little closer, these numbers correlate with racial and ethnic disparities. According to Dr. Elizabeth Howell, MD, MPP, of The Blavatnik Family Women’s Health Research Institute, Black women are fourfold more likely to die from pregnancy and birth related causes than white women. In the same 2019 paper, Howell showed that Native Americans, Asians, and Latinas also experience higher death rates than white women, though these numbers are not as drastic. The final gut punch? Sixty percent of these morbidities are thought to be preventable.
Race and disparities in maternal health care
What has caused such drastic disparities? It is both simple and complex. Main contributors are bias (whether implicit or outright) about non-white patients, structural racism in health care education and practices, historical and economic forces like financial barriers, and communication skills. Over the last couple of years particularly, many have had a lot of time to think about their role, whether passive or active, in racism in America. Important topics, such as the maternal health gap, have been fast-tracked to the top of the priority list.
Bias is one of the most influential players in causing such disparate care. While overt bias exists as a separate issue, implicit bias is sneaky, covert, and much more difficult to dismantle. Dr. Howell calls implicit biases “deeply rooted and deployed unconsciously.” She explains that implicit bias refers to behaviors in reaction to a patient’s characteristics like age, race, ethnicity, gender, sexual orientation, physicality, and disability that shape actions and inform clinical decisions.
An example of implicit bias of physicality might occur with a patient with a higher body mass index (BMI). A practitioner might assume that the patient is eating unhealthily (even though she might be eating a well-rounded diet). The problem? The practitioner might not even recognize the assumptions she is making. By assuming the patient is eating a poor diet, she might miss a diagnosis of something else. This is happening across the board with Black mothers and often with preventable conditions, such as heart complications, stroke, severe bleeding, amniotic fluid embolism, and cardiomyopathy.
Diagnosing risk categories
Structural racism in healthcare settings is equally as cunning. Black physicians make up a mere five percent of their profession. The reasons behind this are many and complicated, but nonetheless significant. For one thing, due to historical and economical factors like housing restrictions and job access, Blacks are less likely to be able to afford the upfront costs of medical school and residency.
Those same barriers play a role in health disparities, but don’t fully explain them. It is true that lower-income neighborhoods are less likely to have access to fresh food and safe parks, and their inhabitants are exposed to more toxins and are more likely to have chronic stress about basic needs being met. But in New York City even a Black woman with a college degree still falls into a higher risk category than a white woman with only a high school education.
Communication, or lack thereof, on both patients’ and practitioners’ ends also impedes proper care. This doesn’t only concern Black and non-white patients, but it certainly affects them as well, and perhaps in different ways due to biases. Historically, non-white patients have been targeted for medical experimentation, so (understandably) distrust is high. Patients have hesitations about speaking up, for they fear either judgment or being a burden.
Practitioners with high patient loads may have difficulty managing time during office visits. They may unintentionally rush a visit and miss key information that could have opened a conversation about symptoms. The system itself presents problems without implicit bias. But implicit bias increases the gap, which must be addressed.
Addressing the gap
How do we even begin to address these issues? For starters, we need to expand the model of care across the continuum of reproductive health, not pigeonholing care into the annual Pap smear and the six-week postpartum visit. Reproductive health gets cornered into what Dr. Howell calls “touch points” throughout a woman’s life. But these touch points may not be enough. Waiting until your next annual appointment or in between appointments throughout a pregnancy can worsen time-sensitive issues.
Watering down reproductive health to paltry categories like birth control, pregnancy, and birth is oversimplified at best. Period health, endocrine disorders, emotional and mental well-being, physical support during transitional phases like pregnancy and postpartum are all part of the complex and nuanced topic of “healthcare.” This is where allied health professionals like doulas and Fertility Awareness Educators can serve a vital role. A patient may have hesitations about bothering her obstetrician about an issue, like those pesky Braxton Hicks contractions, but a doula is educated enough to serve as a middle (wo)man, and oftentimes encourage the patient to address the concern with her provider.
The more supported moms feel between these touch points, the more likely it is that life-threatening conditions can be prevented, simply because women, especially those in minorities, feel they can bring issues up with their providers.
Contraception and race
Fertility Awareness Educators can help empower all women, but especially women of color, in understanding their bodies to make informed choices. Women of color are more likely to have contraception, specifically long-acting reversible contraception (LARCs), pushed on them right after birth. This is problematic, considering IUDs give patients the least amount of agency and come with side effects that are likely to be overlooked in the incredibly sensitive period, hormonally and otherwise, known as postpartum.
This is a two-pronged issue, as the history of birth control itself is steeped in racism and eugenics, which means people of color are less likely to take it. In fact more than forty percent of Black and Latina women think the government promotes birth control to limit births among communities of color. In the New York Times opinion piece, “The Dangerous Rise of the IUD as Poverty Cure,” Christine Dehlendorf and Kelsey Holt, researchers with the Person-Centered Reproductive Health Program at the University of California, San Francisco, explain, “Today, this age-old idea that reproduction is to blame for societal problems has seen a resurgence in the current enthusiasm around long-acting, reversible contraception.” Deirdre Cooper Owens outlines this complex history in Medical Bondage: Race, Gender, and the Origins of American Gynecology. Owens delves into the intergenerational trauma dating back to the origins of the US and slavery, from slave wet nurses who witnessed their own babies’ starvation while feeding their “master’s” white babies from their breasts to the eradication of midwifery in the early twentieth century, which put black women’s healthcare in the hands of white men--again.
Fertility Awareness Methods, by design, put the patient in the driver’s seat. Prioritizing Fertility Awareness Education for communities of color--and more importantly by women of color--can empower non-white moms and assuage their feelings of fear, unease, and pressure in their doctors’ offices, ultimately leading to more positive outcomes for mothers today and their children tomorrow.
Continuing to educate ourselves
Maternal care is sorely lacking for moms in America, and non-white moms bear much of the burden. The more we, as both providers and simply as fellow women, know about the situation, the better the help we can provide, the more effective the action we can take. A great podcast to listen to on this topic is, “Why do Black American women die having babies?” on Equal Time with Mary C. Curtis. Listening well is only the first step, but it’s one we all need to take and one we can start with right now.
The shift in healthcare systems from sterile doctors’ offices to more holistic views, including mental and emotional well-being, are signs of positive change. One organization working to lead the charge in this regard is 4Kira4Moms, which was founded with the mission to advocate for improved maternal health policies and regulations, to educate the public about the impact of maternal mortality in communities, to provide peer support to the victim's family and friends, and to promote the idea that maternal mortality should be viewed and discussed as a human rights issue.
The situation in which we find our nation is multi-layered and complex. With knowledge and proper motivation to improve the situation for ourselves and our sisters, change is possible and powerful.