Maybe you heard about Shalon Irving from Atlanta, who collapsed and died from complications of high blood pressure in the weeks after giving birth to her first daughter, Soleil. She was 36.
Maybe you heard about Marqwetta Johnson from Tulsa, who died from an ectopic pregnancy that led to cardiac arrest. She was 42.
Maybe you heard about Courdeja West from Charlottesville, who died from a stroke four days after the birth of her first son, Keshawn. She was 18.
These black women all died too soon because of causes related to pregnancy and childbirth, leaving grieving loved ones trying to pick up the pieces of their shattered lives.
If you don’t yet know about the numbers, the sad and shocking truth is that non-Hispanic black people are three to four times more likely to die during childbirth or the first year of their child’s life than non-Hispanic white and Hispanic people. (From this point on, when we say “black” and “white,” we’re referring to non-Hispanic people of those races.) For every death that receives national press attention, many others go largely unnoticed.
When talking about black maternal mortality, the same questions come up over and over. Why is this happening? What can we do about it? After all, 60 percent of deaths related to pregnancy and childbirth are preventable, according to the Centers for Disease Control and Prevention (CDC).
Put simply? “This is not an easy problem to solve,” Elizabeth Howell, M.D., who also has a Master’s of Public Policy (M.P.P.) and is the director of the Blavatnik Family Women’s Health Research Institute, tells SELF.
That said, many community and grassroots activists, nonprofit organizations, legislators, medical professionals, and non-clinical birth workers have been working hard to address this issue. Here are some of the strategies experts in this space believe would help save black pregnant and postpartum people.
1. We need to collect more data.
Gathering more research can help further establish the causes behind black maternal mortality and morbidity in order to identify consistent patterns or gaps in care, Dr. Howell explains.
That’s a major sentiment in a statement Michael Lu, M.D., M.S., M.P.H., provided to the Ways and Means Committee in the U.S. House of Representatives during a May 2019 hearing about racial disparities in maternal health. “First, we must review, report, and learn from every single maternal death,” he said when outlining his multi-point plan for reducing black maternal mortality.
“Getting the data right is an indispensable first step toward achieving zero maternal deaths in the U.S.,” he added. One way of doing this is with maternal mortality review committees (MMRCs), which are multi-disciplinary teams that compile as much data as possible on every maternal death so they can try to prevent similar deaths in the future. The CDC developed the Maternal Mortality Review Information Application (MMRIA) to offer a standard way MMRCs can review these cases, with the goal of eventually rolling out a national maternal mortality surveillance system, Dr. Lu explained.
It’s also crucial that we collect more data on the birth process for everyone, not just those who lose their lives. In that vein, the Black Mothers’ Breastfeeding Association (BMBFA) was awarded $ 100,000 this summer to develop an app to gather various types of health reports from breastfeeding families, with the ultimate goal of reducing preterm birth and infant mortality (both of which can be tied to maternal mortality as well).
Another prime area for data collection is the potential benefit of doulas and midwives—especially ones of color—for black people giving birth. (Doulas are non-clinical birth workers who provide emotional support, and midwives are certified medical birth workers.) Some research has linked doulas with improved birth outcomes, like a 2013 study on 225 mothers in The Journal of Perinatal Education. About 77 percent of the pregnant participants were black; 44 percent of the doulas were white and 41 percent were black. The study found that the mothers with doulas were two times less likely to have a birth complication, four times less likely to have a baby with low birth weight, and also more likely to start breastfeeding. Then there’s a 2018 review in SAGE Journals, which noted that midwives may help address the lack of sufficient medical care many black people experience before birth and help black pregnant people feel more empowered. Neither of these findings is super surprising; many black people have expressed gratitude for doulas’ and midwives’ knowledge and advocacy throughout the birthing process. But in order to shape medical and legislative policies that might make doulas and midwives easier to access, we need more rigorous research to support the physical and emotional benefits of these types of birth workers (especially of birth workers of color for black pregnant people). As the SAGE Journals review notes, there’s simply not enough data in this area.
2. We need to address maternal mental health care, too.
“Oftentimes, mental health is at the bottom of the checklist,” Kay Matthews, who founded the Houston-based nonprofit the Shades of Blue Project after she delivered her daughter stillborn in 2013, tells SELF. “We address the issues that have happened to the woman, but not necessarily how she feels about what has happened to her.”
Many new parents find their worries dismissed even when their feelings are beyond normal anxiety or baby blues, Matthews says. “It’s mentally straining, especially when you are surrounded by people telling you, ‘This is normal,’” she explains.
A study published in the journal Psychiatric Services in 2011 examined data from 29,601 women using Medicaid services in New Jersey between July 2004 and October 2007, concluding that black women were less likely than white women to pursue treatment for postpartum depression. Even those who did ask for help were less likely to receive follow-up care. There are lots of possible reasons behind these discrepancies, the study explains, like access to health insurance, but it’s a pretty clear and concerning pattern.
We also can’t ignore another aspect of the mental health and pregnancy/childbirth conversation: During delivery, some people “are being retraumatized or traumatized for the first time,” Latham Thomas, a doula and the founder of Mama Glow and Mama Glow Doula Immersion Program, a global maternal health company and doula training program, tells SELF.
A 2010 Psychological Medicine meta-analysis found that 43.5 percent out of 866 people who were four to six weeks postpartum and had never experienced a traumatic life event reported experiencing one during childbirth. Nearly 4 percent of those people met the diagnostic criteria for post-traumatic stress disorder.
Sometimes this trauma happens when a person survives a life-threatening health complication during childbirth or sees their baby deal with a serious health complication. But sometimes trauma takes root when people feel ignored or taken advantage of in some way during the birthing process. In July 2019, the civil and human rights organization Black Women’s Blueprint (BWB) released a report on the connection between trauma and maternal mortality, which included insight from people who talked about violating and/or non-consensual gynecological and obstetric procedures.
“We have a prominent conversation in the public sphere as it relates to boundaries being transgressed sexually, but when it comes to birth, we do not have these conversations,” Thomas says.
3. We need to counter implicit bias among medical professionals.
“Implicit biases really play into our deaths,” Monifa Bandele, vice president and chief partnership & equity officer of MomsRising, tells SELF. “We need to dismantle [these] racist practices.”
A 2015 systematic review published in the American Journal of Public Health reviewed 15 studies about racial and ethnic biases among health care professionals, finding that 14 of the 15 data sets showed health providers having inherently positive attitudes toward white people and inherently negative attitudes toward people of color. These inherently negative attitudes can manifest in multiple ways when providers should be helping someone through pregnancy and childbirth, including undertreating a patient’s pain or giving different treatment recommendations for health conditions.
“Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color,” the American Journal of Public Health researchers conclude.
Implementing medical training programs to reduce implicit bias is getting a big push from some 2020 presidential candidates. You can read more about that here.
4. We need to uplift the voices of affected communities and families.
“The system is broken, and black women have been this canary in the coal mine,” says Bandele. “We are showing you an issue that is widespread, real, and impacting everyone. We center black women because we believe you have to center the people who are being affected the most.”
Nicole JeanBaptiste, a doula who trained with Ancient Song Doula Services and now owns Sésé Doula Services in the Bronx, explains that black women are leading the charge in the reproductive justice movement even if we don’t hear about these individuals and organizations often enough.
“There are, across the country, so many different communities where there are women-of-color-led initiatives to address this problem,” JeanBaptiste tells SELF. “I’m just Nicole in a small section of the Bronx who recognizes that, and I have to do my small part to ensure that this problem is no more.”
Setting the Standard for Holistic Care of and for Black Women, an April 2018 paper published by the Black Mamas Matter Alliance (BMMA), says that health care providers should recognize the cultural legacy of black birth workers and listen to people doing birth work in affected communities.
“Black women know their bodies and understand what ails them,” the paper says. “The voices of black women must be heard in individual care visits, in policy decisions, and in the design of all medical interventions targeted for black women.”
5. We need to extend Medicaid coverage up to one year postpartum in every state.
This was another major point in Dr. Lu’s statement before the Ways and Means Committee in the U.S. House of Representatives. “Many low-income women lose their Medicaid coverage at 60 days postpartum,” he noted. “Considering that [around] one in eight maternal deaths occur between 42 and 365 days postpartum, extending Medicaid coverage up to one year postpartum could be an important first step toward reducing late maternal deaths.”
According to the CDC, Medicaid was the source of payment for 43 percent of births in 2017. The Kaiser Family Foundation explains that while 36 states and Washington, D.C. have allowed low-income people to extend their pregnancy-related Medicaid coverage after the 60-day postpartum period, there are still 14 states where they must reapply for Medicaid as parents once those 60 days are up. It’s typically harder to qualify for Medicaid as a parent than it is as a pregnant person, so people often lose their insurance. This gap in coverage can leave people uninsured during a stressful, medically vulnerable time, making it more difficult to seek and receive care.
Data out of North Carolina suggests that expanding Medicaid services can make a huge difference in maternal health outcomes. In 2011, the state launched a Pregnancy Medical Home program through Medicaid. The program financially incentivizes doctors to screen pregnant people for health risks (like a history of preterm birth, chronic health conditions, and an unsafe living environment). Doctors in this program are to refer patients with these risk factors to a free “pregnancy care manager,” typically a nurse or social worker, who can help coordinate medical appointments and connect people with necessary services like food banks or housing resources. Doctors also receive financial incentives for doing a postpartum visit. Numbers show that this program has helped close the racial gap in maternal deaths within the state. By 2013, there were around 24 deaths per 100,000 births annually for both black and white parents. That’s still far too high overall, but North Carolina’s success in reducing the racial disparity is undeniable.
6. We need to expand fourth-trimester care.
As of May 2018, the American College of Obstetricians and Gynecologists (ACOG) recommends an “ongoing process” of postpartum care. This is replacing doctors’ traditional recommendation of a single follow-up appointment up to six weeks after birth. Now, ACOG suggests that a new parent meet with their ob/gyn or another obstetric care provider within the first three weeks postpartum and stresses the importance of a comprehensive visit with “a full assessment of physical, social, and psychological well-being” within the first 12 weeks postpartum.
Timely follow-up appointments ensure that new parents are getting their health needs met, which will ideally help reduce deaths from postpartum issues like high blood pressure, stroke, and infection.
Medical care during the fourth trimester is just one piece of the puzzle, though. Other things that play into a new parent’s postpartum health include access to reliable transportation to attend medical appointments, insurance or the means to cover the costs of those appointments, access to medical professionals who treat patients with dignity and respect, access to a grocery store and a safe, clean place to prepare food, a workplace that offers paid time off (or at least the ability to bank time off ahead of birth in order to recuperate), and awareness about postpartum risk factors and when to seek immediate medical attention. Here’s one certified nurse-midwife’s explanation for why postpartum care needs to head in this direction.
7. We need to normalize trauma-informed care.
On another research-related note: “There’s not a lot of data at all around [sexual] trauma as far as it comes to affecting maternal health care,” Sevonna Brown, associate executive director at Black Women’s Blueprint and trained doula, tells SELF.
In addition to detailing how people can experience trauma during pregnancy and delivery, the July 2019 BWB report, which Brown co-authored, also explores how sexual trauma, including harassment and assault, can impact how pregnant people navigate their health care. It includes examples like someone who has experienced sexual trauma avoiding gynecological exams or discussions about their sexual history, both of which are important for ensuring a safe pregnancy and delivery.
In The National Intimate Partner and Sexual Violence Survey released by the CDC in 2011, 22 percent of black women surveyed reported having been raped and 41 percent reported experiencing another form of sexual violence. These horribly high numbers become even worse when you think about the fact that people often don’t disclose their experiences of sexual violence, so the real figures may be even higher. As such, experts believe addressing this trauma is part of making the birth experience better for black people.
This is where trauma-informed care comes in. In the simplest terms, health care providers who practice trauma-informed care understand that patients may have been harmed in the past and do their best not to re-traumatize them.
Trauma-informed care may involve explaining to patients exactly what’s going to happen next and why, offering to let them keep a trusted person in the room with them, asking for permission to touch a patient, and stressing that a patient can ask for an exam to stop at any time, according to a handbook on trauma-informed care that The Substance Abuse and Mental Health Services Administration provides on its website.
A number of doula and midwifery training programs teach trauma-informed care and stress the importance of informed consent in medical settings. However, providing trauma-informed care should be standard across the board.
8. We need to recognize that stopping maternal deaths is just one part of the goal.
“It’s important to understand that while the number of women who die is really scary, particularly in the United States, it’s also important that we not lose sight of so many other issues,” Nicole Deggins, C.N.M., M.S.N., M.P.H., founder and CEO of Sista Midwife Productions and creator of the Sista Midwife Directory where black midwives, doulas, lactation specialists and more can add their information to a searchable database for free, tells SELF. “The women who live—how are they living?”
Getting home from the hospital alive is not enough. The black maternal mortality crisis demands an urgent and nuanced response. This includes holding our elected officials accountable. It includes spreading awareness about possible complications during pregnancy, birth, and the postpartum period. It includes upholding the many organizations across the country tackling this crisis, including those sharing stories of safe and joyful birth—those experiences show that it is, in fact, possible. And it includes seeking solutions immediately while centering the voices of the communities and individuals who are most affected. People’s lives depend on it.