By Fatima Koroma, GW Capstone Student with SWHR
Maternal health refers to a woman’s health, as well as an infant’s health before, during, and after pregnancy. The experiences during these stages greatly impact the health and safety of women and infants. Unfortunately, Black women have a greater risk of developing adverse health outcomes during these stages. In 2023, the maternal mortality rate for Black women was 50.3 deaths per 100,000 live births – significantly higher than rates for White (14.5), Hispanic (12.4), and Asian (10.7) women. The United States has the highest rate of maternal death among high-income nations, with significant racial, ethnic, and geographic disparities. According to a 2022 analysis, U.S. maternal mortality occurs in 22 per 100,000 births, notably higher than Canada (8.4), France (7.6), Switzerland (1.2), and Norway (0.0). Significant work is needed to address disparities in maternal health, including a focus on factors contributing to maternal death rates among Black women.
A Socioeconomic Lens
Several factors contribute to increased maternal mortality rates among Black women, including systemic and structural racism, socioeconomic inequalities, and implicit bias. Systemic and structural racism are defined as forms of racism that are deeply embedded in systems, laws, policies, and beliefs that perpetuate widespread unfair treatment and oppression of people of color in the U.S. As one example, institutional policies such as redlining and segregation in the 1930s drove Black populations into under-resourced communities with limited access to fresh food markets, educational resources, and quality health care. In 2020, researchers found that Black women living in the most racial and income-deprived neighborhoods in Oakland, California, reported higher percentages of experiencing racism while receiving health care than their counterparts in the least deprived neighborhoods. Racism also impacts socioeconomic inequalities in housing, education, and income that limit access to reproductive care and services, often leading to health disparities. Previous studies illustrated significant associations between socioeconomic conditions and excessive gestational weight gain, low birthweight, preterm births, and maternal mental health. One study suggests that addressing socioeconomic factors such as education, income, and access to health care could improve cardiovascular outcomes during pregnancy and ultimately reduce the gap in CVD outcomes between Black and white mothers. This is significant because cardiac and coronary conditions are the leading underlying cause of pregnancy-related deaths among non-Hispanic Black women.
Implicit Bias
Although socioeconomic inequalities contribute to differences in maternal health outcomes across demographics, Kennedy- Moulton et al., found that even Black mothers at the top of the income level distribution had a mortality rate similar to white mothers at the bottom of the income level distribution (approximately 27 deaths per 100,000 births). This suggests that socioeconomic inequalities are not solely responsible for Black maternal health disparities. Another contributing factor that impacts Black maternal health is implicit bias. Implicit bias refers to internalized attitudes, beliefs, or stereotypes that unconsciously affect our perceptions, actions, and decisions. Within the health care system, practitioners’ personal biases can impact how they treat their patients. Unconscious beliefs may influence how practitioners conduct consultations, treatments, and communication with patients, inadvertently perpetuating systemic inequities. A 2019 research study on racial bias in perception of pain demonstrated that health care practitioners were less likely to perceive pain in Black faces. This research echoes the experiences of pregnant Black women like April Valentine, Bevorlin Garcia Barrios, and Shamony Gibson whose complaints of pain were not taken seriously prior to their deaths. Many Black women report feeling unheard by practitioners during and after pregnancy, causing distrust and miscommunication to arise between them and their practitioners. One study examines racial and ethnic disparities in patient-reported communication problems and perceived discrimination in maternity care; researchers found that maternal health conditions such as pre-pregnancy hypertension and diabetes were strongly associated with perceived discrimination. Additionally, the article discusses the impact of perceived discrimination on patient-practitioner communication. The authors suggest that perceived discrimination created barriers to discussion during care and a reluctance to ask questions of their health care practitioners. Implicit bias potentially strains patient-practitioner communication, which can ultimately create mistrust, fear, and mistreatment.
Research
Addressing these complex factors will involve research, community engagement, increased education, and ongoing collaboration at national, local, and individual levels. Expanding research and data on social determinants of maternal health will go a long way in improving patient outcomes. Potential research topics include exploring implicit bias of maternal health practitioners; examining experiences of Black pregnant women across various socioeconomic backgrounds; or longitudinal studies on the Black birthing experience pre- and post- partum, examining the relationship between socioeconomic status and cardiovascular complications during or after pregnancy. New and promising research in this space is increasing. California Health Foundation’s Listening to Mothers in California project compiled the experiences of childbirth in 2,500 women to advance birth equity and address maternal mental health. Similarly, a 2024 Texas study conducted focus groups with Black women to center their discussions regarding experiences of systemic factors in the pursuit of optimal maternal care and to develop potential solutions. Recent research has also begun to highlight specific health conditions in maternal outcomes. Researchers evaluated the risk of cardiovascular events at delivery associated with gestational hypertension and preeclampsia/eclampsia by race and ethnicity to gather data on maternal health outcomes for Black women. Moreover, the National Institutes of Health launched the Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) Initiative, which supports research to reduce maternal death, with a special emphasis on populations that are disproportionately affected. The IMPROVE initiative aims to build an evidence base for improving maternal care and outcomes.
Community Organizations
The Society for Women’s Health Research’s (SWHR) maternal health work aims to raise awareness about knowledge gaps and opportunities in maternal health; promote science-based policies that could positively shape health outcomes for women; and identify clinical and research gaps. SWHR recently convened a Maternal Health Working Group of health care practitioners, researchers, patient advocates, and health care policy leaders to discuss the intersection of maternal health disparities with prenatal and postpartum care, chronic conditions, and mental health, among other topics. Insights from this meeting will be used to inform a maternal health roadmap for patients from preconception to postpartum, later this year. SWHR also greatly relies on collaborating with the expertise of organizations like Expecting Health, March of Dimes, Black Women’s Health Imperative, and Preeclampsia Foundation, just to name a few, as powerful maternal health changemakers in this space. Programming across these organizations includes, CAMT perinatal resource, WHEI maternal health, Dr. Jasmine Jackson interview, Momnibus support, Cardiovascular Disease and Severe Maternal Morbidity and Mortality event at Nurse Practitioners in Women’s Health annual conference.
Legislative Opportunities
Policy change and advocacy also play a crucial role in addressing the maternal health crisis. SWHR’s Legislative Tracker provides information on relevant maternal health legislation, such as the Preventing Maternal Deaths Reauthorization Act of 2023, which seeks to reauthorize federal support of states in their work to save and sustain the health of mothers during pregnancy, childbirth, and the postpartum period; to eliminate disparities in maternal health outcomes for pregnancy-related and pregnancy-associated deaths; to identify solutions to improve health care quality and health outcomes for mothers; and for other purposes. Other key legislation SWHR is tracking includes the Black Maternal Momnibus Act, CARE for Moms Acts, and MOMMA’s Act, all of which aim to improve federal efforts in the prevention of maternal mortality and increase the quality of perinatal care. Maternal health policy can also take shape across the insurance landscape and in national programs like Medicaid. A 2022 Robert Wood Johnson Foundation report examined Medicaid policies adopted in Southern states and nationally to improve maternal health; it notes the need to investigate existing policies and practices and utilize community-based person-centered services to address equity gaps in maternal health.
While progress has been made to address Black maternal health disparities, there is still more work to be done. As we move from Black History Month in February to Women’s History Month in March, we cannot slow down the momentum. The work of community-based organizations, combined with increased research, legislation, and the amplification of women’s health, can turn the tide on the Black maternal health crisis.