Explanation

The Centers for Disease Control and Prevention (CDC) reports that 50,000 women in the United States (U.S.) suffer from pregnancy complications annually, but that Black women are at least three times more likely to die due to a pregnancy-related cause when compared to White women. The estimated maternal mortality rate in 2019 was 20.1 and, in 2020, was 23.8 per 100,000 births which represents about 861 maternal deaths. For Black women, that rate is about 55.3 per 100,000 live births, representing an estimated 1800 maternal deaths, the highest amongst any racial group; this is a number that has continued to increase over the past few years. While each mortality or morbidity circumstance is different, the leading causal factors associated with maternal mortality and morbidity in the U.S. include hypertensive disorders of pregnancy, thrombotic pulmonary embolism, hemorrhage, infection, cardiovascular conditions, cardiomyopathy, and non-cardiovascular medical conditions. While predisposition to underlying health conditions such as hypertension, cardiovascular disease, diabetes, and obesity plays a role in racial disparities in pregnancy-related deaths and other adverse pregnancy outcomes, when these medical conditions are not present, racial disparities persist.

More recent studies have shown that social factors such as historical exposure to racial trauma, discrimination, and marginalization; systemic barriers such as systematic racism and implicit bias within the healthcare system; the possibility of being uninsured; reduced access to reproductive healthcare services; and socioeconomic factors also contribute to pregnancy complications for Black women and must be given consideration. These social determinants of health show that poor maternal outcomes for Black individuals are caused by factors of racism that are embedded in healthcare and affect marginalized groups of individuals disproportionately. Based on socioeconomic status, race, age, and other identifying factors, the health disparities amongst individuals in communities that lack resources and education is exacerbated and continues to expand the gap in access to equitable health. The history of racism within healthcare must be understood to dismantle institutionalized racism in healthcare systems and to create policies that protect Black women. Social and systemic changes are imperative to reduce Black maternal morbidity and mortality. Therefore, the stark differences in reproductive health outcomes for Black women necessitate an increased focus on the intersectional roles of racism, discrimination, and other social determinants of health in influencing disease and mortality risk.

 

An exploration of the factors that contribute to racial disparities in maternal morbidity and mortality among Black women in the U.S. calls for public health, the healthcare system, and community-engaged approaches to achieve equity in maternal health outcomes. These types of barriers could be addressed by targeting the underlying social determinants that fuel the rates of Black maternal morbidity and mortality and by incorporating policy and educational modifications to the healthcare system and industries that supply the healthcare system. The strategies below would greatly reduce racial disparities in maternal morbidity and mortality.

1. Enhance Curriculum and Diversify the Workforce to Address Implicit Bias and to Improve Cultural Humility

Evidence strongly supports the impact that structural racism continues to have on our healthcare sector. Diversifying the medical workforce is imperative to help with this crisis. Currently, although Black individuals make up 13% of the population, they comprise just about 5% of the active physician workforce. “Black female physicians comprise even less, representing only 2% of physicians overall”. This illustrates the importance of racially concordant care and encourages efforts to address implicit bias and to improve cultural humility within the healthcare workforce. Healthcare providers can use clinical resources and tools to recognize and address unconscious bias and stigma in themselves and in their offices to promote cultural awareness and health equity To remedy implicit bias across the continuum of maternal health care, hospitals and healthcare systems can train obstetric and non-obstetric care providers to build knowledge and skills on cultural humility, cultural competency, and person-centered care.

Medical schools and health profession programs should incorporate social determinants of health and health disparities education into the curriculum to equip students with an appreciation of cultural competence, to help them identify and address racial bias in themselves and medicine, and to clarify how health disparities can unfavorably affect both patient and healthcare system outcomes.

 

2. Explore the Impact of Environmental and Occupational Exposures on Maternal Morbidity and Mortality

There is a need to explore the impact of disparate environmental and occupational exposures on maternal morbidity and mortality. Psychosocial stressors such as police brutality can impact Black mothers’ lives when Black mothers endure a gendered racial vulnerability with their added responsibility of teaching their children to respond to police violence in the “police talk”. Such responsibilities that stem from structural racism can cause physical manifestations of stress and psychological distress and have been associated with depressive symptoms among Black women Moreover,  incarceration in the family can play an immense role in affecting BIPOC women’s life and have important maternal and child health considerations, including adversely impacting the availability of adequate support during pregnancy and childbirth among BIPOC populations It is also important to examine how structural racism and discrimination in the workplace environment can take a toll on Black mothers through manifestations such as microaggressions, increased emotional trauma, the gender pay gap, invisibility, negative stereotypes, tokenism, and isolationism.

 

3. Address Social Determinants of Health by Exploring the Impact of Structural Racism on Maternal Health Outcomes

There is also a need to address social determinants of racial disparities in maternal morbidity and mortality by exploring the impact of structural racism on access to factors such as quality healthcare (e.g., the effect of structural racism/historical abuses on health-seeking behaviors and confidence in the health care system), education, income and employment, and quality food. Structural racism affects health through its past and present effects on the quality of, and equal access to key social, and environmental determinants of health. For example, the practice of redlining inhibited communities of color from acquiring residential mortgages and, accordingly, access to public transportation, supermarkets, and healthcare, contributing to the proliferation of residential segregation in the United States. Resultantly, in U.S. communities plagued by segregation, Black persons and other racial and ethnic minority groups are more likely to live in neighborhoods with increased levels of poverty; to have reduced access to employment, credit, housing, educational, transportation, nutritional, and healthcare resources; and to live in health-inhibiting environments, compared to the White population. Systemic racism also inhibits access to vital healthcare services, such as access to reproductive and sexual health services. Therefore, there is a need to address these structural barriers and to acknowledge their role in racially disparate maternal health outcomes.

 

4. Improve Social Policies and Programs

In the wake of the United States Supreme Court’s decision to overturn Roe v. Wade (Dobbs decision), women of color, communities of low income, and other marginalized populations will be disproportionately impacted by barriers to accessing care. This can lead to increased maternal and infant mortality and an enduring impact on women and families, particularly for Black and rural populations. For example, reduced access to reproductive services could impact high-risk pregnancies. Nationally, Black women are three times more likely to die from a pregnancy-related cause than White women. Another way to address structural racism in birth outcomes through policymaking is to expand access to care in terms of health insurance to include coverage for nonhospital care, doula care, and labor and delivery classes. Policymakers should tackle barriers to doula services that include low reimbursement for Medicaid clients, conflicting certification requirements, and complicated paperwork. There should also be continued Medicaid expansion for postpartum women, including women living in non-expansion states, as timely postpartum care is linked with lower maternal morbidity and mortality, particularly for Black women. Expanded coverage for behavioral health care should also be considered. There should be an extension of the Medicaid postpartum coverage limit from 60 days (about 2 months) to at least one year. Furthermore, in addition to the need to improve access to reproductive health services, it is imperative to address gaps in maternal support in the U.S., including in the areas of paid family leave, income for women, and child-care affordability.

 

Conclusions:

Pregnancy-related deaths are tragic and mostly preventable. The stark racial disparities in adverse pregnancy outcomes in the U.S. requires a deeper exploration into the role of social determinants and how structural racism contributes to a greater risk of adverse obstetric outcomes among Black women in the U.S. These social determinants include, but are not limited to, neighborhood environments such as access to healthy food, neighborhood safety, housing, air pollution, pest, and mold exposure; environmental exposures including experiences of racism, discrimination, acculturation, and immigration; socioeconomic status factors such as income, education, and occupation; housing conditions; and health care access and quality. Moreover, structural determinants of health such as slavery and structural racism influence social determinants of maternal and infant mortality. The amelioration of these social determinant disparities may also be the answer to decreasing or eliminating the dismal maternal morbidity and mortality rates and may lead to improved health outcomes for Black women in the U.S. Strategies are needed to undo the legacy of racism that fuels unfavorable pregnancy outcomes among Black women in the United States. Recommendations include addressing implicit bias and improving cultural humility in the healthcare sector, diversifying the workforce, incorporating social determinants of health and health disparities into the medical and health professions curriculum, exploring the impact of environmental and occupational exposures on maternal morbidity and mortality, addressing the impact of structural racism on health outcomes, and improving social policies and programs.