Why the Crisis Continues: Systemic and Structural Racism
The last several years have been accompanied by reporting of drastically disproportionate data of maternity care for black woman . Black women are three to four times as likely to die as a result of a pregnancy-related cause than their white counterparts. At the very same time Black infants are twice as likely to die in the first year of life. The social determinants of health that have contributed to this problem are strongly rooted in the fabric of the nation as we know it and human-centred solutions are needed now more than ever.
At the root of the maternal mortality crisis is a legacy of racism in American medicine and in American society. The contributions of public health experts at Johns Hopkins, characterize that Black women typically experience disregard, neglect, or even overt mistreatment by the healthcare system. Therefore, the distrust these women develop with their personal experiences, or the institutional memory of injustice from intentional exclusion from medical education to unethical research, influences the health care experience and interaction for many Black women.
Black mothers report not being heard, believed or taken seriously when they share symptoms or concerns. Even highly-educated, wealthy Black women are at risk and often far worse than less-affluent counterparts who are white. Substandard care and implicit bias often takes place in hospitals where Black births cluster in under-resourced urban hospitals.
Socioeconomic and Policy Barriers can Exacerbate Health Risks
Although poverty and lack of insurance contribute to poor conditions for all mothers, Black women continue to face additional barriers. Even with Medicaid expansion in some states, Black mothers remain more likely to be uninsured or lose insurance shortly after delivery. Only recently have state and federal policies started fixing the postpartum Medicaid gap while expanding coverage beyond 60 days to a full year but many challenges still persist.
In comparison to various other developed countries, the United States does not have a federal policy which provides paid parental leave. It is a benefit to support healthier pregnancy and recovery outcomes for maternal and infant health. When paid leave is not an option, many women, especially women from low-income and marginalized communities are not able to take time off work for postpartum care due to the risk of losing their wages or job. This financial burden limits access to consistent medical care, transportation, safe housing, and healthy food, which are important determinants of Black women’s maternal health outcomes.
Chronic Stress and Mistrust of Healthcare
Systemic racism exists around the world which specifically impacts black women. Discrimination is a learned experience. While we are contending with overt or subtle discrimination, our bodies are in a state of "weathering," which is the biological phenomenon of growing less resilient to stress, thus more likely to experience stress-related outcomes (hypertension, heart disease, and diabetes, etc). Additionally, the fear of being dismissed, ignored or harmed while pregnant, or during the birthing process, can lead to mistrust, and with it delays in treatment will often occur, thus compounding risk during the perinatal period.
Infant Mortality: A Crisis within a Crisis
Black infants face higher mortality rates (i.e., death at birth, prematurity, and sudden infant death) compared to infants of other races, which can often be traced to similar circumstances of their Black mothers concerning access to care, environmental exposures, or lack of systemic protection. The two are intertwined as maternal health and infant health are related as you cannot direct efforts to advance one without considering the other.
International Parallels: A Global Crisis
Women from the black communities are not the only group who experience discrepancies. It's a necessity for us to remember that throughout the world, women from countries that are marked by poverty, discrimination, and gender-based violence face systemic barriers that undermine not only their own well-being but also broader progress toward gender equality. Through their struggles, we get to know the realities that are far more widespread than what is often acknowledged. According to the WHO, 700 women die from preventable complications of pregnancy each day globally. Black infants face mortality rates compared to infants of other ethnicities due to similar reasons of their Black mothers, e.g., access (to care), environmental exposures and systemic ("equity directed") support. The two are linked where you cannot develop initiatives to address maternal and infant health separately.
Promising Pathways to Equity and Solutions
Solutions are beginning to surface from experts and advocates including researchers from Johns Hopkins University and local community doulas which state that :
There should be continuous efforts to expand and streamline comprehensive Medicaid coverage for all postpartum women for all women for up to one year. There must be an increase in workforce diversity in health care. This includes health care practitioners and allied professionals that aren't necessarily considered medical providers such, as, but not limited to, Black OB/GYNs, midwives, paediatricians, home visiting, etc. Anti-racist and implicit bias training for all health care professionals, where medical skill is matched by cultural competence.
Support programs and interventions that extend community based, social support across health system contexts, attending to the fact midwives, doulas, and home visiting programs build trust and facilitate continuity of care for mothers and babies; this is especially required in Black communities.
Support funding to address the social determinants of health (e.g., safe housing, transportation stability, food security and workplace protections, etc.) because they also contribute to preterm pregnancy risk outcomes.
Involve Black voices in the design of healthcare policy, health systems and research - shifting from the patient experience as a passive recipient of care to an active partner in formulating the care that they need.
Ensure that health plans and hospitals are held accountable by reporting outcomes (with transparency), and identify any deficits; linking these outcomes and funding with measurable improvements over time.
Conclusion:
Solutions must move beyond the clinical response to embrace the complete context of Black women's lives in the United States of America and even across the world. As a result there is a need of creating a systematic framework which is majorly influenced by empathy, respect, and shared accountability. Closing the Black maternal mortality gap is possible because achieving this will not only save mothers and babies, but also enhance the ideals of health equity, social justice and dignity for generations ahead.
