Racial Disparities in Maternal Health May Be at a Pivot Point

Whether you're looking at prenatal care, delivery, maternal mortality, or postnatal care, the problem is clear: There is a significant issue with treatment and outcomes based on racial inequality. And it will require changes not just in reproductive healthcare systems, but also from legislators, medical schools, community advocacy groups, and at the individual level.

This disparity has existed for well over a century, but that doesn't mean it's insurmountable. It's possible we may have reached a pivot point.

Racial disparities in maternal health aren't only about implicit and explicit bias and differences in treatment access. They're part of a larger web of challenges that include economic concerns, racism, generations of stressors, criminal justice, and many other considerations.

"This is such a complex issue, because the factors we're dealing with are systemic and historic, but also cultural and social," says Hyagriv Simhan, MD, division chief of gynecology and reproductive science at the University of Pittsburgh Medical Center's Magee-Womens Research Institute. "The solutions will need to be wide-ranging, from changes at a societal level to training every healthcare professional about bias. But the first step is, of course, greater awareness about these disparities."

Depth of the Problem

According to a report in Clinical Obstetrics and Gynecology, Black people are three to four times more likely to die a pregnancy-related death compared to White people. This disparity, the report adds, has existed for over a century and has actually widened over the last 100 years.

Research published by the Centers for Disease Control and Prevention (CDC) found that American Indian and Alaska Native people also have higher rates of pregnancy-related deaths, and are two to three times more likely to be at risk compared to White people.

Postnatal care is similarly challenging. While a 2011 study in Psychiatric Services found that postpartum depression rates don't differ by race and ethnicity, people of color and/or low-income parents received suboptimal treatment for postpartum depression when compared with White people.

The people of color observed in the study were also around half as likely to initiate mental health care than White people, even though the issue can have severe health impacts.

Complex Problem, Multiple Causes

As Simhan notes, the complexity of this issue is a large part of what makes it overwhelming, and there are many factors both within and outside of the healthcare system.

Perceptions, Assumptions, and Biases

Unequal treatment can begin during the interaction between patient and doctor, and healthcare professionals may not be aware of their implicit biases, according to Richelle Whittaker, LSSP, an educational psychologist specializing in maternal mental health for people of color. "Often, Black women are viewed as aggressive or abrasive when asking questions, trying to gather information, or report concerns," she says.

Another study, published in Proceedings of the National Academy of Sciences, found that a substantial number of White medical students and residents hold false beliefs about biological differences between Black and White people, such as that Black people's skin "is thicker," and that they require less pain medication.

Patient Mistrust Magnified by Historical Context

Generational stress can be considerable, and can be further amplified for some people when getting prenatal care or coming back for postnatal checks, says Karen Craddock, PhD, applied psychologist and visiting scholar at Wellesley Centers for Women.

"No one Black woman walking into a hospital is alone; she's carrying generations of complex discrimination and necessary resistance on her back," Craddock says. "We know this can bring her strength, but it contains trauma, and that can translate into difficulties with physiological health and psychological wellness."

Added to these are other issues like healthcare access, potentially limited postnatal insurance coverage even under the Affordable Care Act, and not being heard, says Madeline Sutton, MD, a medical epidemiologist, OB/GYN, and faculty member at Morehouse School of Medicine.

For example, Sutton points out, CDC epidemiologist Shalon Irving died three weeks after giving birth in 2017 due to complications of high blood pressure, even though she'd sought help for the condition.

That same year, tennis player Serena Williams almost died the day after delivering her daughter when she told a nurse something was seriously wrong and was told her pain medication was probably making her confused. When she insisted on being checked, a lung CT scan showed multiple blood clots.

Those stories were so alarming—and unfortunately, so common—that the Harvard T.H. Chan School of Public Health published an article in its magazine titled "America Is Failing Its Black Mothers."

Possible Steps Forward

Like many social justice issues, racial disparities in maternal health have been discussed and known for a long time, with advocacy groups calling for change—but despite halting steps forward, systemic transformation has felt largely out of reach. Until now.

Just as it has with other large-scale societal challenges, the Black Lives Matter movement may have some power in not just increasing awareness, but also fueling actual change that could have a considerable impact on maternal health going forward, believes Naomi Torres-Mackie, PhD, a social justice-focused psychology clinician at Lenox Hill Hospital in New York.

For example, she says, Lenox Hill Hospital just had an education session on Black maternal mortality disparities. As awareness increases, change becomes more possible, and what she's seeing on a hospital-wide level is likely going to be felt across every hospital.

Implicit and explicit bias training is also gaining prominence, adds Cynthia Shellhaas, MD, maternal fetal specialist and professor of obstetrics and gynecology at Ohio State University Wexner Medical Center.

"With this type of training, it needs to happen for everyone," Shellhaas says. "That means not just doctors and nurses, but front desk staff, appointment setters, lab technicians, billing supervisors, and everyone who works with patients.

"You can be the best midwife or OB/GYN in the world, but you need to listen to how your front office staff is talking to your patients. To change bias, you have to change the whole culture of a place," says Shellhaas.

Another step forward is wider use of telehealth services, which were broadened—and covered by insurance—due to the COVID-19 pandemic, but also present an opportunity to provide greater care to pregnant people of color and for postnatal care. "Access to care is a big part of this disparity, so if we can address that with something as simple as telehealth, that's a major step forward," says Shellhaas.

"As long as we can keep moving toward reimagining a different pathway with different outcomes, we can see real transformation happen," says Craddock. "It feels like we're at a pivot point."

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.