Black Maternal Health And Maternal Health Equity

Earlier this month, professional tennis star Serena Williams called attention to inequities that persist in Black Maternal Health by penning an essay for Elle Magazine. The essay detailed her harrowing labor and delivery experience while welcoming her daughter, Alexis Olympia, to the world in 2018.

As a 23-time tennis grand slam winner and a 4-time Olympic gold medalist, Williams is considered one of the greatest athletes in history. She has amassed millions of dollars in prize money and endorsements, affording her access to the best medical care available. She fuels her body with a healthy diet rich in vitamins and key nutrients. A strong family unit provides helpful support and guidance. Yet Williams, with no chronic illness or disease, nearly died while giving birth to her daughter.

Now imagine if Williams was a woman who received little prenatal care, in a low-income household, had a weak family support system, a low health literacy, or no health insurance? Sadly, Serena Williams’ maternal health experience is not uncommon.

Maternal Health - Caring for the ones who care for the nation’s children

Maternal health describes the period in a woman’s health before birth, during birth, and six weeks postpartum. Vulnerabilities in maternal health exist in each of these stages for all women, but as compared to their peers, Black women face increased disparity and are at a greater risk for maternal demise.

Black Maternal Health week, observed April 11 to 17, is a subset of National Minority Health Month. These health observances are recognized to bring awareness to and further conversation around the maternal health crisis Black women face in the United States.

Black women experience heightened risk of birth complications

Maternal health equity is a serious issue with dire consequences. Recent data shows that 17.4 of every 100,000 pregnancies in the U.S., about 700 annually, will result in maternal demise. Of these maternal deaths, non-Hispanic Black women accounted for 41.7% of pregnancy-related mortality from 2014-2017. In contrast, non-Hispanic White women experience approximately 13.4 % mortality per 100,000 live births.

This information places the U.S. as the leader among industrialized nations for maternal mortality. Maternal demise is typically a death that results within 1 year of pregnancy. Experts classify most pregnancy related deaths as preventable.

What maternal health issues do Black mothers face?

A deeper dive into some of the social drivers persisting within maternal health and affecting maternal health equity will help to identify areas of opportunity for improving black maternal health outcomes.

Accessing care in the U.S. can be expensive and challenging to navigate. Black women, aged 18-64, tend to have a higher rate of uninsurance (14%) compared to their White counterparts (8%).  Uninsured women are reluctant to seek out non-emergent healthcare or delay prenatal care due to the expense. This means uninsured Black women may miss critical preventative pre- and post-natal screenings. These screenings are intended to manage expectant mothers’ health throughout the duration of pregnancy and serve as early detection for potential complications and negative changes in health status.

Healthy pregnancy outcomes are often accompanied by access to care services before, during and after pregnancy.  An average of 75% of Black mothers engage in first trimester prenatal care as compared to 89% of expectant White mothers and 79% of Hispanic mothers. During regularly scheduled screening visits, medical practitioners identify and monitor chronic conditions that may be exacerbated during pregnancy, such as high blood pressure and diabetes. These visits are also used to identify treatment plans that may be necessary to reduce negative outcomes like pre-term labor, pre-eclampsia, low fetal birth weight, and hemorrhage.  If prenatal care is delayed or inadequate, patients may be left unaware of underlying medical conditions or vulnerabilities leading to negative health outcomes during pregnancy.

Common comorbidities among Black mothers

Black women have a higher prevalence of comorbidities that can lead to unfavorable outcomes and complications throughout the duration of a pregnancy. Common comorbidities in black maternal health include:

Gestational diabetes (GD)

Gestational diabetes is a common complication that presents in 2-14% of U.S. pregnancies and puts women at a higher risk to develop diabetes mellitus type 2 (DM) later on in life.  Black women are at a 63% higher risk to develop GD than White women.  For Black women, the racial disparities can be attributed to poor screening adherence, genetic factors, undiagnosed DM or pre-diabetes in the absence of pregnancy, and lifestyle factors such as obesity, poor diet, and insufficient exercise. Complications from GD can lead to higher birth weights in infants, premature delivery, and increased need for cesarean delivery.

Preeclampsia

Preeclampsia is the development of high blood pressure during pregnancy and is the leading cause for maternal death worldwide.  Black women are at a 64% higher risk for stroke during labor and 66% risk during postpartum and are nearly 2 times mores more likely to suffer an in-hospital death from complications of a pregnancy-related stroke than White women. Some common symptoms of preeclampsia align with normal pregnancy symptoms which may leave the condition underdiagnosed and untreated, especially among pregnant women who miss screenings and consistent prenatal care.

Fibroids 

Fibroids are non-cancerous growths in the uterus.  Although the specific cause is unknown, Black women tend to experience fibroids at 2-3 times the rate as compared to white women. Fibroids can lead to pain, bleeding, and often require surgical intervention for removal.  The presence of fibroids or scar tissue that results from removal procedures can often complicate the uterine environment during pregnancy.

Make maternal health care more equitable

Medicaid, which funds approximately 4 in 10 births in the U.S., recently released an expansion of the Affordable Care Act that allows for additional post-partum coverage beyond the then-standard 60 days to up to 12 months for women who qualify based on the Federal Poverty Level.  This expansion provides additional support to birth mothers who are healing or recovering from childbirth, addressing complications, require intervention for depression or anxiety, or to support family planning needs. The expansion has been adopted by 39 states; adoption by the remaining states is necessary to provide care for recovering and adjusting mothers.

Address maternal healthcare bias

Navigating the healthcare system can be challenging for pregnant women in the best of circumstances.  For racialized communities, the system may be especially costly, deliver lower quality care, and lack support.

Implicit bias at the hands of medical practitioners can result in medical misjudgments. Caregivers may also be less attentive to patient woes like pain and discomfort. Black patients are often aware of the disparities that exist within maternal health and lead to lower faith in their practitioners and treatment plans. This skepticism leaves black maternal health patients with little confidence for self-advocacy and less likely to step up to seek additional support.

Expand access to maternal health care and assess for social needs

Health care practitioners need to lean on quality, patient-centered reproductive care practices that help derive a better picture of all socioeconomic factors impacting a woman’s health and pregnancy.

Assessing for needs such as food and housing insecurities, transportation, and health coverage can add context to a patient’s complex care needs. Knowledge of these and other social determinants of health (SDoH) can aid collaborative patient/practitioner medical decision-making.

Providing additional options for care, including community health clinics, access to doulas and midwives, and telehealth services, can support maternal health needs outside of regular medical office visits.

Eliminate racial biases in maternal healthcare

We know that implicit biases exist in healthcare and can impact patient care interactions and clinical decision-making.  In the interest of maternal health equity, practitioners need to face the uncomfortable truth that comes with identifying biases. Evidence-based education and training designed to identify and reduce biases can help to standardize care across all populations and plays an essential role in promoting this change.

Support maternal health equity policy advancement

Additional advocacy efforts can also help to reduce the maternal health disparities for Black mothers.  Standardization of paid family and medical leave would allow for additional time and resources for women to care for their newborns and post-partum health needs.

Expanded access to medical services and food and nutrition benefits could also play a part in narrowing the margin of inequities and set new mothers up for a quicker recovery and babies for healthier starts. NCQA and CMS have added additional social needs evaluation and promise a greater focus on SDOH in their quality programs.

Pregnancy and birth are vulnerable times for Black women

Although Serena Williams had the financial resources and access to the informed, attentive medical teams, she found it necessary to self-advocate for her health in the delivery room when emergent conditions presented.  While she had a documented health history including a high-risk status for blood clots, she found her concerns dismissed by her caregiver. Williams could have questioned her instincts and deferred to the medical professional, which we now know could have been to her peril.

Fortunately, Williams persisted; she demanded to be put on a blood thinner after her c-section surgery.  In the 24 hours post labor, Williams presented with excruciating pain and breathing difficulties that did not align with a normal post-partum recovery.  After alerting her care team of her status, Williams was labeled as overly dramatic and loopy at the hands of pain medication. However, she insisted on additional tests including a CT scan.  Had she not advocated for her medical needs, her multiple blood clots, pulmonary embolism, and hematoma could have gone undiagnosed and the outcome of her birth story could have had a very different ending.

We help payers and providers improve health outcomes for Black women

At RTI Health Advance, we help stakeholders better understand the needs of their populations, support healthcare quality advancement for all, and set up the next generation of patients and practitioners to have more favorable health outcomes. Learn more about our health equity consulting solutions today.