With such a high rate of Black mothers dying during childbirth from preventable causes, the plan by HHS fails to adequately address racism as a cause for the disparity.
Peter Mwaura remembers standing in the hallway of Mercy Hospital in Minnesota, confused and upset. His wife’s attending doctor wasn’t answering her concern. “Why can’t I have a natural birth?” Chantel questioned hospital staff repeatedly as they insisted she have a cesarean.
She was scared of “being cut,” since c-sections are associated with a higher rate of severe injury and death. They ignored her, he said, and eventually only directed their answers and attention to him. “They gave her minimal time and attention. I don’t know why they were talking to me,” he said. “She was conscious and alert.” The added fear and frustration of COVID-19 seemed to complicate an already poorly managed situation. Chantel sums up her childbirth experience with three words: “It was horrible.”
With such a high rate of Black mothers dying during childbirth from preventable causes, Peter just wanted both his wife and unborn child to not only survive this ordeal but be treated with respect and listened to. Now, he’s convinced that she was a victim of racial bias and is avid about seeing a real plan from the government and healthcare officials to address it. “Something needs to be done to stop these negative experiences Black mothers are going through [during childbirth],” he said.
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On December 3, the Department of Health and Human Services (HHS) released an action plan intended to reduce maternal deaths and eliminate the disparities that put birthing women at risk.
The number of pregnancy-related deaths in the U.S. far surpasses other similarly wealthy countries at 700 per year, and more than 50,000 women are seriously injured during childbirth. By 2025, the HHS wants to improve maternal health outcomes in the U.S. by reducing the maternal mortality rate by 50 percent, reducing low-risk cesarean deliveries by 25 percent, and achieving blood pressure control in 80 percent of reproductive-age women with hypertension (high blood pressure).
Obtaining these results would be a feat toward the equity of US health culture. Still, these actions must address the root causes of why the maternal mortality rate is so high, especially for Black and Native American women. Under the scope of the pandemic, racial health disparities have become magnified.
Dr. Laurie Zephyrin, M.D., OB-GYN and vice president of healthcare delivery system reform at independent healthcare research foundation the Commonwealth Fund, said the conversation about racism in maternal health care had been a long time coming. “When I first started this journey, no one was talking about racism or root causes,” she said.
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Black mothers are two to three times more likely to die from pregnancy-related complications than white mothers. The first and most emphasized action item in HHS’ plan focuses on improving the cardiovascular health of women of reproductive age, pointing to the higher rates of high blood pressure in Black women as a cause for their higher rates of maternal death. The department is dedicating $1.6 million to assist family planning centers with screening and referring women of childbearing age to the appropriate healthcare providers for hypertension. What it does not address, however, are the social factors and systemic inequities at play.
“When we’re talking about disparities, we need to understand why the disparities exist,” Zephyrin said. “Why do we have these disparate outcomes?”
People with inadequate or no health insurance coverage are less likely to control or care for their hypertension. Researchers also link early life stressors, such as poverty or racism, with increased blood pressure rates among people of color. The American College of Cardiology says such social determinants of health play a key role and that “health care policies at the state and national levels to address these issues will be essential to reduce these disparities.” HHS’s proposed actions do not include a plan for ensuring access to health insurance or care, decreasing the poverty that disproportionately affects Black Americans, or tackling racism in the healthcare setting.
Another major part of HHS’s plan to reduce maternal death and injury includes prevention toolkits for hospitals. The kits include evidence-based best practices and steps to help hospital staff act quickly in the case of hemorrhage and preeclampsia, two of the leading causes of maternal death. California has experience with a similar initiative through the California Maternal Quality Care Collaborative (CMQCC). The organization provides toolkits for hospitals and clinical settings in California to end the largely preventable maternal deaths and injuries. Between 2006 and 2013, the state reduced maternal mortality by 55 percent statewide, but disparities persisted for Black mothers. This prompted them to shift to focusing on birth equity and racism instead.
Zephyrin, along with three colleagues, conducted research comparing maternal mortality and maternity care in the U.S. to 10 other developed countries. They found that in the U.S., there is an overall shortage of maternity care providers, obstetricians, and midwives, compared to births and that our country lacks comprehensive postpartum support.
Midwives are trained to care for birthing mothers in a well-rounded way, including medically, socially, and emotionally. This care and support extend beyond the birth of the baby. Zephyrin’s research also shows that OB-GYNs are overrepresented in the U.S. compared to midwives. Black mothers with midwives, especially Black midwives, have healthier outcomes. Midwives can also serve as a barrier between Black patients and racially charged treatment in hospital settings.
Zephyrin has witnessed implicit bias and has focused her professional efforts on improving healthcare systems through evidence-based maternal care policies.
As a Black OB-GYN, Zephyrin relates to the type of struggle the Mwaura’s endured. “The privilege of being a healthcare provider is that I can push and ask questions and request second opinions and feel empowered to do so on my behalf and that of my family members, but everyone shouldn’t need a personal advocate to navigate through the healthcare system,” she said.
Advocacy groups like Black Mamas Matter were created by members of the Black community in response to the need for Black birthing mothers to get the medical attention and care they deserve. As a part of this initiative, HHS has solicited their help—a move in the right direction to ensure the plan addresses the systemic inequities involved and not just the clinical factors.
A spokesperson for HHS spokesperson told COURIER that the department used roundtables and listening sessions to formulate the maternal mortality and morbidity action plan. “HHS will continue to consult and partner with these organizations to effectively improve maternal health outcomes for Black mothers and families and other vulnerable and underserved populations.”
The HHS Office of Minority Health plans to offer ongoing development and cultural competency training for medical providers. Culturally and linguistically appropriate services (CLAS) “is about providing care that respects and is responsive to the needs and preferences of women of all racial and ethnic backgrounds.”
Zephyrin says, “It’s so exciting to see a collective plan addressing this. So, I think this is a huge opportunity, particularly with the increased societal understanding of the impacts of inequities.” She goes on to say, “This is going to be a multi-agency effort, multi-system effort. Having it as a priority across all relevant federal agencies and providing resources to states, systems, and communities to really get this work done is going to be really critical.”
The Mwauras went home with a healthy baby and memories of a stressful and traumatic birth experience. Peter hopes better for other families like his. “I don’t know much about having a baby, but it’s already a hard experience, and it’s like they make it tougher,” he said about their experience with maternity care providers at the hospital. “That’s what I don’t like about it. Somebody’s got to stand up and say enough is enough.”
Whether HHS’ plan to reduce these experiences and poor outcomes for birthing people in the U.S. is yet to be known.