Focusing on maternity and postpartum care for Black mothers leads to better outcomes

The United States has long struggled with having one of the highest maternal mortality rates among wealthy and industrialized nations. And, the number of people in the nation dying from ­pregnancy-related complications is on the rise; more than 850 people died in 2020 compared with around 750 in 2019 and around 650 in 2018 (Hoyert, D. L., National Center for Health Statistics, 2022). But Black women suffer the greatest impact, as they are 3 times more likely to die during and after childbirth than White people. Similarly, Black babies are twice as likely to die as White babies (Greenwood, B. N., et al., PNAS, Vol. 117, No. 35, 2020). Black birthing people are also more likely to experience long-lasting mental health concerns after childbirth than their non-Black counterparts, even though they typically get less treatment for postpartum depression.

Research points to several reasons why this racial and socioeconomic disparity exists for Black people, such as lack of access to high-quality health care, missed or delayed diagnoses of issues like hypertension (Peterson, E. E., et al. Morbidity and Mortality Weekly Report, Vol. 68, No. 18, 2019), and lack of action or knowledge from providers around warning signs. Data from the U.S. Centers for Disease Control and Prevention (CDC) suggest that 60% or more of maternal deaths could have been prevented by addressing these types of issues.

Many psychologists say stress is another factor that can contribute to poor maternal health outcomes for Black people.

“The reason we have paid little attention, I believe, to Black maternal health is because we don’t listen to Black women. If we listened…we would understand that mental health is playing a role. Racism is a chronic, unrelenting stressor,” said Angela Neal-Barnett, PhD, a psychologist at Kent State University and expert in anxiety disorders within the Black community.

Neal-Barnett, among other psychologists, says mental health screenings should be part of an initial gynecological appointment for anyone who is pregnant. She says it is particularly important to incorporate mental health into clinical practices now that Roe v. Wade has been overturned. CDC research shows Black women are the group most likely to seek abortions, and the real lack of control over their bodies is adding a new layer of stress.

Psychologists like Neal-­Barnett are pioneering and continuing to engage in strategies that are culturally sensitive and relevant to patients’ lived experiences. Some initial data show they can work. “You want someone who understands what it’s like to be a Black woman in 2022,” Neal-Barnett said.

Generational trauma, medical racism

Historical and structural racism for Black Americans is deeply ingrained in the nation’s medical history. Racial inequities across many areas have made it difficult for people of color to stay healthy, says Isabel Morgan, director of the Birth Equity Research Scholars Program at the National Birth Equity Collaborative (NBEC), a nonprofit organization dedicated to reducing birthing inequities.

“It’s not just access to health care that impacts health. It’s also housing, environmental toxins…access to food and affordable, healthy foods,” Morgan said.

When it comes to reproductive health care, Morgan says there’s long-standing distrust of the medical community that must be addressed. For example, James Marion Sims, an Alabama surgeon who is often credited with developing modern gynecological practices, experimented on enslaved Black women without using anesthesia. The contributions of those women—known only by their first names, Lucy, Betsy, Anarcha, and more—have long gone unappreciated, even though they helped advance reproductive health care systems that Black women still can’t fully access.

The resulting medical distrust is compounded by the fact that Black doctors are greatly underrepresented in the medical field, and Black patients often report feeling misunderstood or ignored by their providers (Daley, G. Q., et al., Med, Vol. 2, No. 1, 2021). Some research shows White doctors can harbor biases against Black patients, for example, assuming they are exaggerating their health concerns rather than trusting their expertise on their own bodies.

“So often we’re thinking about the psychological stress of the birthing person. It’s also important to think about the psychology of Whiteness and people who are invested in upholding White supremacy,” Morgan said. Black pregnant people and Indigenous pregnant people are most often impacted by mistreatment (Chambers, B. D., et al., Women’s Health Reports, Vol. 3, No. 1, 2022). “Being scolded, yelled at, not being listened to by providers and in maternity care settings are forms of mistreatment that adversely impact Black birthing peoples’ maternity care experiences,” Morgan said.

Black pregnant people experience distress due to racism before, during, and after childbirth. Prior research has shown that expectant Black mothers were not only 4 times more likely to experience ­posttraumatic stress disorder (PTSD) than non-Black mothers, but they were also less likely to seek or receive mental health treatment. And other studies found the stress resulting from exposure to pervasive and systemic racism—like modern day instances of police brutality toward people of color and news of violence against Black people—can actually impact a person’s genetic code, making them biologically more susceptible to illness (Thames, A. D., et al., Psychoneuroendocrinology, Vol. 106, 2019; Chatlani, S., KBPS, July 6, 2020).

“You’ve got these three generations of people who have had a lot of abuse and they’re raising one another. … You cannot have been traumatized and not received…intervention for that trauma and have it not affect the next generation,” Neal-Barnett said.

Neal-Barnett’s research has shown that Black women experience racism, trauma, negative thinking, and perceived stress much more than non-Black women, which can impact their pregnancies (Journal of Racial and Ethnic Health Disparities, Vol. 8, 2020). The chronic stress results in high cortisol levels—or stress hormones—that can cause a weathering effect on the body. “Weathering does things like constrict the uterine lining. It increases blood pressure. …Levels of cortisol play a role in what we see medically,” she said.

Chronic stress can lead to issues like depression, which can contribute to that weathering effect. According to a 2021 study in the Journal of Women’s Health (Chinn, J. J., et al., Vol. 30, No. 2), depression is linked to a higher risk of preeclampsia, gestational diabetes, and low-birth-weight babies. In fact, non-Hispanic Black women are twice as likely to give birth to a low-weight infant than non-Hispanic White women are.

Promising interventions

Research has shown that mental health care services are most effective when they are integrated into maternity services to reduce poor health outcomes, especially for Black women. Three interventions that can help are niche therapies and sister circles, patient advocacy, and self-advocacy and ­cultural-sensitivity training (Knight, M., et al., Saving Lives, Improving Mothers’ Care, 2015).

Neal-Barnett started the Spirit of Motherhood Program in 2021, which screens expectant mothers for PTSD and chronic stress, with the hopes that treatment of these symptoms can reduce maternal mortality rates.

The program offers participants group therapy designed specifically for Black women, and it is led by community health workers, including doulas, who can guide Black expectant and new mothers through different parenting-related stressors. Neal-Barnett says the program uses cognitive behavioral therapy and music to help reduce stress and regulate emotions for not only these expectant and new mothers but also for their older children. Neal-Barnett says the music featured in the lesson is specifically chosen for its calming properties (JMIR mHealth and uHealth, Vol. 7, No. 6, 2019).

“The children and the mothers come together, they engage with the music, have this positive interaction with each other, and it reinforces the lessons,” said Neal-Barnett.

The program builds upon prior work around an intervention she calls “sister circles,” which are support groups. These build upon existing friendships, culturally relevant discussions, kin networks, and a sense of community to help reduce anxiety and stress among Black women (Clinical Psychology: Science and Practice, Vol. 18, No. 3, 2011).

Cheryl Johnson, MD, an obstetrician at Summa Health, works with Neal-Barnett and says she’s seen the positive impacts of Black-centered group therapy and support groups on the health outcomes of expectant Black mothers. Johnson works with a grassroots organization to offer sister circles to her patients. She provides medical education, and Black therapists help with reducing anxiety and offer community bonding and support. Johnson says patients talk about issues like police brutality against Black men, an issue that can cause stress to expectant mothers who are worried about their children.

“They’re able to help us work through that with the mothers. Whereas when we practice in silos, just in my regular office, we’re not able to address those unique needs of the patient,” Johnson said.

Johnson says they teach pregnant women and existing mothers how to engage in deep breathing, provide them with examples of positive affirmations, and give them stress-relieving strategies they can use at home.

“We have noticed that our preterm delivery rate is lower. We have also seen that our breastfeeding rates are higher among our moms who do our circles, and…our low-birth-weight metrics have improved,” she said.

Physicians, scientific researchers, and writers who treat or discuss the health concerns of Black women are often not Black themselves. That’s because pervasive racism prevents many Black people from having equitable access to career advancement and funding.

Despite a push by the National Institutes of Health to include more representational data from different racial and ethnic groups, Black women are largely underrepresented in medical research on effective interventions. Most of the data fails to reflect the tremendous diversity of Black women, such as birthplace and country of ancestry (Chinn, J. J., et al., Journal of Women’s Health, Vol. 30, No. 2, 2021).

Lediya Dumessa, PhD, a clinical psychologist in Washington, D.C., says it’s important for therapists to be advocates for their patients, especially if their patients feel as though their physicians aren’t listening to them.

She got interested in improving patient advocacy for Black mothers when she became a mother herself and had to change her prenatal care provider numerous times to find someone whom she felt listened to her and made her feel comfortable.

“Unfortunately, I learned how common that experience is for Black mothers.”

Therapists can improve their patients’ relationships with their other health care providers by speaking to them on their patients’ behalf. Therapists could help translate some of their patients’ concerns to their physicians or tell them that they need to do a better job of listening to their patients.

There’s even momentum in Congress to reduce racial disparities in maternal health. APA has endorsed federal legislation like the Black Maternal Health Momnibus Act of 2021 and the Into the Light for Maternal Mental Health and Substance Use Disorders Act of 2022, which both seek to increase access to mental health care for pregnant women.

Carrying and delivering a baby and learning how to become a parent are emotionally taxing, even under ideal circumstances. Jessica Smedley, PhD, a clinical psychologist in Washington, D.C., says that even seasoned parents can get anxious, especially if they’ve already experienced trauma from past experiences of racism in medical care.

“They’re on their second or third child having those fears…and then you couple that with the fear of Black women who are thinking about what it means to have a child in this world,” she said. “It just feels like it’s layered from the moment of conception throughout the parent journey.”

Smedley says the onus is, in large part, on physicians and other health care providers to learn how to become culturally sensitive so they can be receptive to the needs of Black people.

“It starts at the foundation of training for providers who are coming through the system now. It requires intentionally deconstructing old belief systems and humanizing people of color in a way that we weren’t in prior research,” she said.

Given the general lack of cultural sensitivity, Smedley says another important intervention is teaching patients how to advocate for themselves. That work can begin with helping patients equip themselves with knowledge about their own health.

“Teaching self-empowerment and self-advocacy to remember that our experiences are valid and that they are real and that we deserve to have all our needs met and access all the resources that we may require,” Smedley said.

Psychologists acknowledge that mental health interventions alone cannot resolve the Black maternal health crisis in the United States. Persistent and structural barriers make it difficult for people of color to access not only health care, but also other factors and services that are critical to developing a healthy life—employment that offers health insurance, a safe neighborhood, and access to public transportation, nutritious food, and quality schools, to name a few.

Lack of access to all these things negatively impacts communities of color and contributes to poor health outcomes for Black pregnant people. The accessibility and wider use of telehealth is making mental health more available, although Dumessa says that it is still not enough to meet the needs of Black mothers.

“If you don’t have that kind of flexibility from work to be able to take an hour off every week, even if you’re at home, you’re still not going to be able to get treatment,” she said.

She explained that the best way to integrate mental health services into clinical practices is to meet people where they are. The best approach, she says, is having diverse providers go into communities and offer culturally sensitive services, like sister circles, that are relevant to clients’ lived experiences.

“Representation matters,” Dumessa said. “Having people that share an aspect of that cultural background helps to make any kind of treatment effective for our patients.”