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Racial disparities in maternal health represent an ongoing and worsening crisis in the United States. Black women face a range of inequities in pregnancy and childbirth, and maternal mortality rates (MMR) in the US are 2 to 4 times higher among Black women compared to White women.1 Such findings have been attributed to myriad factors largely stemming from systemic and structural racism.2
“Addressing these issues requires a multidimensional approach that includes improving access to quality health care, addressing socioeconomic inequities, and confronting structural and systemic racism within and beyond the health care system,” said Melva Craft-Blacksheare, DNP, CNM, RN, associate professor in the School of Nursing at the University of Michigan-Flint.
Recommendations for Providers and Health Systems
Among the measures needed to reduce mortality and improve maternal health among Black women, Dr Craft-Blacksheare recommends:
- Healthcare practitioners acknowledge and respect the diverse social identities of patients.
- Providers address the emotional health needs as well as the physical health needs of women and encourage their active participation in decision-making about their health care.
- Implicit bias is highly prevalent among health care providers, necessitating a commitment to cultural competency, inclusive shared decision-making practices, and increased awareness of such biases to reduce disparities in maternal care.3
Using clinical resources and educational tools, health care providers can learn to recognize and address unconscious bias and stigma in themselves and others to promote cultural awareness and health equity.- Hospital and health care systems train all providers in cultural humility, cultural competency, and person-centered care.
- Health profession programs embed social determinants of health and health disparities education into their curricula to help students better understand these issues and mitigate their impact.
“By developing cultural competence and identifying and addressing racial biases, health care providers can better understand and tackle the ways in which health disparities negatively impact patient and system outcomes, thereby promoting greater health equity,” Dr Craft-Blacksheare said in an interview.
She also emphasized the importance of racially concordant care and the disproportionately low rates of Black health care providers in the US. While Black people represent 13% of the US population, research findings have shown that Black physicians comprise only 5% of the active physician workforce, and Black women specifically comprise only 2% of this workforce.2
“Although interest in OB-GYN residency programs has increased in the US, the proportion of medical graduates identifying as Black has consistently declined over the past decade, which will significantly impact the Black community,” Marshall H. Blue, Sr., DNP, MSN, RNC-NIC, CNL, PHN, director of pediatrics at St Joseph’s Medical Center and Dignity Health in Stockton, California said.4,5 A recent study found that the proportion of Black residents entering OB-GYN programs declined from 10.2% to 7.9% between 2014 and 2019.5
Among certified nurse midwives and certified midwives, only 7.0% identify as Black, according to recent data from the American Midwifery Certification Board.6
“Addressing the crisis in maternal health and mortality, particularly among Black women, requires a concerted effort to diversify the medical workforce,” Dr Craft-Blacksheare said. “Increasing the presence of Black health care providers can facilitate racially concordant care, which may improve patient trust and health outcomes.”
The Need to Recruit and Train Minority Providers
To promote progress in recruiting and training greater numbers of Black health care providers, there is need to “formulate a pathway for health care providers who look like the clients they serve to open and build practices within the communities where Black and Brown people live and work,” explained Marshall H. Blue, Sr, DNP, MSN, RNC-NIC, CNL, PHN, director of pediatrics at St Joseph’s Medical Center and Dignity Health in Stockton, California, in an interview. “There is a sense of comfort expressing yourself and discussing issues with someone you feel has had similar experiences or who can understand your concerns due to historical association.”
He explained that creating this pathway will require an emphasis on strong educational guidance in primary and secondary school systems, as well as community involvement and legislative mandates to encourage students of color to enter health care. “The community must partner with local, state, and federal legislative bodies to ensure that support is provided to the local school systems to fund viable healthcare career program opportunities highlighting the need for Black physicians, nurse midwives, and other providers, as well as the impact it would have on mortality outcomes within the community,” he said.
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Although interest in OB-GYN residency programs has increased in the US, the proportion of medical graduates identifying as Black has consistently declined over the past decade, which will significantly impact the Black community.
As an example of programs that may serve as models of how to address disparities in health care, Dr Blue described a program in his community called HOPE (Helping Our People Elevate), which was founded by his colleague, friend, and mentor Anitra Williams, VP-CNO of St. Joseph’s Medical Center in Stockton, California.
“The HOPE program was created to address the shortage of RN graduates within the community and assist individuals who had a desire to become a registered nurse but then ‘life happened,’” he said. In collaboration with the local community college, the program “assists in increasing the number of potential candidates who have achieved the minimum requirements to have a chance at a career in nursing and support the community by increasing the number of students each year.”
To date, the HOPE program has successfully placed 3 graduating cohorts within the community, all of whom passed the National Council Licensure Examination, and a fourth cohort is set to graduate in May 2024, according to Dr Blue.
“The hope is for each student to broaden their sights on current possibilities to potentially grow in the profession and further enhance their lives and that of the community for future posterity,” he said. “They may ultimately decide to become nurse practitioners and midwives.”
To address maternal health specifically, Dr Craft-Blacksheare highlighted the promise of community-based care models.2 “By facilitating closer-to-home services, such care models allow for a broader reach, especially in under-resourced areas,” she said. “By integrating home visits from certified midwives, leveraging community-operated clinics, establishing free-standing birth centers, and initiating targeted health campaigns, the healthcare system can effectively bridge gaps in care.”
Along with providing medical care, “these services can foster an environment of health promotion and education, enabling greater awareness of one’s health options and helping individuals develop skills to advocate for their medical needs,” she said.
In a survey-based study of 227 perinatal health workers that was co-authored by Dr Craft-Blacksheare and published in 2023, respondents recommended the inclusion of specialists such as social workers, mental health professionals, and nutritionists in team-based care models to further promote comprehensive care for expecting mothers.7
In addition, Dr Craft-Blacksheare points to the critical importance of addressing health care policy and insurance coverage to support comprehensive community-based care, including the provision of nonhospital care such as doula services and childbirth education.
“Most notably, extending Medicaid coverage for postpartum care from the current 60-day limit to at least 1 year post-delivery could significantly impact maternal outcomes,” she said.7 “Ensuring consistent postpartum support has been linked to decreased maternal morbidity and mortality, a change that is particularly beneficial for Black women who disproportionately face adverse maternal health outcomes.”2 More broadly, Dr Blue cited the need for organizations with political influence to engage in efforts to increase diversity, equity, inclusion, anti-racism, and accessibility (DEIAA). “Organizations like DNPs of Color (DOCs) and the Association of California Nurse Leaders (ACNL) are committed to promoting fair and equitable health care policies for all individuals, especially those who are disenfranchised,” he said. “This is why I continue to designate time for these organizations, as they both align with my personal and professional values.”
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