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The horror stories of Black women dying or coming close to death in childbirth never seem to stop coming. The most recent headlines have been about the tragic case of three-time Olympian Tori Bowie, who died in her home from childbirth complications. Her teammate Tianna Madison wrote on Instagram, “THREE (3) of the FOUR (4) of us who ran on the SECOND fastest 4x100m relay of all time, the 2016 Olympic Champions have nearly died or died in childbirth.”
Even Serena Williams, one of the wealthiest and most famous women in the world, had to demand — over and over — the lifesaving care that she needed, all the while being dismissed by her care team following an emergency C-section.
While these athletes’ stories have made the headlines, what they experienced happens every day to Black and Brown women in this country. And it has to do with racism, generational trauma and stress, and institutionalized biases that supersede social constructs like economic standing, education, or even access to care.
As a maternal health advocate, people often ask me, “What can be done to address social determinants of health that are associated factors seen with poor maternal health outcomes?”
I have to confess that this question ruffles my feathers a bit. But it has also lit a fire under me to educate health care providers of the much larger picture. Social determinants of health have become an excuse to place the blame back on the patient for a staggering crisis in the U.S.
The American College of Obstetrics and Gynecology places heavy emphasis on environmental conditions shaping health outcomes: “It is well established that social determinants of health are responsible for a large proportion of health inequities that exist in the United States.”
This seems like a reasonable statement — yes, it is true that someone with less access to a healthy environment is often less healthy.
But that isn’t the whole story. It seems that providers are simply more comfortable talking about social determinants of health than they are with doing the hard work of tackling bias.
The U.S. maternal mortality rate increased 40% between 2020 and 2021, according to the CDC. This rise in deaths related to pregnancy and childbirth was especially significant for Black women. In the U.S., no matter their level of education or socioeconomic status, Black women die of pregnancy-related complications at rates three to five times higher than their white counterparts. Black women die at a rate 2.6 times higher than their white counterparts. Even in states with the lowest pregnancy-related maternal deaths, women with higher levels of education still have significant differences. You can be a healthy, wealthy, educated, and aware Black woman and still have a higher risk of maternal mortality. The problem is not access to care.
Yet instead of being candid about that, many providers focus instead on social determinants of health, which are conditions in the environments where people are born, live, learn, work, and play. In doing so, physicians are essentially blaming their patients rather than looking internally at their own practices and implicit bias. The system is broken, not the sistas.
The fundamental rationale of the social determinants of health approach is that it is possible to improve health outcomes and reduce health inequities by analyzing and acting on the most influential of those social determinants. When warranted, providers should use known social determinants of health to better relate to their patients.
But it’s also critical for physicians and other health care workers to recognize and check internal biases and cultural stereotypes that contribute to patient oppression and higher mortality rates in women of color. In no way does the focus on social determinants of health solve for a problem in a country that was built on the notion of race superiority.
As the executive director of the Tulsa Birth Equity Initiative, my team and I work tirelessly to reduce maternal health disparities in a state where Black and Native women are twice as likely to die as their white counterparts. Our work is grounded in empowering pregnant women to use their voices, as well as educating health care providers on how to provide patient-centric care.
That means looking for warning signs like headaches and shortness of breath at every birth equally. Tori Bowie’s death may have been caused by eclampsia; her teammate Allyson Felix, another Black woman, underwent an emergency C-section at 32 weeks after experiencing severe pre-eclampsia.
It also means changing the ways providers and patients communicate. For instance, TBEI partners with Ariadne Labs to spread and sustain TeamBirth, an evidence-based process to improve communication between the patient and health care providers during perinatal hospital stays. TeamBirth uses a shared decision-making model that keeps the patient at the center; a few core components involve: a multi-disciplinary team with a project manager and structured patient huddles. Empowering patients with a voice in their care allows them to feel heard and involved in understanding their care. During the pilot trial, 99% of patients had the role they wanted in making decisions about their labor, and 99% of patients reported that their nurse and provider talked about their labor in a way they could understand.
Providers must accept that they don’t treat them all the same, even if it’s not a conscious decision. They make assumptions due to bias the moment they see Black patients, regardless of their education and socioeconomic status.
Everyone has biases, but we can all work to check them when they arise and ask ourselves if the immediate thought is reality.
Omare Jimmerson is the executive director of the Tulsa Birth Equity Initiative and a 2023 Aspen Institute Healthy Communities fellow.
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