Black maternal health disparities persist in the United States

Ten days after Jonisha Brown gave birth to her second son, she was sitting at home talking with a “well-wisher” who came to see her and the new baby. All of a sudden, she said, she felt a strange pressure in her chest.

It was a feeling Brown, a family medicine physician in Charlotte, had never experienced before and one that wouldn’t go away. The sensation developed into uncontrollable vomiting and shortness of breath. 

Brown knew something was wrong and went to the emergency room.

The provider who saw her that day initially thought she was having a panic attack, or perhaps heartburn related to pregnancy. They dismissed her condition as nothing more serious, Brown said.

Because she came in with chest pain, her blood work had to be processed before she could be discharged — standard protocol, even if a provider suspects that nothing is wrong.

She said that testing saved her. From the results, Brown was diagnosed with a condition called spontaneous coronary artery dissection. One of the blood vessels in her heart had torn and was leaking, causing a heart attack.

Brown’s medical scare happened more than six years ago, but she still thinks about how close she came to being added to the tally of Black women across the United States and North Carolina who die from pregnancy-related conditions every year.

She shared her story Tuesday during a public forum in Charlotte that was focused on improving Black maternal health outcomes.

“Compared to other rich, resourced countries, we have the worst maternal health outcomes,” Brown said at the event hosted by the Reimaging America Project, a group started shortly after a Minneapolis police officer murdered George Floyd in 2020, to tackle discrimination in various fields.

The problem is not new but, in recent years, the disparity in outcomes between white and Black birthing people has gained more attention. Various people and projects are working to improve outcomes for Black women, but a wide gap persists.

Doug Robinson, a recently retired doctor who spent 27 years at Charlotte-based Atrium Health, helped organize the forum in Charlotte to keep the topic of Black maternal health disparities part of the conversation. He said it’s an issue that needs to be continually highlighted until meaningful change occurs.

“Everybody knows someone who’s experienced problems being a Black person in the health care system, and everyone knows a mother, a daughter, a sister who’s experienced problems during pregnancy in our health care system,” Robinson said.

A stark disparity 

The maternal mortality rate in the United States greatly exceeds the maternal mortality rates of other Western countries. The U.S. maternal mortality rate in 2021 was 32.9 deaths per 100,000 live births, according to data from the Centers for Disease Control and Prevention, up from a rate of 20.1 deaths per 100,000 in 2019. This amounted to 1,205 women dying from maternal causes in 2021.

These pregnancy-related deaths disproportionately impact Black women, who were 2.6 times more likely to die than white women, according to the CDC. 

In North Carolina, the overall rate of maternal death is even higher than the U.S. average. In 2021, the state’s maternal mortality rate was 44 deaths per 100,000 births, according to CDC data compiled and analyzed by the investigative news organization MuckRock.

Experts argue that the stark maternal health disparities are driven by deeply embedded social and structural inequities. For example, differences in health insurance coverage and in access to care and education drive worse maternal health outcomes for people of color.

Research has found that disparities persist even when controlling for these underlying social and economic factors, which points to the “roles racism and discrimination play in driving disparities,” according to a report by KFF, a nonpartisan nonprofit focused on health research and policy.

Additionally, more than 80 percent of maternal deaths are preventable, according to data collected from Maternal Mortality Review Committees — groups that gather to examine deaths during or within a year of pregnancy.

Despite this, deaths continue to rise. 

System-level changes

Eight panelists — all Black women — with various roles providing maternal health care, from physicians to midwives to mental health therapists, reflected on current deficiencies in how the health care system provides care to Black women and ways this population can be better served. 

Increasing the diversity of the health care workforce was repeatedly emphasized as an important foundational step to provide better health care to this population. 

Black birthing people have life experiences and are affected by social factors that affect their health that can often be best understood by Black providers, explained Brown, who is a family physician. However, she cautioned that Black people are not a monolith and that having the same race does not guarantee understanding.

Whitney Coble, a Black maternal mental health therapist, agrees about the power of representation. She said her common ground with Black clients fosters greater understanding because she can relate to the specific concerns and fears Black women face.

“Mentally, we are faced with so much fear going into pregnancy and the postpartum period — even possibly dying in the postpartum period,” Coble said.

Additionally, because there is a shortage of Black physicians, Venus Standard, a certified nurse midwife at UNC Chapel Hill, said that the care team needs to be expanded to better include Black nurse practitioners, midwives, doulas and lactation consultants who can offer support and help fill gaps in representation to better serve some patients. 

For all health care workers, panelists said, health equity needs to be centered in medical education, and medical practitioners need to regularly complete racial bias training.

“It should be woven into everything that’s done,” Standard said. “If you have a patient that comes in and is of a different culture or a different religion from you and you took that course four years ago, you may not remember some things that are very important to that person.”

Pamela Cobb, an OB-GYN in Charlotte, said there’s still a long way to go toward breaking down ingrained racial biases.

“When I’m talking to a medical student and they say to me if a Black woman gets pregnant, she is at higher risk for preterm labor, that may in fact be true. But that’s looking at her Blackness as the risk,” Cobb said. “What we need to say is ‘the life experience of this Black person when she becomes pregnant puts her at risk for delivering this baby early.’”

“We need to retrain our minds to understand that the lived experience is what is tied to outcomes — how people are seen and how people see themselves.”

Transforming traditional approaches to care

The panelists also said how care is delivered from conception to pregnancy to birth and even after needs to be transformed. What’s always been done clearly isn’t working, they said.

Instead, the health care system needs to center practices that make Black patients feel most comfortable.

Cobb said conventional prenatal care provided by OB-GYNs tends to be a “revolving door” where people are quickly ushered into exam rooms to make sure everything is good and then out in 15-minute appointments that are more likely curtailed to seven minutes. She said this fast and limited care is too often “the nature of the beast” in a fee-for-service health care system that depends on volume for providers’ reimbursement.

Cobb observed flaws with this type of care that can make it challenging to be relationship-centered and address racial biases. She knew care could be delivered differently to better serve Black women, and that’s why Cobb brought CenteringPregnancy to Atrium in Mecklenburg County. The program provides group prenatal care where a woman is seen by one provider over the course of their pregnancy alongside other women of similar gestational ages. Care takes place in the community, where people feel more comfortable, not in doctor’s offices.

Cobb said that CenteringPregnancy data shows that this group approach has decreased preterm labor, promoted longer breastfeeding and improved the experience of the pregnancy for patients and providers. 

“I think the reason that the outcomes are improved is that when you go to where folks are and take care out of the health care system and move into the community, people surround themselves with family and so it’s much more of an organic, sustainable, nurturing environment to have a child,” Cobb said.

Panelists also said greater access to and use of doulas — nonmedical trained professionals who provide physical, emotional and informational support before, during and after childbirth — could help improve Black maternal health outcomes. That’s because, historically, Black people do not trust the white medical community, whereas Black doulas who look like them are given trust.

Research has found that having the support of a doula has decreased the rate of C-sections, decreased preterm labor and increased birth weights. 

But access to doulas is lacking, particularly for populations who could most benefit, said Standard, who leads a program training Black doulas to support Black mothers. Standard said doula services are not covered by most insurances, and the average cost can be $1,200 to $1,500 — an amount that can be unattainable for some families who are juggling expenses like rent and gas.

Even when doulas are working with patients for months leading up to the birth, they can still face barriers serving patients during childbirth. Aryca Wynn, a doula, said that when she goes to the hospital with a client, she often faces pushback from hospital staff who do not treat her as part of the care team.

“Specifically in the Triad area, most doulas are charged to actually come into the hospital to deliver the services, so that could pose a problem where maybe that doula doesn’t have the funds to assist the client at the hospital,” Wynn said. “In the Triangle area, [doulas] also have to have contracts they have to sign in order to come into the hospital to support their clients.”

Tiffany Bishop, a Black maternal mental health provider, also said she would like to see mental health kept more closely in the conversation around maternal health as well as greater awareness of the anxiety and mood disorders women can experience related to pregnancy.

“We don’t hear about everything that maternal mental health encompasses, we only really hear about postpartum depression,” Bishop said. “That really puts mothers and birthing people at a disadvantage because there are so many more challenges and disorders that one can experience.”

Keeping the conversation going

The Reimagining America Project — in partnership with the local organizations the Coalition for Truth & Reconciliation, Health Care Justice-North Carolina and the League of Women Voters of Charlotte Mecklenburg — will hold another forum focused on improving Black maternal health outcomes on Jan. 30 at 6 p.m. This session will focus on advocacy, legislation and the role of federal, state and local agencies in addressing disparities.

The discussion will be at Caldwell Presbyterian Church at 1600 Park Drive in Charlotte and will also be streamed online.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.