This is a guest article by Shiara L. Robinson of Brooklyn Law School.

“When there is no name for a problem, you can’t see the problem, and when you can’t see it, you can’t solve it.” Kimberlé Crenshaw[i]

1. A MOST PRECIOUS GIFT

The United States ranks 55th globally in its maternal mortality rate.[ii] Amongst high-income countries, the United States has the highest maternal mortality rate,[iii] though the Centers for Disease Control and Prevention found that 84% of maternal deaths are preventable.[iv] In 2018, there were 17 maternal deaths for every 100,000 live births in the United States,[v] with Black women three times more likely to die from pregnancy related causes than white women,[vi] and the infant mortality rate of Black babies was 10.8 deaths per 1,000 live births compared to 4.6 per 1,000 live birth of white babies.[vii]

1. AN ANALYSIS OF THE SYSTEM

a. Historical and Institutional Disparities

There are several factors that contribute to the disproportionately high rate of pregnancy or childbirth related deaths, and infant mortality deaths within the Black community including societal, institutional, and healthcare related issues. Reproductive health equity researcher Rachel Hardeman credits structural racism as the root cause of the gap between infant mortality of Black babies and other babies,[viii] defining structural racism as the “normalization and legitimization of an array of dynamics – historical, cultural, institutional and interpersonal – that routinely advantage white [people] while producing cumulative and chronic adverse outcomes for people of color.” [ix]

Before babies enter the world, Black pregnant women deal with a host of healthcare disparities rooted in structural racism. Myths that Black people have thicker skin, higher pain thresholds, and countless other false notions fuel structural racism and hidden biases that plague Black women during primary and maternal healthcare. As recent as 2016, many medical students and residents believed these false truths; 40% of first- and second-year medical students endorsed the belief that “Black people’s skin is thicker than white people’s.”[x]

There are misconceptions that a Black woman’s financial situation, level of education or lifestyle are a direct correlation to maternal death and infant mortality. However, the most famous athlete in the world, Serena Williams, experienced a near-death experience after delivering her first child due to nurses minimizing her needs.[xi] If the critically acclaimed G.O.A.T., is easily dismissed by healthcare staff multiple times, the likelihood of everyday Black women having similar interactions is high.

b. Alternative Routes to Motherhood / Childbirth

Therefore, many Black women have turned to alternative methods for pregnancy and childbirth support. Doulas and midwives are experts that can aid families in making the transition from pregnancy to parenthood.[xii] A birthing and/or postpartum doula provides nonmedical techniques, and recovery and emotional support[xiii]—things often overlooked in traditional medical facilities, as women are generally discharged from hospitals three days after vaginal birth.[xiv]

Certified nurse-midwives are licensed, independent health care providers,[xv] recognized under federal law as registered professionals.[xvi] The Cleveland Clinic defines a midwife as a healthcare provider who is trained to provide obstetric and gynecological services, including primary care, prenatal and obstetric care, and routine gynecological care like annual exams and contraception.[xvii] Between 2019 and 2020 there was a 30% increase in Black women who opted to give birth in a “community birth setting”—a birth center or home birth—not a hospital.[xviii]

1. SOLUTIONS TO SWADDLE FUTURE BABIES

The crux of this crisis is of discriminatory origin and at the center are Black women who find themselves at the intersection of being Black, being women, and being pregnant. The gift of a successful birth and healthy baby transcends racial lines and should be something that unites us as Americans.

a. Two Hundred and Seventy-Five Days

To eradicate the Black maternal health crisis and subsequent Black infant mortality crisis, several changes must occur.

i. Legislative Action

Legislation that will help lower the Black maternal and infant mortality rates will address access to health insurance and doula and midwifery care, funding for community-based organizations, postpartum healthcare, and non-clinical support during and after pregnancy. The Black Maternal Health Momnibus Act is comprised of thirteen titles, each introduced as a standalone bill by a Member of the Black Maternal Health Caucus.[xix] The Act was officially introduced to Congress in the Senate on May 15, 2023, by Senator Cory Booker.[xx]

ii. Implicit Bias Training

Much of what we learn comes from home or how we are brought up, so people can only be faulted for their unconscious biases to an extent. Unconscious bias training seeks to raise awareness of the mental shortcuts that lead to snap judgments that are often based on race and gender.[xxi] The most effective training goes beyond pure awareness by teaching trainees to manage their biases, change their behavior, and track their progress.[xxii]

This training should be integrated into medical curriculums at all levels and cover racial discrimination, racial-based myths, and require the delivery of quality patient care to all patients, regardless of race. The training should also include bedside manner, social skills, and empathy—skillsets that are not always second nature to extremely intellectual people such as doctors—and the implication of one’s unconscious bias on those skills.

iii. Doula and Midwife Access Expansion

With so many Black women turning to doula and midwifery care, access to this alternative maternal healthcare should be expanded and promoted. Insurance plans should emphasize this benefit to policy holders. Specifically, coverage for certified midwives and certified nurse midwives—certified professionals who can practice at hospitals, clinics, birth centers or clients’ homes.[xxiii] Additionally, more education about the safety and efficacy of these alternative maternal healthcare methods needs to be shared.

iv. Community Activation and Education

“Without community there is no liberation.” Audre Lorde[xxiv]

Equally important is community activation and education to spread awareness about the crisis. To truly see change, individuals besides Black mothers and families need to care. Pregnant and non-pregnant Americans of all races must join the fight to combat this crisis. And it begins in personal circles, during community conversations, across social media platforms, at fireside chats and beyond; simply by sharing facts.

b. Challenges

This will not be without challenges. Most concerning are lack of connection or care about the issue and shifting the center. When issues have a centralized message, people tend to shift the center, making it about them or deflecting from the people who are at the center. The change this article seeks is not to disparage other pregnant women or invalidate their issues. It is about the Black maternal health crisis—the disparities faced by Black women, that are statistically backed.

Another concern is that the rising spotlight on the issue could cause severe backlash. This could manifest in counter organizations that claim additional support for Black expecting mothers and babies is unfair treatment and an equal protection violation. In the wake of the multitude of affirmative action lawsuits, this would not be surprising. Backlash might also arise by medical providers refusing to submit to implicit bias training or claiming they have none.

However, the change that I am seeking will not just benefit Black women and families but all Americans looking to expand their families as racial equity historically benefits all Americans.[xxv]

---

[i] Kimberlé Crenshaw, The Urgency of Intersectionality, TED WOMEN (Oct. 2016), https://www.ted.com/talks/kimberle_crenshaw_the_urgency_of_intersectionality?language=en.

[ii] 4 KIRA 4 MOMS, http://www.4kira4moms.com (last visited Dec. 13, 2023).

[iii] Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, THE COMMONWEALTH FUND (Nov. 18, 2020), https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.

[iv] BUSINESS WIRE (Jan. 19, 2023, 3:00 PM), https://www.businesswire.com/news/home/20230119005321/en/Bobbie-for-Change-Elevates-Elaine-Welteroth%E2%80%99s-Birth-Story-to-Fight-for-Improved-Black-Maternal-Care-and-Policy-Change-in-the-US.

[v] Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, THE COMMONWEALTH FUND (Nov. 18, 2020), https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.

[vi] 4 KIRA 4 MOMS, http://www.4kira4moms.com (last visited Dec. 13, 2023).

[vii] Tanya Russell, Mortality Rate for Black Babies is Cut Dramatically When Black Doctors Care for Them After Birth, WASHINGTON POST (Jan. 13, 2021, 3:47 PM), https://www.washingtonpost.com/health/black-baby-death-rate-cut-by-black-doctors/2021/01/08/e9f0f850-238a-11eb-952e-0c475972cfc0_story.html.

[viii] Tanya Russel, Mortality Rate for Black Babies is Cut Dramatically When Black Doctors Care for Them After Birth, WASHINGTON POST (Jan. 13, 2021, 3:47 PM), https://www.washingtonpost.com/health/black-baby-death-rate-cut-by-black-doctors/2021/01/08/e9f0f850-238a-11eb-952e-0c475972cfc0_story.html.

[ix] Id.

[x] Janice A. Sabin, How We Fail Black Patients in Pain, AAMC (Jan. 6, 2020) https://www.aamc.org/news/how-we-fail-black-patients-pain.

[xi] Serena Williams, How Serena Williams Saved Her Own Life, ELLE (Apr. 5, 2022, 7:00 AM), https://www.elle.com/life-love/a39586444/how-serena-williams-saved-her-own-life/.

[xii] Doula vs. Midwife: What’s The Difference, HEALTHLINE (Apr. 7, 2023), https://www.healthline.com/health/pregnancy/doula-vs-midwife.

[xiii] Id.

[xiv] NEW YORK-PRESBYTERIAN, https://www.nyp.org/womens/pregnancy-and-birth/labor-delivery/frequently-asked-questions#:~:text=How%20long%20will%20I%20stay,approximately%202%20nights%2C%203%20days.

[xv] Essential Facts About Midwives, AMERICAN COLLEGE OF NURSE-WIVES (May 2019), https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000007531/EssentialFactsAboutMidwives-UPDATED.pdf.

[xvi] 42 CFR § 440.165 (1982).

[xvii] CLEVELAND CLINIC, https://my.clevelandclinic.org/health/articles/22648-midwife.

[xviii] Nicquel Terry Ellis, As The Nation Battles A Maternal Health Crisis, More Women of Color Are Choosing Birth Centers Over Hospitals, CNN (Dec. 9, 2023, 1:00 PM), https://www.cnn.com/2023/12/09/us/women-of-color-birth-centers-reaj/index.html.

[xix] BLACK MATERNAL HEALTH CAUCUS, https://blackmaternalhealthcaucus-underwood.house.gov/Momnibus.

[xx] Black Maternal Health Momnibus Act, S. 1606, 118th Cong. (2023).

[xxi] Francesca Gina and Katherine Coffman, Unconscious Bias Training That Works, HARVARD BUSINESS REVIEW (Sept.-Oct. 2021), https://hbr.org/2021/09/unconscious-bias-training-that-works.

[xxii] Id.

[xxiii] CLEVELAND CLINIC, https://my.clevelandclinic.org/health/articles/22648-midwife.

[xxiv] Audre Lorde, The Master’s Tools Will Never Dismantle the Master’s House (1984).

[xxv] Wally Adeyemo, Racial Equity Benefits All Americans, U.S. DEPARTMENT OF THE TREASURY (Jun. 7, 2023), https://home.treasury.gov/news/featured-stories/racial-equity-benefits-all-americans.