This piece is published in collaboration with Echoing Ida, a Forward Together project.
In the United States, Black women are three to four times more likely than white women to die from pregnancy-related causes. It’s worse in places like New York City, where Black women are 12 times more likely than white women to die from pregnancy-related causes. Overall, maternal mortality in the United States is increasing, while rates are decreasing in other parts of the world.
Clearly, the United States has a maternal health problem. Could increasing the number of Black health-care providers help solve this problem? The answer to that question is not just relevant for Black birthing parents, but for all U.S. parents who aren’t doing that well compared to the rest of industrialized nations.
On the surface, data show that the top medical causes of maternal deaths are cardiovascular diseases like high blood pressure that are brought on or exacerbated by pregnancy; non-cardiovascular diseases such as gestational diabetes; infection or sepsis; excessive bleeding known as hemorrhage; heart failure; and embolism, or blood clot. Some data suggest that while Black and white women are equally likely to experience pregnancy-related hemorrhage, for example, Black women are more likely to die from hemorrhage than white women. The same is seen for preeclampsia and eclampsia, which are pregnancy complications connected to high blood pressure.
But what underlies that?
Medical causes of maternal death are influenced by a variety of factors, including economic stability, neighborhood context, education, food, racial discrimination and stress, and social support, which all contribute to health status. And, of course, health care is a major influencer. It is a well-established fact that the rate of maternal mortality is higher among women who did not receive any prenatal care. Lack of access to health care—due to location, transportation, or financial challenges, among other things—is one of many factors that contribute to maternal death.
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Dr. Joia Crear-Perry, president of the National Birth Equity Collaborative, explained that access to care is required to improve maternal health outcomes. “If we are ever to see any equity in maternal mortality rates for Black women, we will have to increase the access and quality of care to women in their communities,” Dr. Crear-Perry said.
Reaching Black birthing parents where they are could prove challenging, given growing provider shortages in the United States.
In the United States, there is already a shortage of both general and maternity care providers, which hits communities of color the hardest. Data show that by 2020, there could be a shortage of as many as 8,800 obstetricians and gynecologists (OB-GYNs). The number of nurse midwives has increased recently, but remains low, and over half of counties in the United States lack a midwife. To make matters worse, the number of Black health-care providers is disproportionately lower than the Black population in the United States: Only 6 percent of practicing physicians are Black; 4 percent of OB-GYNs are Black; and fewer than 4 percent of certified nurse-midwives are Black, compared to Black people making up 13 percent of the population.
The underrepresentation of Black people as health-care practitioners is harmful to the Black community. Black providers are more likely to practice in high-poverty communities than other providers and offer care to the underserved. Although it’s unclear whether Black specialists are inclined to serve in these same communities, an increase in primary care physicians could help address the underlying medical causes contributing to poor maternal health outcomes.
Furthermore, one in five Black patients prefer Black providers, sometimes with good reason. Personal experiences of discrimination and perceived racism are often the driving force behind the preference for same-race providers. When interacting with the health-care system, Black people are less likely than white people to receive adequate, appropriate, and quality care, regardless of their ability to pay.
Increasing the number of Black health-care practitioners trained to provide high quality maternity care could meet the service provision needs of Black people. While more research could provide additional information on the exact mechanism, current research suggests increasing the number of Black providers is likely to improve patient satisfaction, which could increase the frequency at which patients seek out the care they need.
Training more Black people to provide care seems like a simple enough solution, but it’s not without its challenges.
“The pathways for becoming an OB-GYN are filled with many roadblocks for Black folks. In order to be a successful applicant for medical school in the first place, there has to have been an investment in your learning since elementary school. We know that schools in Black neighborhoods are underfunded,” Dr. Crear-Perry told Rewire.
Barriers to becoming a midwife or doula exist as well. A midwife provides medical care while a doula provides non-medical support and coaching during childbirth and post-delivery. Noelene K. Jeffers, a certified nurse-midwife and board of directors chair of the International Center for Traditional Childbearing (ICTC), explained, “The main barrier to increasing the number of Black midwives is the general lack of awareness in America about midwifery. Many people still don’t know what midwifery is or think that midwifery is an extinct profession. When I tell someone that I am a midwife, the next response is often, ‘Those still exist?’”
Even though midwives were once seen as pillars of their communities, lack of awareness presents a barrier to pursuing midwifery or other maternity care provision as a career. Dr. Aletha Maybank, deputy commissioner for the Center for Health Equity in the New York City Department of Health, pointed out that, “Black women who want to be doulas may suffer from a lack of mentors and role models.”
Furthermore, personal and household finances may present another barrier. Dr. Maybank also shared, “Most new doulas volunteer while they gain experience, but that’s not practical for women on the lower end of the economic spectrum.”
Overcoming these barriers to increase the number of Black maternity care providers, and general practitioners, could play an important role in filling growing provider shortages for all people, while potentially meeting the service provision needs and preferences of the Black community. More providers could translate into a greater chance that people will be able to access care locally, although financial barriers might still remain.
So, where do we go from here? What will it take to increase the number of Black health-care providers, which would undoubtedly benefit the entire medical community and communities they serve. There are at least three examples of efforts seeking to support Black people across the United States.
A 2015 New York Times feature reported that Xavier University of Louisiana, a historically Black university in New Orleans, yields more Black students who apply to and graduate from medical school than any other college in the country. Its key to success is taking action to help students overcome years of educational gaps caused by racial disparities in public K-12 education. The university connects students to tutors; encourages study groups where students support each other; implements a tailored biology and chemistry curriculum for freshmen; and provides intensive help with preparing medical school applications.
ICTC also works to increase the number of doulas, midwives, and childbirth educators. The Portland, Oregon-based organization provides programs that build leadership, business, and birth support skills among people of color. Jeffers at ICTC shares, “Doula work is a known pipeline for midwifery but the ICTC Full Circle Doula Training program, more specifically, is a national pipeline for a more diverse midwifery force. ICTC works to improve birth outcomes by training doulas from communities of color that, historically, experience racial and ethnic health disparities and barriers to midwifery training opportunities and care.”
The New York City Department of Health has a doula apprenticeship program designed to help aspiring doulas overcome financial barriers and to increase the capacity of birth workers in neighborhoods with need. Dr. Maybank reports, “Though we cannot pay non-certified doulas to attend births, we will pay them for the time they spend in our mentorship program, and for shadowing By My Side doulas.” By My Side, a Healthy Start Brooklyn birth support program, currently employs 13 doulas, ten of whom are women of color.
These efforts are building the pipeline of Black health-care providers by helping them overcome the various barriers to their success. In so doing, they are helping Black birthing parents access the maternity care they need. Could more providers and better access to care improve Black maternal health outcomes? We won’t really know until we follow these examples and make a concerted effort to try.