We Can Reduce Disparities in Maternal Mortality by Listening to Women of Color

Becoming a mother should be a healthy, happy time for all women and their families—but for too many women of color, it is a time of loss.

Black women are nearly four times more likely to die from pregnancy-related complications than white women in the U.S. In New York City, the disparity is even greater: Black women are eight times more likely to die as a result of pregnancy than white women, and Asian and Latina women were at an elevated risk of such suffering, too.

The numbers tell an important story, but focusing only on data can obscure the social context. Structural and institutional racism, along with the intersection of gender oppression, are the underlying driving forces behind this unacceptable chasm.

Since this nation’s beginnings, Black and Latina women have endured physical and sexual violence, reproductive coercion and medical experimentation. This painful and violent history reverberates across generations—and must be both acknowledged and confronted if we are to successfully eliminate disparities in maternal health. A critical step toward narrowing the racial gap in maternal health outcomes is deceptively simple: We must listen to and trust women of color.

Listening to Mothers, a national survey of U.S. mothers, documented a wide racial gap in how women view their treatment by maternity providers: Black and Latina mothers reported poor treatment from hospital staff at twice the rate of white women and were less likely to have ever met their birth attendant at the time of the delivery. Women of color too often do not have a relationship with a provider whom they trust during delivery.

Fears about potential mistreatment have real consequences on the health of women and their babies. Black women who experienced chronic worry about being a target of racial discrimination have elevated risk of preterm birth, a leading cause of infant death. Some might assume that being more educated buffers against these risks, but in New York City Black women college graduates still have higher rates of pregnancy-related complications than women of all other races who never finished high school.

The life-threatening birthing experience of world-renowned athlete Serena Williams crystallizes what happens when even privileged Black women speak up but are ignored. Williams knew the symptoms of pulmonary embolism and advocated forcefully with her care team to get the treatment she needed, which saved her life. But Williams, and other Black women, should be able to trust that doctors and nurses are concerned about their well-being, even if they don’t know the symptoms of such grave complications.

Women of color need to know that their health is taken seriously by health care providers, that their voices are valued and that their concerns acknowledged and acted upon. Unconscious bias, high patient volume and limited resources contribute to disrespectful care and poor communication.

In New York City, one of our first steps to understanding this problem was to hear from community advocacy groups that have been raising concerns, who agreed to form a New York City Department of Health Community Engagement Group (CEG). As member Barbara “Bobbi” Hart states: “In order to heal our community, we need to hear from everyone.”

Through these conversations, we gathered a better understanding of what needed to change: Doctors must take note of their implicit biases and how they affect the care they deliver, and their patients must be the standard-bearers for respectful care.

Despite advanced training, and often altruistic intentions, health care providers hold roughly the same levels of implicit bias as the general population. Doctors must listen and learn from women’s experiences; in doing so, they will build stronger bonds with their patients and improve the care they offer. There is no substitute for hearing directly from women and their families about their experience during pregnancy, childbirth and the early postpartum period.

Women play an integral role in defining what safe and respectful care looks like. Respectful care is not what providers think—it’s what women experience. Qualitative work on this issue has shown that women report being better able to cope with medically traumatic birth experiences when they are well-informed on what has happened and feel included in the decision-making process.

To achieve these changes, New York City is making a public investment in the maternity care system that will include direct attention to provider bias and support for hospitals to enhance their quality of care. We want hospitals to provide information that is timely and relevant to women and their families in response to the needs already articulated by the community.

Just this week, we announced our new Standards for Respectful Care at Birth, a document to assert that a safe birthing experience is a human right, which will be distributed citywide. We are also collaborating with hospitals to interview mothers who survived a life-threatening complication, an often preventable event which affects more than 50,000 women a year nationwide; each event offers a much needed opportunity to shine light on interactions with maternity care providers and identify opportunities for systemic change. NYC Health + Hospitals, the City’s safety net hospital system, will be using simulation training to help providers recognize the warning signs of life-threatening complications.

It is hard for experts to listen—and it can be hard for women who have been told to stay silent to speak up. But providers, patients and families share a critical goal: to work together so that each woman who prepares to welcome a new person to this world is respected, cared for and safe.

About and

With more than 25 years of experience in public health and health care delivery, Dr. Oxiris Barbot has dedicated her career to achieving health equity and was named New York City’s Health Commissioner last December, becoming the first Latina and first Puerto Rican to lead the city’s Health Department. She is a pediatrician who was born in the Bronx and previously served as medical director for New York City’s schools and Baltimore’s health commissioner from 2010 to 2014. She was the chief of pediatrics and community medicine at a health clinic in Washington, D.C. She is also, of course, a lifelong Yankees fan.
Dr. Herminia Palacio is New York City’s Deputy Mayor for Health and Human Services.