The ability to protect the health of mothers and babies in childbirth is a basic measure of a society’s development,” wrote Smita Nadia Hussain of the advocacy group MomsRising in her testimony before the U.S. House. “Yet, currently, the United States holds the worst record for maternal and infant mortality in the developed world.”
Hussain and other advocates (including me) testified in support of the Preventing Maternal Deaths Act, which passed in December 2018 in the House with bipartisan support. The following day, a companion bill, the Maternal Health Accountability Act, was approved by the Senate. This legislation, said Monifa Bandele of MomsRising, “treat[s] maternal mortality as the national emergency that it is.”
The U.S. is one of only eight nations in the world to have a rising maternal mortality rate, meaning a woman is more likely to die in childbirth in the U.S. than in any other developed country. Somewhere between 700 and 900 women die from childbirth and pregnancy-related causes each year, and 60 percent of these deaths are preventable, according to the Centers for Disease Control and Prevention (CDC). There are alarming racial disparities in the maternal mortality statistics: A black mother, regardless of education or income, is three to four times more likely to die than a white one.
Ensuring that all mothers thrive in childbirth is an important American value. A commitment to this value was made in 1935 with the inception of Title V of the Social Security Act, national public health legislation aimed at promoting and improving health and welfare services for mothers and children. A few decades prior, the U.S. maternal mortality rate was 607.9 per 100,000 births and the rate of black women dying in childbirth was about 1.5 to two times that of their white counterparts.
Landmark projects undertaken through Title V have produced guidelines for the health supervision of children from infancy through adolescence; influenced nutrition care during pregnancy and lactation; recommended standards for prenatal care; identified successful strategies for the prevention of childhood injuries; and developed health safety standards for child care facilities.
But by the late 1960s, this reliance on building up the medical and public health infrastructure, without improving the social conditions under which moms and babies live, led to a worsening in the racial disparity of outcomes. Investing in things instead of investing in people is how our systems and policies create inequities between black people and their white counterparts—and, specifically, our gap in the maternal mortality rate. For black women, nine months of prenatal care cannot overcome a lifetime of health inequalities caused by racial disparities in housing, transportation, education, food, environmental conditions and economic security—all of which have racism as a root cause.
It is a historical and current fact that there are systems—health care, education, housing—built on the belief of a racial hierarchy. For instance, when, as the White House has recently proposed, we specifically target caring for opioid-addicted mothers— who are predominantly white—we create policies and systems that can leave mothers who are addicted to alcohol, cocaine, tobacco and other habit-forming substances with worse health outcomes in the future. In acknowledging the racism implicit in this policy priority, we gain an opportunity to envision a government that values all mothers who are addicted.
It’s not just institutionalized racism that’s to blame. Personally mediated racism, disrespectful care, not being listened to or valued—all of these things contribute to women, especially black women, dying in childbirth.
In my work as an OB/GYN, advocate and public health official, and as a black mother, I know that it is critical for us to be able to identify racism, classism and gender oppression as barriers to wellness. We know we have internalized ideas about our place within this harmful and imaginary hierarchy. These ideas cause some of my fellow black physicians to opine that if their patient would just eat better and make all of their appointments, they would have better outcomes for themselves and their babies. But the data shows that this is not true.
A black woman who is normal weight and who enters prenatal care in the first trimester still has worse health outcomes than a white woman who is obese and one who has late or no prenatal care. Researchers have suggested that “weathering”—or the impact of chronic stress due to racism and discrimination throughout a lifetime—may be at least partly to blame, especially since data shows that black women have better birth outcomes if they have children in their teens rather than their 20s. For white women, it’s the opposite.
The legislation passed in December will support states in recording and investigating the causes of pregnancy and childbirth-related deaths and in seeking out solutions. “We must improve our understanding of why mothers are dying in pregnancy, during childbirth and postpartum,” wrote Reps. Diana DeGette (D-Colo.) and Jaime Herrera Beutler (R-Wash.), the House bill cosponsors, “so we can then unleash every possible resource to protect women in this critical season of life.”
In the meantime, if we want mothers and children to thrive and not just survive, we’ll invest in holistic doula services for Medicaid mothers; we’ll expand the availability of midwifery to low-income and rural mothers; we’ll increase Medicaid reimbursements, which cover half of all U.S. childbirths but equal, on average, 60 percent of what private insurance pays; and we’ll provide respectful care with providers listening to and valuing the concerns of women.
Together we can build a system in which black mamas do matter.