By Foxy Robinson | Special to The OBSERVER
Maternal and infant mortality within Black communities is not a new problem.
The Centers for Disease Control reported that the maternal mortality rate for non-Hispanic Black women across the United States was 55.3 deaths for every 100,000 live births in 2020. That was more than double the national average and nearly three times the rate of non-Hispanic White women.
The stories Black mothers share reveal a larger problem they face while planning to give birth and navigating life after.
According to the Giving Voices to Mothers Study, a community-participatory research study surveying childbirth experiences across the United States, 23% of Black women reported experiencing at least one form of mistreatment by health care providers compared to 14% of White women. Black women were found to be twice as likely as White women to experience health care providers ignoring, refusing, or failing to respond to their requests.
“You’re asking Black women to go into a [health care] system that has not treated them well,” said Jennifer James, assistant professor at the University of California, San Francisco, and member of Black Women Birthing Justice. “They are worried about how they are being perceived, fearing that their newborn will be taken away. Black women have higher chances of being seen as angry and noncompliant when trying to let their caretaker know about their childbirth preferences.”
At times, the health care system has conflated racial identity as a risk factor during pregnancy. Black women are at a greater risk of receiving Cesarean deliveries due to predictive delivery tools and even the time of day they choose to deliver their babies. Black mothers who deliver during the day have a greater likelihood of delivering through Cesarean section, even if they prefer vaginal delivery.
Obstetricians rely on vaginal birth after cesarean, or VBAC, scores as a predictive tool for a mother’s likelihood to have a successful vaginal delivery, deciding whether mothers should pursue vaginal or cesarean delivery options. Until 2021, the VBAC calculator recommended more cesarean deliveries for Black and Latina women.
“Cesarean section deliveries are often overused and these delivery decisions may not be based on medical needs,” said Dr. Tanya Khemet Taiwo, assistant professor of midwifery at Bastyr University. “They take eight weeks of surgical recovery. During that time, a mother may be trying to recover while trying to take care of a newborn and her family.”
Each mother may face a number of stressors ranging from family, finances, food insecurity, housing, transportation to community, along with her own physical and mental health needs. These stressors are often not addressed within childbirth care plans.
Black mothers are left discouraged from presenting their authentic selves with each visit to avoid negative perceptions from health care providers and medical records labeling their lifestyles and behavior as “noncompliant.”
“There is a level of racism and fat-phobia in our medical system. Black women who are pregnant and have a higher body mass index are labeled as a risky body,” James said. “Black women tend to be heavier and have higher body mass indexes. Our bodies are seen as risky and [unable] to give birth due to obesity and preeclampsia, which is a blood pressure condition that can affect a mother’s kidney and liver function. Black women are often told to diet before giving birth, monitoring her weight gain, and told not to gain more. If they gain weight, then they are being ‘negligent’ and ‘unfit.’”
Education remains a challenge throughout pregnancy and expectations after. With each appointment, test, belly measurement, and urine sample, women, especially for first-time mothers, are often left wondering how their health is affecting their pregnancy.
The Giving Voices to Mothers Study reported that 95% of Black women believe it is important to have time to ask questions about their health and care options. On average, they have short prenatal appointments from 10-15 minutes.
Giving Birth Blind And Alone
At the start of the COVID-19 pandemic, Black mothers had a difficult time finding care and resources in the community to support them through their perinatal and postpartum care. Hospitals reduced perinatal appointments, ultrasounds, and tests, including testing for preeclampsia.
“We had a sudden decrease in perinatal care,” James said. “Women called their doctor’s office and, click, no one would answer. In one of our Black Women’s Birthing Justice sharing circles, a mother having her second child during the COVID-19 pandemic in summer of 2020 said this was her blindest pregnancy. There were no tests and no ultrasounds before giving birth. Since she had been pregnant before, she knew how her body was supposed to feel, so she knew when something wasn’t right.”
First-time mothers may not know what to expect or how to manage. Birth is often a time where Black women, their immediate family, extended family, and community celebrate a new life entering theirs. With COVID-19, it became difficult to gather, celebrate, and exchange knowledge with sheltering-in-place and social distancing. Many community centers closed while the need for social support increased.
In the early pandemic, Black women also found themselves isolated in the delivery room. They gave birth alone, where their partner or doula were not permitted to enter the delivery room with them, making it more challenging to feel supported in their decision-making and self-advocacy.
The Myth Of The Impervious Black Woman
The pandemic also put a strain on mental health, taking the form of depression and anxiety in addition to the stress of navigating new guidelines and perinatal care.
“There’s a stigma that Black people don’t go to therapy,” said Kenya Fagbemi, program director at Her Health First. “We want to help normalize mental health support. People think mental health conditions only happen to them. In reality, anything can trigger it, like loss or hormone imbalance. People aren’t talking about perinatal or postpartum mood and anxiety disorders — or PMADS — in addition to postpartum depression. We need mothers and their families to recognize what these disorders look like, what therapy looks like, how to manage what’s going on, and what can trigger it.”
Black women are often painted as strong and resilient, supporting their family, friends, neighbors and communities while subjugating their own physical and mental health. Black moms are the first to say “I got it,” never asking for help. The “I got it” moms may come from a perception that Black women always have to be strong women and a deep personal belief that they don’t deserve the help of others. This feeling, paired with their own mental health needs, can pile up before they can catch up to it.
‘You Are The Expert Of Your Body’
Even when mothers suspect they are experiencing something irregular in their pregnancy journey, health care providers often disregard them.
“If I know there’s something that I need like a test and a physician disagrees, I know I can ask that they document my request in my medical file,” said LaTanya Mosley, senior program manager at Mutual Assistance Network and Lead for the Black Child Legacy Campaign in Arden Arcade. “They can explain their reasoning in my file, and it might even give them time to rethink their decision. That is your right as a patient to ask for conversations to be documented and create a record.”
Mothers always can also ask to switch to an obstetrician who better relates and listens to them. A change in provider can build trust instead of fear when asking for tests, information, or detailed explanations about their care plan.
Black women are often hesitant to feel empowered in their decision-making. Whether moms ask for an alternative exam, treatment or birthing position, they are discouraged from their preferences. Care providers warn them of the “dead baby,” weighing that a mom’s decision could put her baby at risk.
“Know that you have a voice and you need to use it,” said Jessica Walker, co-chair of the Sacramento Maternal Mental Health Collective and co-chair and digital lead of Be Mom Aware. “No one else will speak for you. You have to protect yourself and your children. They’re cheering you on to succeed. You have so much in you.”
Mothers Better Connect With Birth Workers Who Encourage Their Autonomy
“We have a health system that abandons people,” said Dr. Khemet Taiwo. “In obstetrics, the next visit after you give birth is six weeks after. In that time, you can have blood pressure spikes, bleeding, cesarean section wounds may not be healing. There’s no safety net. Mothers end up in the ER. In contrast, midwifery care plans three to five visits after post-operation to follow-up on a mother’s progress.”
Midwives support mothers through their pregnancy, childbirth, and postpartum through evidence-based medical care, such as skin-to-skin where newborns are immediately placed in contact with mothers to encourage bonding, newborn body temperature regulation, and breastfeeding.
The Centers for Medicaid and Medicare Innovation Strong Start for Mothers and Newborn Initiative revealed that midwifery birth centers offered throughout pregnancy and the first year after birth as a low-cost, affordable option. Midwifery birth centers also were found to lead to fewer emergency room visits and lower preterm birth rates. Mothers were found to have more weekend deliveries, indicating that mothers gave birth physiologically, based on their own body’s timing, rather than through induced labor.
Birth workers are considering new care models for mothers, including one in which obstetricians provide care for mothers with high-risk pregnancies while midwives provide care for physiological births. Mothers also can receive support from doulas while planning for their birth and life with a newborn.
Doulas provide education, emotional, and physical support during a mother’s third trimester through their labor, advocating for the mother’s comfort and health at home and in the delivery room.
“Having a doula lowers the risk of cesarean section and depression because you can have the birth you want and it makes for a better experience,” Fagbemi said.
Black women often live in areas with limited lactation support and education. Both midwives and doulas provide lactation support for breastfeeding, encouraging bonding while reducing the risk of depression in the mother and asthma and food allergies in the baby.
Maternal Health Outcomes Can Shift With Policy, Storytelling, And Community
The demand for midwives and doulas is increasing, but their funding isn’t. Physicians and nurses often can seek financial support to remove their student loans before and after medical training, while midwives and doulas have none.
California Senate Bill 65 aims to address this need by funding midwifery and doula education, training, and retention.
The National Association of Certified Professional Midwives also is encouraging more Black and Indigenous midwives to enter the field by offering the Tanya Khemet Taiwo Midwifery Student Scholarship Fund (nacpm.org/scholarships), honoring Dr. Khemet Taiwo’s commitment to midwifery education, medical care for historically underserved communities, and racial equity. The scholarship provides tuition and educational support for second- and third-year Black and Indigenous midwifery students.
Community health workers also are investing in strategies to better incorporate doulas into delivery plans, allowing them better access to delivery rooms in hospitals.
“During the pandemic, hospitals were limiting the number of visitors and doulas were getting pushback: doulas need to show their credentials; take COVID tests before entering the delivery room; they can’t leave a waiting room until their COVID tests come back,” Fagbemi said. “Meanwhile, hospitals were understaffed processing COVID tests. We know these hospital policies are in place to promote health. The way that these policies are enforced changes the outcome [of the birth environment]. A mother’s partner may not be able to assist with communicating her needs the way that a doula can.”
Her Health First is partnering with Blue Shield of California to develop a pilot program for pregnancy and postpartum care with community health workers and doulas.
Hospitals and medical care teams are exploring new strategies to engage mothers and newborns during medical visits. One is to pair pediatrician visits with birthing visits for the mother to assess any mental health conditions, such as postpartum depression, while the baby receives care. Another strategy is hosting group medical visits for perinatal and postpartum care, giving mothers a chance to comfortably ask questions and hear the birth experiences of other mothers. They can still receive their 15-minute one-on-one visit with a care provider, while finding community through their stories.
Black mothers thrive when they are surrounded by community and have support networks that they know they and their babies can rely on.