I am a sucker for a happy ending. I make deliberate choices when selecting the movies I watch and the books I read. But, for far too many Black women in America, their pregnancy story does not have a happy ending. Things don’t just “work out.” Concerns are dismissed. Care is delayed or even denied until it is too late. Then the “if only” begins. People make excuses. They blame, sometimes appropriately, sometimes less so.
I think of a painful parallel: mass killings in schools. I think of the police or security being blamed for not acting quickly or timely enough. It’s not that they couldn’t have or shouldn’t have acted differently, but their failure should not be used to deflect from the bigger problem, namely allowing adolescents to have weapons of war without military training or need on domestic streets.
The morbidity and mortality rates for Black women will improve if their health needs are addressed before they get pregnant. They will do better if they receive compassionate and medically sound prenatal care. They will do better if their concerns are addressed appropriately as soon as they are raised—not hours or days or weeks later. Because, even if heroic actions save some in the end, they won’t save all who could have been saved if the right measures had been put in place sooner.
There has been a start. The “Preventing Maternal Death Acts of 2018” became law on December 21, 2018. In an effort to help states improve maternal health and to eliminate health disparities in “pregnancy-related and pregnancy-associated deaths,” the CDC was authorized to increase state and tribal funding for maternal mortality review committees (MMRCs). If it were not for those types of committees, we would not have known that over 60% of the deaths are preventable and of the continued and worsening disproportionate negative impact of the maternal mortality crisis on Black women.
Other legislation appears to be on its way. The Maternal Health Quality Improvement Act will provide funding to support access to maternal care in rural communities, training to reduce and prevent discrimination in the delivery of maternal healthcare, and funding for programs that improve the quality of perinatal care delivered.
The Black Maternal Health Momnibus Act of 2021 goes further. This bill is particularly important on many levels. It addresses multiple reasons for the disparities in Black maternal health and the maternal health disparities of other at-risk communities. If enacted, and if the resources allocated are used effectively, I believe this bill could really help to turn the tide and improve Black maternal health in this country. If the bill is passed, among other initiatives, investments will be made in housing, transportation, and nutrition to support women in the perinatal period. The community organizations, which have been working hard to support maternal health and improve equity, will receive funding. Investments will be made to expand and diversify the workforce that cares for mothers in the perinatal period to ensure that every mother receives the culturally competent care they need. Maternal mental health will be supported. Data collection processes and quality measures will be improved to allow continued understanding of the causes and the solutions. Investments will be made in digital tools to improve maternal outcomes in underserved areas. Innovative payment models will be promoted “to incentivize high-quality maternity care and non-clinical perinatal support.”
In December 2021, Vice President Kamala Harris announced a call to action to improve the health of parents and children in the first federal Maternal Health Day of Action. A number of private entities detailed ways in which they planned to support maternal health. Several public sector investments were also described. Notable among the public sector initiatives is a call for states to expand Medicaid post-partum coverage to twelve months. Studies have shown that in states with Medicaid expansion, uninsured rates are lower and Medicaid coverage rates are higher. As we are sometimes painfully aware, it takes time for legislation to be approved, and in the interim the lives of more Black mothers will be at stake. Large organizations mean well, but depending on their size, implementation takes time. Fortunately, smaller community organizations, many whose advocacy has led to these initiatives, are still working to ensure that progress is made.
While leading two health centers for the Baltimore Medical System, I had to learn and implement PDSAs (Plan, Do, Study, Act), brief cycles of interventions with specific measurable goals. The outcome was documented, and lessons were learned whether the intervention was successful or not. The hope was that successful interventions would be implemented on a larger scale. Even in our low-resource setting, we were able to plan, do, and study multiple such initiatives. Nevertheless, resources, especially human capital, are needed to support full-scale implementation of successful initiatives. I often found the champions of the work to be physicians who were passionate about the care they were delivering to patients. However, due to clinical duties their time was limited. They were ably supported by medical assistants, who were equally passionate about the care, but who also found it difficult to divide their time between the initiatives due to their other clinical responsibilities.
Sometimes the projects were effective, but due to changes in the workforce they often could not be sustained. However, I still was able to see the potential of these projects. Working with these physician-champions reinforced and enhanced the lessons I had learned about physicians who still choose to deliver mainly clinical care. They have innovative ideas based on their experience and, if given the support, including financial, technical, and human capital, some are capable of implementing improvements that extend far beyond the individual interaction in the exam room. Many do not want to leave patient care; they just need a little time and space to grow beyond that role—an opportunity they are seldom given, due to obligations of seeing multiple patients in a short span of time.
While we recognize that our physician workforce needs to develop its delivery of culturally sensitive care, let’s not forget that the workforce consists of human beings. Human beings who often have altruistic reasons to pursue medicine, to pursue obstetric care, but imperfect human beings, nonetheless. If these human beings are overly burdened like many are now, if the demands on them continue to grow, many may be led to decrease the hours they devote to the field of obstetrics or other fields of medicine, or leave the field completely. For many, the toll could be even worse. The suicide rate among male physicians is 40% higher than the general suicide rate for men, and among female physicians that number is 130% higher. According to a Medscape 2021 survey, on average, 13% of physicians have had suicidal thoughts. For OB/GYNs it is even worse: they topped the list with 19% reporting suicidal thoughts. Let’s not forget that, as a country, America will likely continue its trend of worsening maternal health for women, and even more so Black women, if the caregivers, the physicians, and other health professionals are not cared for. These clinicians need to be allocated sufficient time and resources to continue in their vocation of caring for women.
As investment continues for the care of Black mothers, responsible, passionate, goal-oriented champions need to be identified and nurtured, so they can plan new initiatives and advance care. Some initiatives need to be on a scale small enough to be carried out in the short term. If successful, they should be quickly implemented and if not, they should be abandoned with the lessons learned carefully documented. We cannot solely rely on long-term solutions. In addition to measures in maternal-health outcomes for Black women and their babies, it is equally important to measure whether healthcare professionals and institutions have improved their delivery of care to Black patients in a culturally sensitive and unbiased manner.
Change takes time, but it is possible. I think collaborations are key. I think large healthcare organizations and insurance companies need to continue to actively engage in the conversations and implement solutions. Medical schools and other training programs for healthcare professionals need to double down on their commitment to train knowledgeable, compassionate, and culturally competent healthcare professionals for the workforce of the future. These burgeoning healthcare professionals need their humanity to be recognized so that they can receive support in developing their strengths and overcoming their weaknesses. Political leaders need to continue to work together to pass much-needed legislation. Employers should be more supportive of their pregnant and postpartum patients and spare them the judgment that is generously heaped on many, often more so if they happen to be Black. Individuals can show support even if that support is only the ability to offer a kind word to a pregnant person.
Community organizations need to continue to share best practices to improve the health of Black women, including pre-conception, during pregnancy, and post-delivery.
In 2018 when I did my TEDx talk I shared the hope I had for America—hope to eliminate health disparities in maternal health and improve the maternal health for all women in America. My hope is to help ensure that any mother who died in the pregnancy and childbirth period did not die in vain. I realize the journey is long. The journey is costly, and the journey can be painful. But as I said, I am a sucker for happy endings. I believe America has all it needs to improve Black maternal health and to eliminate disparities. I believe that the lessons learned will improve the maternal health of all women in America. The only question I have for you is: “Are you on board?”
This is an excerpt from the afterword of Pregnant While Black.