A national conversation about the United States’ indefensible Black maternal mortality problem is underway. The issue is critical — but it's also not new. In fact, it seems like every few years, something brings the vital topic back into the public consciousness, even though it’s been a problem for as long as records have been kept.
Last year, a study put a horrifying number to the epidemic: Black people in America are over three times more likely to die from pregnancy-related causes than white people, the Centers for Disease Control and Prevention reported. More recently, the tragic deaths of Sha-Asia Washington and Amber Rose Isaac led to a spate of heart-wrenching news stories decrying the racist disparity.
Hopefully, these headlines about Black people dying during childbirth help generate awareness and empathy. But Black birthing bodies need — and deserve — radical solutions, not just sympathy.
In my first book, The Mocha Manual to Fabulous Pregnancy, a guidebook for Black women, I wrote: “Just being a Black woman places you at a higher risk of poor birth outcomes...and at the root of it are the stresses of racism and the biased treatment you may receive.”
I wrote that in 2006. It’s been 14 years, and I’m still saying the same thing. We’ve done enough talking. It’s time to confront the hard truths about the root causes of what’s killing pregnant Black people, and what it will really take to solve it.
Repeated analysis by the CDC and other agencies indicate that 60% or more of childbirth-related deaths are preventable. The reasons that Black women are inordinately affected are complex. But it’s already known that Black people are subject to medical racism and implicit biases that can contribute to issues like missed or delayed diagnoses. They’re also more likely to have preexisting conditions that can increase their risks during pregnancy, especially when coupled with a historic lack of access to high-quality care.
There are actionable steps that can protect Black people and lower the maternal mortality rate. They are in the community and have been for years. By not focusing on them, we create a culture of fear that leaves Black people vulnerable to control and coercion by others, and that attempts to strip away the joy from their pregnancies and deliveries. I believe one key step is to increase access to and awareness of “de-medicalized childbirth” strategies.
De-medicalizing childbirth means no longer treating pregnancy as a medical problem that requires medical intervention. It’s not about reducing access to medical care for pregnant people; everyone should be able to receive the level and the quality of care they need and want. But my experience and research has led me to believe that it’s also important for more people, especially Black people and others in vulnerable communities, to know that they may have the option of giving birth outside of a hospital setting, under the care of midwives rather than (or in addition to) doctors.
A Brief History Of Midwifery In The U.S.
In the U.S., in the early 1900s, around half of all births were attended by midwives. By 1937, that number had dropped to under 13%, though midwives were still used in more than half of all Black births.
Around the turn of the century, though, the white male medical establishment started trying to “[elevate] the importance of obstetrics in the eyes of practitioners, medical students, and the laity,” in part by calling for the “gradual abolition of midwives in large cities,” as seen in a 1912 paper published by J. Whitridge Williams, MD.
Physicians did not gently elbow out their competition as birth grew increasingly medicalized in the 20th century. They actively advocated for the elimination of “granny midwives” (a term sometimes used in the South in reference to Black midwives) in medical journals. In 1915, for instance, prominent obstetrician Joseph DeLee referred to midwifery as “a relic of barbarism.” “Women of color suffered devaluation and stigmatization and were viewed as illegitimate medical practitioners,” sociologist Alicia D. Bonaparte, PhD, wrote in her dissertation, The Persecution and Prosecution of Granny Midwives in South Carolina, 1900–1940.
The rest, as they say, is history. The rise of obstetrics led to the demonization and downfall of midwifery. The impact of the dominance of a medical establishment with racist, sexist, and classist roots can still be seen. To this day, in 16 states it’s illegal for midwives to practice outside a hospital setting.
How Medical Racism Harms Pregnant Black People
A more medical approach to birth is not all negative, of course. Rates of maternal mortality decreased by about 99% between 1900 and 1997, the CDC states. But due to the systemic racism that is built into this country and its institutions, including the medical system, Black people receive a different level of care by physicians than people of other races, from childhood to adulthood.
The body of evidence about the prevalence of bias and racism in provider care is clear and conclusive. White physicians are less likely to educate their Black patients about preventative care; they’re less likely to offer preventative testing; and they’re less likely to refer them to “state-of-the-art” specialty facilities, according to a 2013 meta-analysis performed by sociological researchers at Texas A&M University.
Black women are more likely to be given Cesarean sections than other races, even in low-risk pregnancies. (In 2018, over 30% of Black women with low-risk pregnancies delivered via C-section, compared to under 25% of white women.) And a 2008 review found that the race-based discrepancy in C-section rates persisted even after adjusting for the fact that Black people are more likely to have preexisting conditions that might necessitate the procedure.
Every woman should have access to C-sections, as they can be life-saving. But they’re also major surgeries and as such, they carry risks, including infection, hemorrhage, and death. As the WHO points out, “When [C-section] rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10%, there is no evidence that mortality rates improve.”
Studies have shown that healthcare providers consistently dismiss or ignore complaints of pain in Black patients compared to white ones. This has affected even renowned tennis player Serena Williams who, in an interview with Vogue, related that she developed shortness of breath after delivery, and told her nurse she needed a CT scan. Her nurse “thought her pain medication might be making her confused.” Doctors performed an ultrasound on her legs, which came up clear, before giving Williams the CT scan she had asked for — which revealed several small clots in her lungs. Her condition was treated, but due to complications, she was bed-bound for six weeks after giving birth.
Williams ultimately got the care she needed. Amber Rose Isaac, a 26-year-old Black woman who died in April after being given an emergency C-section in a hospital in the Bronx, did not.
The New York Times reports that during her pregnancy, Isaac had raised concerns about the fatigue and shortness of breath she was experiencing. She felt dismissed by her doctors, so she tried to arrange to deliver under the care of a midwife instead. But after reviewing her medical records, the midwife told Isaac she couldn’t work with her: Her platelet levels were very low, a condition that can impede clotting, making the pregnancy high risk — something that none of her doctors had mentioned. After being induced at a hospital a month before her due date and given an emergency C-section, Isaac bled to death during labor, which her partner says was partially due to the low platelet levels, according to The New York Times.
The systemic racism in medical institutions will take decades to fix, but giving Black people greater access to community advocates and care providers can be done now — which is why it’s so essential.
How Midwives & Doulas Can Help
Black women who worked with a midwife reported that they were more likely to receive care based on trust and listening, and that they felt supported and empowered, found a four-year study from Black Women Birthing Justice (BWBJ) in California. “None of our participants who worked with a midwife/doula team reported feeling disempowered or very disempowered, compared to 31% of those who were attended by a physician/nurse team,” the researchers wrote in their book, Battling Over Birth. None.
In other research, when a doula — whose job it is to advocate for and support the person in labor — was assisting, people were two times less likely to experience a birth complication involving themselves or their baby, according to The Journal of Perinatal Education.
It would be remiss to make midwives and doulas out to be miracle workers, though. They are not. They are best able to offer support when they’re integrated into existing healthcare systems. States that have done so, including Washington, New Mexico, and Oregon, report lower rates of obstetric interventions and lower rates of neonatal mortality, according to a five-year study by researchers in Canada and the U.S. Many of the states where the policies and laws are most restrictive or where some midwives are illegal, however, also tend to have higher populations of Black and brown folks.
To do their work effectively, midwives and doulas must be paid well, properly reimbursed by insurance and Medicaid, and treated as legitimate by the medical community, which is not always the case. Due to COVID-19, for example, many hospitals restricted visitors during the worst of the pandemic. In some cases, only one support person could be present during delivery; in other cases none were allowed at all. Doulas were not granted an exemption, leaving people to choose between having their partner or their advocate, the person who is oftentimes critical to their survival, with them.
What Real Solutions Look Like
The onus for solving the epidemic of Black people dying during childbirth lies with the medical institutions that are responsible for our care and our lives, and that are rooted in racism, bias, and systemic oppression.
But I believe it’s also important to focus on adequately funding the community-led programs that seek to address the epidemic of Black death during childbirth. There are so many organizations that support Black maternal health that could use community support and donations.
The Tara Health Foundation and the California Healthcare Foundation, for instance, recently funded the Frontline Doula Hotline COVID-19 initiative. It offers cash awards to doulas serving Black women, nourishing meals, and virtual doula support in areas of California. After Isaac’s tragic death made headlines nationwide, doulas and community organizers rallied behind the SaveARose Foundation, started by Isaac’s partner, to raise funds to bring a childbirth center to the Bronx.
The non-profit Every Mother Counts puts up grants and loans to support community-based maternal health organizations that fight for racial and birth justice. One grantee is the Commonsense Childbirth Institute in Florida, which uses a midwife-focused model of care, designed by Jennie Joseph, “to reduce the racial, class, and gender disparities which have plagued American families for decades.”
The Washington D.C.-based Mamatoto Village provides perinatal support for Black women and families, and seeks to help women of color forge careers in the public health and human services industry. Sista Midwife Productions, a birth advocacy organization in New Orleans, connects Black people with doulas and midwives and provides doula training. Uzazi Village in St. Louis offers prenatal, labor, and postpartum support as well as lactation consultant and doula training.
Yes, the Black maternal mortality and morbidity crisis is an unconscionable public health and racial justice problem in the U.S. But instead of the doom and gloom narrative, we need more focus on Black woman-led and community-centered solutions. As I often say, “Whatever the question, the answer is in the community.”
Kimberly Seals Allers is an award-winning journalist and the founder of Irth (Birth, but we dropped the B for bias), an upcoming Yelp-style app that allows Black people to publicly review and rate hospitals and physicians as a way to identify and address patterns of racism and bias in maternity care.