The disproportionately high rates of Black infant and maternal mortality in the United States—compared to rates for non-Hispanic white infants and women—necessitate a systemic and philosophical shift to prioritize Black women’s health. Black women have unique health needs resulting from their experiences with both racism and sexism, and their health must be supported holistically—before, during, and after pregnancy—so they and their infants can live full, healthy lives.
Traditionally, health systems and policies have prioritized the needs of infants over those of mothers. In 1921, the first legislation to address infant and maternal mortality reduced infant mortality but failed to reduce maternal mortality; specifically, the legislation prohibited the funding of maternal medical care and instead funded hygiene education for mothers. Nearly a century later, in 2017, Title V—a federal program that promotes maternal and child health—spent 36 percent more on infants than on pregnant women, and the program’s services and systems reached 99 percent of infants versus 86 percent of pregnant women. Although legislative efforts to address infant and maternal mortality have expanded since 1921, there is considerable room for improvement.
The following are research-based policy recommendations to better address the unique needs of Black women and their infants, and thereby reduce Black infant and maternal mortality.
Fund development of an allostatic load measure to identify and support expectant mothers at risk for complications. Allostatic load is the physiological deterioration caused by chronic stress. In the United States, Black women have higher allostatic load scores than any other demographic. Although research suggests a link between allostatic load and poor pregnancy outcomes, no validated measure exists to evaluate pregnant women’s allostatic load. Policymakers should support the development of such a measure, which must also be culturally responsive to allow researchers to more easily collect health data that is relevant to screening protocols for Black women, disentangle allostatic load from normal stress effects of pregnancy, and analyze how Black women’s allostatic load responds to pregnancy (and vice versa). This measure would also help physicians identify high-risk pregnancies that might otherwise go undetected and bolster a growing knowledge base.
Mandate that maternal mortality review committees evaluate quality of care. The Preventing Maternal Deaths Act of 2018 funds review committees to “identify adverse outcomes that may contribute to” maternal mortality. We recommend that “adverse outcomes” be defined to include quality of care—a measure of patients’ experiences of equitable health care treatment—which committees have typically overlooked to focus on patient characteristics, such as obesity, smoking, and health insurance coverage. Obesity is often overestimated in Black populations, and a study based in New York City found that non-obese Black women had higher rates of maternal complications than non-Black obese women. Further, pregnant Black women are less likely to have smoked cigarettes than pregnant non-Hispanic white women. Finally, health insurance coverage may not always be a predictor of maternal health outcomes for Black women. Through the Preventing Maternal Deaths Act, state health agencies can prioritize the review of quality of care.
Expand access to doulas. Black mothers report that medical providers often disregard their perspectives and experiences, raising the risk that health emergencies may go unaddressed. Doulas advocate for women and help make their voices heard in medical decisions that affect them. At least one study has shown that Black women often desire doula support but lack access to culturally competent doula care. Only three states—New York, Minnesota, and Oregon—have expanded Medicaid to cover doula services, and these states have experienced unique challenges in developing the best funding model for doulas to be paid equitably. Medicaid reimbursements for doulas would benefit Black, Medicaid-insured mothers who may otherwise be unable to afford doula services. State health departments can provide fee waivers to alleviate potential financial barriers to certification for doulas who are culturally competent in Black maternal care. Finally, under the Preventing Maternal Deaths Act, which includes support for activities that “promote community support services for pregnant women,” states can support activities to expand access to doulas.
Disaggregate infant and maternal mortality and morbidity data to show within-group diversity. The Preventing Maternal Deaths Act aims to “eliminate disparities in maternal health outcomes,” and explicitly mentions “African American women and other groups of women with disproportionately high rates of maternal mortality.” We recommend expanding “African American” women to include all ethnicities of Black women. While rates of Black infant and maternal mortality are higher overall, there are important differences within the data due to the variety of lived experiences among Black women. For example, allostatic load increases for Black African immigrant women the longer they live in the United States. Disaggregation of data to analyze within-group diversity would help identify the diverse maternal experiences of Black women, including those who also identify as additional races or ethnicities. Collecting these data in states and counties with significantly diverse Black populations, and expanding them to include maternal morbidity, would help protect patient privacy and increase the feasibility of data collection.
 Authors’ calculation based on data from the Health Resources and Services Administration’s Title V Funding by Individuals Served resource, pie chart “FY 2017 Expenditures – Federal & Non-Federal By Population Served,” available at https://mchb.tvisdata.hrsa.gov/Financial/FundingByIndividualsServed.
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