A day before Mother’s Day, activists, physicians and lawmakers alike descended on the nation’s capital to rally against racial inequities in maternal mortality.
The CDC confirmed in a Tuesday report that black women are three to four times more likely to die from childbirth than their white counterparts, irrespective of income and education. Though advocacy groups have long fought for the acknowledgment of racial disparities within the reproductive healthcare system, the crisis has only recently gained traction within the national political discourse, resulting in a spate of legislative proposals.
Since 2018, four Democratic senators, all of whom are 2020 presidential candidates, have introduced bills that aim to address poor maternal health outcomes: Kamala Harris, Kirsten Gillibrand, Cory Booker and Elizabeth Warren. Though their policies overlap in certain key areas, their differences underscore the fact that maternal morbidity is a multipronged problem requiring a multipronged approach.
A soaring maternal mortality rate
Last year, Serena Williams brought national attention to the risks of childbirth for black mothers when she opened up about her harrowing postpartum complications. The tennis star, who has a history of blood clots, said doctors repeatedly ignored her health complaints shortly after giving birth to her daughter. Sure enough, a CT scan confirmed that Williams had several small blood clots in her lungs.
“Every mother, everywhere, regardless of race or background deserves to have a healthy pregnancy and birth,” she wrote in a CNN op-ed. “Demand governments, businesses and health care providers do more to save these precious lives.”
Williams’ childbirth experience is all too real for many African American women who face pregnancy complications that often go unaddressed. While maternal deaths are on the decline in most developed countries, the U.S. has seen numbers more than double over the last two decades, with black women disproportionately impacted.
No single factor fully explains this phenomenon, but mounting evidence points to institutionalized racism throughout the healthcare system. Black women of reproductive age are more likely than white women to experience gaps in access to health insurance coverage, lower quality of care and discrimination.
Designing policy to reduce maternal mortality
Lawmakers have introduced more than 80 bills from January to April of this year, each addressing critical components of the persistent biases found in healthcare. “I often say, if we could put them together in an omnibus bill, we’d have a decent one,” says Monica McLemore, an assistant professor at University of California, San Francisco’s family health care nursing department.
But policy gaps exist across the board, on such issues as diversifying the healthcare workforce; making adequate investments in maternal health research; and fostering partnerships with community organizations that represent marginalized people.
Of the proposed bills sponsored by the 2020 presidential contenders, some are more promising than others. Sen. Cory Booker’s MOMMIES Act, substantially extends postpartum Medicaid coverage for new mothers from the standard 60 days after childbirth to a full year; increases access to primary health providers; and offers the use of services from midwives, doulas and holistic birth workers.
The bill has garnered support from advocacy groups like the Black Mamas Matter Alliance and the National Partnership for Women and Families. “A lot of maternal demise occurs after that immediate [60-day] window, and so if you have a woman who is under-insured, saying to them, ‘Okay, have a baby and now we’re going to cut off your medical insurance’ doesn’t make sense,” says Dawn Godbolt, a health program associate at the National Partnership for Women and Families.
A 2018 study exploring the effect of Medicaid expansion on the U.S. infant mortality rate saw an association between expanded coverage and significantly improved health outcomes for black infants. “There’s kind of this misconception that [you have] pregnancy problems and once you deliver they go away. But the postpartum period might be more dangerous for a woman because you’re not seeing a doctor every week anymore and you’re kind of on your own,” says Cynthia Gyamfi-Bannerman, maternal-fetal medicine specialist at NewYork-Presbyterian/Columbia University Irving Medical Center.
Sen. Elizabeth Warren’s proposal aims to hold hospitals accountable for their treatment of black women by rewarding them with a bonus if they are able to raise survival rates. But many reproductive justice groups have expressed concern that an incentive-based approach could further penalize hospitals that serve the most vulnerable. A more comprehensive approach, advocates say, would instead regulate how healthcare organizations track maternal deaths and create standardized guidelines to measure their quality of care.
“Hospitals must be held accountable and we like that component, but we want to make sure that the intervention doesn’t cause more disparities,” says Monifa Bandele, senior vice president at the advocacy group MomsRising. “Hospitals that are not doing well may, in fact, need greater resources.”
No policy would be complete without confronting the systemic racism that is baked into the healthcare system. Studies show that black patients are more likely to receive little to no treatment for pain and have their symptoms ignored or dismissed. Sen. Kamala Harris’s Maternal CARE Act, introduced as a complement to Sen. Kirsten Gillibrand’s MOMS bill, would incorporate bias recognition into medical school curricula and award grants to maternal healthcare providers for unconscious bias training. But the efficacy of these programs is unclear and in some cases has even been found to worsen biases. “There has to be accountability for the training . . . and evaluation mechanisms need to be in place,” says Bandele, pointing to qualitative measures such as patient experience surveys.
Although legislation alone won’t cure the racial gap within healthcare, advocates say that certain aspects of each of the proposed bills could help build the framework for a solution. “We really hope that whoever emerges from this race is able to take all of these proposals and sit down with black women leaders . . . to design a mega plan that has components of all of them,” says Bandele. “There are many layers to it.”