Maternity Care in the United States Remains Separate and Unequal
This past weekend, birth workers convened in Atlanta for the first Black Maternal Health Conference and Training Institute. The Institute brought together doulas, midwives, nurses, doctors, public health advocates, researchers and mothers with a singular commitment to address a national crisis: Black mothers are three to four times as likely to die from pregnancy complications as White mothers.
The Black Mamas Matter Alliance convened the Institute, and advisory committee members noted that Congress has introduced 20 different bills this session to address maternal mortality. However, these bills do not sufficiently address a fundament problem: racism, not race, is a key contributor disparities in maternal mortality. And after almost two decades as a practice obstetrician, I have come to appreciate that as a health care provider, I am complicit: I practice in a system that is designed to deliver unequal care. This unequal care perpetuates structural and institutionalized racism – the “differential access to the goods, services, and opportunities of society by race” for Black, Indigenous and other People of Color.
Consider prenatal care. During pregnancy, 2 in 3 White pregnant individuals have private insurance, while 2 in 3 Black pregnant individuals have Medicaid. This difference in income and insurance coverage is the legacy of racist policies such as redlining and segregation, that have caused a yawning gap in wealth between Black and White Americans. As Jessica Roach noted in her opening plenary, these racist policies are the underlying cause of adverse social determinants of health, such as unstable housing, lack of transportation, food insecurity and poverty, that disproportionately impact people of color. And yet, despite the complex challenges facing patients living in poverty, patients with Medicaid are typically seen by doctors-in-training, while privately insured patients receive care from board-certified physicians. Why is it acceptable for patients to receive care from inexperienced trainees? If trainees are well-supervised and just as capable as fully trained doctors, then both private and publicly insured patients would be seen by trainees, with faculty supervision. And if care by a fully-trained physician is superior, would a just society not demand that its highest-risk patients see our most experienced providers?
In part, these differences in care provided are about money – specifically, the enormous gap between Medicaid and private payer reimbursement. In North Carolina, Medicaid pays providers just $1327.53 for global OB care, which includes up to 14 prenatal visits, delivery, and postpartum care. For the same services, private insurance where I practice reimburses more than $2800. Why is it considered acceptable to pay half as much for a Medicaid patient?
This gap reflects the value our society places on reproduction, depending on who is reproducing – a phenomenon known as “stratified reproduction” that impacts people of color regardless of income or education. As Mama Shafia Monroe put it in the opening plenary, “We need to reclaim that our black babies are welcome and wanted in this world.” We need that reclaiming because Black mothers are too often disrespected and disbelieved, even when they are privately insured. In a blog post, Denene Millner describes how she paid for the "deluxe" package at a New York City hospital, but her nurse refused to believe that she had paid for the luxury package, or that she had a husband. Similar disbelief confronted Serena Williams, who had to fight her nurses and doctors to be treated for a life-threatening blood clot in her lungs. These implicit biases contribute to stark differences in outcomes: in New York City, Black patients with a college degree have higher rates of life-threatening birth complications than patients of other race/ethnicities who never graduated high school.
The diminished value placed on the reproduction of people of color is pervasive. Consider a recent video celebrating the successes of a quality collaborative in a South Carolina: A professionally-produced film describes five initiatives, set against soaring music and soft-focus images of moms and babies. In a state where 28.8% of birthing women are Black, there were only three Black women in the 10-minute video – two clinicians and a patient, all in a segment on postpartum Long-Acting Reversible Contraception (LARC). A Black mother describes how getting a Nexplanon implant immediately after birth enabled her to get a driver’s license, enroll in a training program, and get a better job to support her family. It was an uplifting argument for access to contraception – access that is an essential component of reproductive autonomy. And, as the only image of a Black mother in a state where 16,000 Black women give birth each year, it was an insidious reinforcement of the narrative that if Black women could just keep their legs crossed, they could pull themselves out of poverty.
I shudder to think how many times in my 17 years of obstetrics practice I have high-fived a colleague for “talking her into Nexplanon.” It is tidy to think that if we can just control the fertility of marginalized people, they can transcend institutionalized racism and realize the American Dream -- as though a birth control implant will somehow compensate for the fact that a Black mother earns $0.51 for every dollar earned by a non-Hispanic White father. We must recognize that coercive contraception does not correct institutional racism – it perpetuates it.
As Dr. Joia Crear Perry noted in the opening plenary, our system of unequal care reflects the roots of obstetrics and gynecology in centuries of mistreatment of Black women. That mistreatment spans Marion Sim’s experimental surgeries on unanesthetized enslaved women through the forced sterilization of “undesirable” women that extended well into the 20th century. Only by understanding these racist legacies can we take steps to redress wrongs and dismantle the bias within our unequal health care system. This unequal system is perfectly designed to get the results that it gets: Black infants die at twice the rate of White infants, and Black mothers die at three times the rate of white mothers.
And yet, as Deray McKesson argues, if the system is perfectly designed for the results it achieves, “… it was designed...people made this up, and because people made it up, we can make something different." So let’s commit to something different. We can begin by celebrating the strength of Black families with events like Black Breastfeeding Week’s “Lift every baby.” We can support organizations like the Black Mamas Matter Alliance, SisterSong and Black Women Birthing Justice to lift up the voices of Black women as leaders in state quality collaboratives, community advisory boards and quality improvement initiatives. We can center solutions on the lived experiences of people of color. We can enact the Black Mamas Matter Standard for Holistic Care of and for Black Women, with approaches that support families with a collaborative team of community health workers, doulas, midwives, family and clinicians.
We can name and dismantle the structural and institutional racism impacting our healthcare practices, policies and systems. We can demand payment schedules that provide equitable reimbursement for care of marginalized people, including coverage for doulas and other birth workers. We can ensure that patients with the most complex needs are seen by the most experienced medical providers. We can mentor diverse trainees and commit to foster communities that support them to become part of a workforce that looks like the patients we serve. We can tailor care to the needs of each pregnant and parenting family. And every day, we can own our implicit biases and practice cultural humility. Before we enter a patient’s room, we can pause and prepare to see them as an individual, listening more than we speak and recognizing their unique strengths and vulnerabilities. As Ancient Song doula Chanel Porchia-Albert put it, “Be humble. That’s it.”
And we can raise the bar. As Dr. Crear Perry said, “What would it look like for women to not only survive pregnancy, but to thrive?”
Alison Stuebe is a Maternal-Fetal Medicine physician practicing in Chapel Hill, North Carolina. She is a member of the board of the Society for Maternal-Fetal Medicine.