Too many women in the United States die or suffer serious complications from pregnancy, but black women appear to be at even higher risk for poor prognosis.
According to statistics from the Centers for Disease Control and Prevention, maternal deaths in 2021 increased by 40% compared to the previous year. Black women are 2.6 times more likely to die from maternal causes than white women, according to federal data. According to a Commonwealth Fund analysis, black women are twice as likely to suffer from serious maternal complications compared to white patients.
In commemoration of Black Maternal and Child Health Week (April 11-17), medical leaders are drawing attention to this crisis. Dr. Kisha Davis, director of the American Academy of Family Physicians, outlines the many reasons for the disparity in outcomes for Black mothers.
Black women are more likely to have uncontrolled high blood pressure, Davis said. Many people suffer complications in the days and weeks after giving birth.
“I don't want to minimize the impact of racism or the experience of racism,” Davis says.
Black women are too often ignored by clinicians when they sense something is wrong. Tennis legend and global icon Serena Williams has spoken out about the complications she experienced and her frustration at being ignored when she told her caregivers that something was wrong. Wrote an essay for Vogue magazine. Davis pointed to Williams' harrowing story and similar experiences of lesser-known Black mothers.
In an interview with Chief Healthcare Executive®, Davis outlines steps to improve outcomes for Black mothers. She will discuss the role that family physicians can play, the need to educate health care providers, addressing stigma, and how hospitals and health systems can improve outcomes.
“Childbirth is a very sensitive time for all women, especially black women,” Davis says.
(Watch part of our conversation in this video. Story continues below.)
addressing access
According to the March of Dimes, more than one in three counties across the country are considered obstetric care deserts because they lack an obstetric provider. This situation is particularly problematic for Black patients living in these counties.
“It's a really big challenge,” Davis says.
Since 2011, 267 rural hospitals have stopped providing obstetric services, according to an analysis published by the Chartis Center for Rural Health. More than 130 local hospitals have closed since 2010, according to a report by the American Hospital Association.
Family physicians can help fill the void in areas where obstetric care is limited or non-existent, she says.
In addition, primary care physicians can help build relationships with patients and monitor issues such as high blood pressure. These help women get healthy before thinking about having children.
“The best birth outcomes start before the baby is conceived,” says Davis.
Telemedicine can provide additional support to women who don't have easy access to obstetric care, she added. Some healthcare providers are using telemedicine and remote patient monitoring to monitor high-risk patients before and after delivery. Boston Medical Center used remote patient monitoring to monitor hypertensive patients who had just given birth.
“One of the benefits of COVID-19, especially given the desert of obstetric care, is that we've learned how to do telemedicine in a way we haven't seen before,” Davis said.
Davis also said greater availability of doulas to guide women during pregnancy and childbirth could improve outcomes for Black women. Doulas can also help patients express their voice and help clinicians understand if something is wrong.
She says that while doulas can lead to better outcomes, funding for doulas is difficult and many doula programs are privately funded. But she would like to see doulas used more widely.
“We've seen some really great results,” Davis says.
Clinician education
Given Black women's higher rates of mortality and morbidity, it is clear that health care providers need better education to achieve better outcomes.
Clinicians need additional training to provide better care to pregnant Black patients.
Davis pointed out that bias is used in calculating the risk for patients who deliver vaginally after a C-section. Black and Hispanic patients are less likely than white patients to have a vaginal birth after cesarean section, in part because risk calculators reflect bias, AMA Ethics Journal reports did.
“Race is a factor in these tools,” Davis says. “And we know that it has led to different outcomes. We need the medical community to stop using these tools and develop new tools that will help us better assess someone, regardless of race. I was encouraged to be there.”
Healthcare providers need better guidance to care for Black mothers and make them feel heard when they raise concerns, Davis said.
Health systems and other health care providers must engage in implicit bias training to help clinicians better understand where they can improve and better communicate with patients.
“We are asking the health care team – nurses, doctors, midwives, anesthesiologists and everyone involved with that patient – to demonstrate how to actually implement the patient-centered care we talk about. I think we can do a better job of educating, too,” Davis says. “That's why we're making sure we're listening to our patients and educating our teams about bias and the impact it has on patients.”
Health care providers can look to implement training practices that can reinforce lessons for caregivers, she says. Additionally, providers can also have more in-depth conversations with Black patients about potential warning signs that may indicate complications.
What hospitals can do
In addition to providing better training for clinicians, hospitals and health systems need to do more screening of patients to assess potential risk factors, Davis said.
If hospitals aren't already doing so, Davis says they should assess patients for social determinants of health, such as housing and food insecurity and other factors that “impact the lives of mothers, babies, and families.” he says.
“Every hospital should at least do social determinant screening,” Davis says.
But Davis said health systems and hospitals need to go beyond screening. Patients should be connected to local health departments and community-based organizations to ensure they receive the help they need.
He emphasized the need to strengthen collaboration between hospitals, doctors and outpatient health workers to care for patients, including after they are discharged from the hospital. That's a problem Maryland is trying to address, said Davis, the health director for Montgomery County, Maryland.
“I think we all think these medical institutions are communicating with each other,” Davis says. “But in reality, they don't talk to each other enough.”
Davis, the county's chief health officer, often finds cases where better coordination could have saved patients.
“Looking back, I can see there were some points along the way where we could have communicated better or things could have gone more smoothly. That would have resulted in a better outcome.” says Davis.
Davis is encouraged by the increased focus on maternal health, including disparities for Black patients. According to KFF, most states currently offer her 12 months of postpartum coverage through their Medicaid programs.
Like many other maternal health advocates, Davis is not resting on her quest for more progress. According to the CDC, more than 80% of maternal deaths in the United States are preventable. According to the Commonwealth Fund, the maternal mortality rate in the United States is more than twice that of other high-income countries.
As Davis says, “No one is doing it well.”
“I think it’s important to not only look at the issues and think about them, but actually implement best practices,” Davis says. “We know what those best practices are, and it takes the will to actually put them into practice.”
