Black Maternal Health in the US
Written by Amani Bright & Jillian Levovitz
With the recent release of the 2021 maternal health data by the CDC, it’s become alarmingly clear that the United States is trending in a dangerous direction for mothers and infants. The report, released in March, exposed that the maternal mortality rate in 2021 was 32.9 deaths per 100,000 live births — an unprecedented increase from the 23.8 and 20.1 deaths recorded in 2020 and 2019, respectively.
Sadly, not only have the rates of maternal morbidity and mortality been sharply increasing over the past several years, but the US continues to have worse outcomes compared to other developed countries.
Maternal conditions, such as preeclampsia, gestational diabetes, and mental health challenges double the risk of childbirth complications and are increasing in prevalence. These trends are consistent with poorer long-term health among women and a higher prevalence of preexisting conditions. The rates from 2015-2018 of pregnant women with preexisting hypertension have risen 31%, diabetes 27%, obesity 100%, and depression 35%.
This macro view of maternal health in the US, however, only tells part of the story. In the United States, Black women have a significantly higher probability of poor health outcomes both during and after pregnancy.
Black women are 3-4 times more likely to die due to pregnancy-related causes and are twice as likely to suffer from severe maternal morbidity (SMM). Black women also have higher rates of pregnancy and postpartum complications, preterm deliveries, and babies born with low birth weights.
Preconception & Prenatal Health
Racial, socioeconomic, and healthcare disparities all contribute to the current burden Black women face when considering pregnancy. However, one of the most critical factors driving the high Black maternal mortality and morbidity rate is the prevalence of preventable or manageable preconception conditions.
For example, high blood pressure, which significantly raises a woman’s probability of developing preeclampsia, is 50% more likely to impact Black women compared to White women. Preeclampsia is 60% more common in Black women and increases the risk for cardiovascular disease, stroke, preterm birth, and maternal and infant death.
There are numerous factors contributing to the increased prevalence of pre-existing health conditions in Black women including social inequalities and weathering, increased stress, and access to care challenges.
Many women with pre-existing conditions can have healthy pregnancies with the right care and management, but a report by the March of Dimes found that one in seven infants born had inadequate prenatal care.
In 2020, only 20% of Black women received adequate prenatal care and Black women are less likely to get prenatal care in their first trimesters. Without proper prenatal care, women may lose the opportunity to prevent or manage maternal complications such as anemia, high blood pressure and preeclampsia, gestational diabetes, and other chronic or mental health conditions in a timely fashion. Early and regular prenatal visits can also support full-term pregnancies and healthier infants.
Barriers to Quality Prenatal Care
Unfortunately, many barriers exist that make it difficult for Black women to receive consistent, high-quality prenatal care. Recent studies have shown that 8.8% of Black women will receive late or no prenatal care compared to only 4.8% of White women.
Additionally, 1 in 6 Black babies are born in maternity deserts or areas of limited access to maternity care services. Maternity deserts have higher risks for adverse health outcomes and complications for mothers and babies.
Even in communities where care is available, social and structural determinants of health barriers may additionally impact the access and quality of care. A lack of availability of appointments, transportation, financial constraints, an inflexible work schedule or challenges navigating the system may keep Black mothers from getting the care they need. This, combined with additional health barriers including depression and current substance use all impact Black women’s access to, and utilization of, prenatal care.
Hospital Disparities
Black women are more likely to deliver in non-teaching, Black-serving hospitals, and racial disparities in maternal mortality were still present after adjusting for comorbidities.
Women delivering at medium to high Black-serving hospitals have an elevated rate of SMM compared to rates at low-Black-serving hospitals and Black women delivering at high-Black-serving hospitals had the highest risk of poor outcomes.
Examining the disparities in maternal mortality by hospital type found similar mortality ratios (8.6 per 100,000) in Black and non-Black serving teaching hospitals, regardless of race. This differs greatly when looking at maternal mortality among non-teaching hospitals, Black-serving hospitals, which had a significantly higher mortality ratio (8.1 per 100,00) compared to non-Black serving hospitals (4.1 per 100,000).
Insurance coverage
An additional challenge disproportionately impacting pregnant Black women is the cost associated with pregnancy and childbirth. Black women are 14% more likely to be uninsured. They are also more likely to have gaps in coverage due to changing jobs or loss of employment.
From preconception to postpartum, almost half of Black women experienced discontinuity in their insurance. The resulting lack of consistent healthcare before pregnancy can result in a higher prevalence of pre-existing conditions. This means that when Black women do become pregnant, the associated costs of pregnancy are generally higher due to the higher rates of pregnancy complications.
Improving Access to Quality Care
While many Black women receive high quality, respectful, culturally competent care, research shows that Black women receive lower quality care compared to White women and will avoid seeking care due to discrimination. The lack of access to care and quality of care translates to the maternity space from preconception to postpartum.
Different healthcare delivery models should be explored to address access to care/quality care to improve outcomes for Black women specifically.
These include:
Community-based Doulas
Midwifery care
Offering non-hospital-based care such as birth centers
Group prenatal care (i.e. Centering Pregnancy)
Expanding and improving reimbursement for midwives and doulas who help reduce poor outcomes for women and infants.
Virtual care and remote monitoring
Telehealth and remote monitoring can reduce barriers to accessing care such as distance to healthcare facilities, transportation, and inflexible work schedules. These solutions can also reduce the need for in-person visits for the management of acute and chronic conditions. Medicaid now includes reimbursement for providers delivering telehealth services and any additional costs such as technical support and equipment.
Remote patient monitoring allows healthcare professionals to collect a variety of patient health data conditions such as weight, high blood pressure, and diabetes. With assistance from healthcare professionals, patients are able to use a range of devices such as blood glucose meters, blood pressure monitors, heart monitors, and fetal monitors.
Throughout pregnancy and after, telehealth and remote monitoring can be used for virtual prenatal visits, monitoring of vitals, mental health care, virtual postpartum care, communication with providers, and lactation support. The option for virtual care and monitoring can reduce barriers associated with in-person care, even for patients with high-risk pregnancies. While all states and Washington D.C. provide some form of Medicaid reimbursement - only 34 states provide reimbursement for remote monitoring tools.
Expand insurance and maternal health services coverage
The solutions to the disparities in maternal mortality are layered, complex, and rooted in social and structural inequities. The ability to obtain insurance is essential to accessing quality, affordable care. Without quality insurance or insurance at all, policies may not cover tests and services that improve outcomes for Black women, such as remote patient blood pressure monitoring devices and glucometers. Additional costs not covered by insurance can lead patients to decline additional tests and critical care needs during and after pregnancies.
Pregnant women covered by Medicaid will lose coverage after 60 days, despite the postpartum recovery phase extending far beyond that time period. As of April 2022, states have the option to extend postpartum coverage from 60 days to one year.
Research has shown that states who adopt Medicaid expansion have maternal mortality rates that increase much less when compared to non-expansion states. When stratified by race/ethnicity, Black women had the largest effect size, significantly associated with a lower maternal mortality rate compared to non-expanded Medicaid states. This effect is also seen in the reduction of low birth weight and preterm birth outcomes in Black infants in Medicaid-expanded states.
Companies to Watch
Health in Her Hue is a digital platform that connects women of color to culturally competent and sensitive healthcare providers, evidence-based health content, and community support.
Mae is a digital platform that provides pregnancy and postpartum support for Black people including a pregnancy tracker, personalized lifestyle and care tips, and access to culturally competent experts.
Cayaba Care is a maternal health company offering community-based clinical services via technology-enabled multidisciplinary care teams.
TruDiary is a digital health company that provides culturally relevant curated content by moms and Social Determinants of Health (SDOH) services to Black and Brown moms in under-resourced communities.
Dove Black Birth Equity Fund provides Black expectant mothers and birthing individuals with immediate financial access to doula services.
About the Authors:
Amani Bright, is a Senior Project Coordinator at Ariadne Labs on the Delivery Decision Initiative Team. In this role, she leads project management and regulatory processes for various portfolio projects.
Jillian Levovitz, MBA, is an experienced healthcare executive, the Founder, and CEO of OcciGuide, and Chief Strategy Officer at FemHealth Insights where she is responsible for consulting and research projects.
