Confronting racism in Black maternal health care in the United States
Maternal-health researcher and obstetrician Kecia Gaither outlines the research needed to save more Black mothers’ lives.
CAREER FEATURE: 12 December 2022
Science is steeped in injustice and exploitation. Scientific insights from marginalized people have been erased, natural-history specimens have been taken without consent and genetics data have been manipulated to back eugenics movements. Without acknowledgement and redress of this legacy, many people from minority ethnic groups have little trust in science and certainly don’t feel welcome in academia — an ongoing barrier to the levels of diversity that many universities claim to pursue. In this next in a short series of articles about decolonizing the biosciences, obstetrician and gynaecologist Kecia Gaither advocates a multi-pronged approach to address structural racism in the health care of Black pregnant people. Gaither, who is director of maternal fetal medicine at NYC Health + Hospitals/Lincoln in the Bronx, New York, explains how better screening during pregnancy and enhanced anti-bias training for physicians could help turn the tide on maternal death rates.
My interest in serving Black and brown people as an obstetrician, gynaecologist and researcher stems from growing up in Harlem, New York, where I saw how Black people weren’t getting high-quality health care.
I did my residency and fellowship training in Brooklyn, New York, and Newark, New Jersey. I saw how people from the African diaspora who had poor access to health care and lacked insurance had high rates of conditions such as obesity, diabetes, chronic high blood pressure, diabetes, HIV/AIDS and substance-use disorder.
I then worked in West Palm Beach, an affluent urban area in Florida, where I saw a stark difference in how wealthy white women were treated and cared for compared with women in lower socio-economic groups. There seemed to be greater respect for rich white people; they were listened to and offered help, treatment and labour pain relief as soon as needed. But people of colour were labelled harshly because of their social situation. They were stereotyped as lazy, substance-using people and so on, and not listened to.
I remember one incident in which a Black pregnant woman with the autoimmune disease lupus and severe pre-eclampsia (a sudden rise in blood pressure during pregnancy) was in labour. Nobody in the care team had bothered to decide how she was going to have her delivery. She had to wait about 12 hours until I came to work and performed her Caesarean surgery. I had never seen this level of indifference happen with any of the white mothers.
Black people are particularly prone to poor maternal-health outcomes owing to many factors, with systemic racism being a primary driver. Women of colour, in the United States are less likely to have insurance, transportation and access to medical care compared with white women. Furthermore, undocumented immigrants often avoid hospital-based care for fear of deportation.
Black people also have a higher incidence of underlying conditions, such as heart disease, diabetes, HIV and high blood pressure, which puts them at risk of complications during and after pregnancy. They can have peripartum cardiomyopathy, a rare type of heart failure that can start between the last month of pregnancy and five months after delivery. Black people are also more likely to experience bleeding during pregnancy and premature delivery. I see these complications where I work, which is part of the largest US public hospital system, and served 202,881 people in 2021. The south Bronx, a community with predominantly Black and Hispanic people, has among the country’s highest perinatal morbidity and death rates.
Racism adds to pregnancy stress Why are Black people at greater risk for developing these complications? Experiencing racism and bias are certainly contributory factors, and these stressors can compromise immune function and functions that control blood circulation. Furthermore, the extra stress that comes with carrying a child as a Black woman increases the risk of poor outcomes. However, more research is needed to understand how the particular stressors faced by Black women affect their health.
In 2019, I started a programme called A Mother’s Heart at the hospital where I work, after observing a high incidence of peripartum cardiomyopathy in Black pregnant people with undiagnosed heart diseases. I set it up to identify people at risk of cardiovascular diseases using grant funding from the New York State Maternity Hospital Quality Improvement Network, multinational manufacturing company Procter and Gamble and TD Charitable Foundation.
A Mother’s Heart is designed for women from the African diaspora and Latin American countries. We screen pregnant people and include them in the programme on the basis of risk factors such as obesity, diabetes, high blood pressure and family history of cardiac disease. The programme has identified people with cardiac arrhythmia, structural heart defects and other problems. We also check nutrition status, fitness levels and genetics, and screen the heart of the fetus in certain cases.
We established a cardio-obstetrics team — a multi-disciplinary team including maternal—fetal medicine specialists, obstetricians, geneticists and cardiologists. Since the programme started, there has been a marked reduction in the incidence of cardiovascular deaths in people at Lincoln compared with what I saw in 2017. For example, there have been no cases of postpartum cardiomyopathy or undiagnosed cardiovascular decompensation, symptoms that indicate that the heart can’t support proper circulation. Because cardiac disease plays a significant part in adverse outcomes, I think there should be a more concerted and stringent screening process as part of prenatal and postpartum care. We really need to do the research to see whether rigorous screening would improve outcomes.
Setting up more programmes similar to A Mother’s Heart, especially in US rural areas where there’s a predominance of under-served women of colour, can help not only Black and brown women but all pregnant people to have better maternal-health outcomes. We should also direct more research towards how using medical support staff — such as those who help people navigate the medical system, doulas and midwives — could improve Black maternal-health outcomes.
‘Fourth’ trimester care It’s also worth looking at parts of the world that have better maternal-health outcomes and learning from them. In contrast to people in many countries, a lot of people in the United States do not have access to low-cost health care during the postpartum period. Nearly half of US births are covered by Medicaid, which offers free or low-cost health care for low-income people, which only covers mothers’ care for the first 60 days after birth.
Researchers say that, to catch more medical problems earlier, Medicaid should provide financial cover through at least the ‘fourth trimester’, or the first three months of the baby’s life, and ideally up to a full year after birth. (In 2021, the US Congress approved a Medicaid extension for 12 months after birth and 27 states have adopted such plans so far.) Each state has different policies on health-insurance coverage for fourth-trimester care, which leaves many people vulnerable.
Another important aspect is that we need to train physicians, starting in medical school, to unlearn biases and to centre the experiences of Black people during health care. US universities could create a curriculum through all four years of study dedicated to teaching medical students to be more aware of the impacts of bias and racism in health care. This training could continue and be built into the process of licence renewal, so combating racism and bias stay at the forefront of doctors’ minds.
The truth is, it’s difficult to change people’s hearts, especially when it comes to changing how they think about certain groups. Compensating or disciplining physicians financially for the health outcomes of Black patients could be an excellent way to keep them mindful of how racism and bias lead to poor results.
In general, we need more physicians and researchers who look like us. According to data from the Association of American Medical Colleges, as of July 2019, only 5% of US doctors identified as Black or African American.
Data show that Black patients fare better when they have Black doctors taking care of them. Unfortunately, research shows that about 53% of Black Americans struggle to find a doctor who identifies as Black where they live1.
And from the research perspective, if you are familiar with a particular set of issues because you are from the same background as the participants, then you can address nuances in your research more readily and build rapport and trust.
This interview has been edited for length and clarity.
Lyn, D. P. J. Gen. Intern. Med. 37, 1310–1312 (2022).