Sen. Kamala Harris (D-CA) and 13 other Democratic senators introduced legislation last week aimed at addressing racial disparities in rates of maternal deaths across the United States.
The Maternal Care Access and Reducing Emergencies (CARE) Act focuses on eliminating racial discrepancies in U.S. maternal mortality rates—the death of a woman while pregnant or within 42 days of termination of pregnancy, from complications related to pregnancy, labor, delivery, or abortion—by creating two key Department of Health and Human Services (HHS) grant programs. The first is designed to provide training for doctors and nurses to recognize implicit bias toward people of color, and the second seeks to help medical providers provide integrated maternal care to pregnant people who are enrolled in Medicaid. “Health equity for Black women can only happen if we recognize and address persistent biases in our health system,” said Harris in a statement on the measure. “This bill is a step towards ensuring that all women have access to culturally competent, holistic care, and to address the implicit biases in our system.”
Though Harris has been speaking about the racial disparities in maternal death rates for some time, her effort to address the issue through legislation comes as visible Black celebrities like Serena Williams and Beyoncé revealed their struggles with the maternal health care system—demonstrating that Black pregnant bodies are treated with disregard in maternity wards regardless of income status.
Maternal death rates are higher in the United States than most industrialized nations despite the fact that more money is spent in this country on health care than those with comparable levels of economic development. According to a 2016 report from the American College of Obstetricians and Gynecologists (ACOG), which has endorsed Harris’ bill, the overall rate of maternal death in the United States in 2014 was about 24 deaths per 100,000 live births. However, a deeper look at the issue reveals that the main driver in the high U.S. rate is wide racial disparities in pregnancy-related deaths, specifically the extremely high mortality rate for Black mothers compared to other races.
Data from the U.S. Centers for Disease Control and Prevention (CDC) shows that across the country from 2010 to 2014, Black women died from pregnancy-related causes at a rate of 40 deaths per 100,000 live births versus 12 deaths per 100,000 live births among white women and nearly 18 deaths per 100,000 live births for women of other races. The CDC’s report on racial disparities in the maternal mortality rate only breaks down race by Black, white, and “other races,” erasing the very real differences between specific marginalized communities of color. As a 2010 Health Resources and Services Administration (HRSA) report explains, “The risk of maternal mortality remained three to four times higher among black women than white women during the past six decades.”
“When You Think Someone Is Superhuman, It’s Actually Dehumanizing”: How a Doctor’s Implicit Bias Affects Black Pregnant Bodies
The first initiative tackled in the bill is a $5 million annual grant program through fiscal year 2023 to create medical school curriculum addressing implicit bias among health care providers. Jennie Jacoby Altscher, federal policy counsel at the Center for Reproductive Rights described in an interview with Rewire.News the phenomenon as “the implicit attitude and stereotypes that can result in judgments about patients, treatment, and care.”
Implicit racial bias in medical settings has real-world consequences for people of color, especially those who are pregnant. In an interview with Rewire.News, Monifa Bandele, vice president of maternal justice programs at MomsRising, pointed to a study published in 2016 “where they found that medical students still held this mythology that somehow Black people’s bodies could withstand more pain, that somehow Black bodies are more resilient.”
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“So we see those mythologies that [doctors] hold happening all across various health situations,” she said. “Black people are given less pain medicine for reporting the same amount of pain. When you think someone is superhuman, it’s actually dehumanizing.”
The Harris bill would give grants to medical and nursing school training programs to create training programs designed to help future health care professionals recognize implicit racial bias in their interactions with patients of color. “Essentially this bill would give the director of [HHS] the authority to establish a competitive grant program where they would award these grants to certain accredited medical schools and nursing schools, all with the purpose of having an evidence-based implicit bias training program,” explained Jacoby Altscher.
According to Dr. Aisha Wagner, a family medicine doctor practicing in California, the stress that women of color experience which stems from the implicit bias of doctors and medical providers can increase the risk of high blood pressure and other stress-related risks for pregnant people versus that of white patients.
“What studies are basically showing is that, when we make everything else equal, equal finances, fairly equal backgrounds, we still have this difference between Black women and white women and so we think that a lot of this difference [in maternal mortality rates] can be attributed to just stress in general of being a person of color in the medical system,” Dr. Wagner said in an interview with Rewire.News.
Such was the case for YoLanda Mention, a Black woman whose story was featured in a USA Today report on the Black maternal death rate. Mention underwent a cesarean section at McLeod Regional Medical Center in South Carolina and was inexplicably discharged with dangerously high blood pressure before later passing away at home. “Who sends someone who’s had major surgery home with stroke-level blood pressure?” asks Bandele, who pointed to the incident as an example of the kind of risks Black people may encounter from biased medical providers during pregnancy and delivery. “So of course, that person died. And this was at a good hospital! But there was a disregard for a black mom and her care. So these are the types of things that we see.”
Pervasive racial bias against and unequal treatment of Black women exists in the health care system, often resulting in inadequate treatment for pain and dismissal of cultural norms with respect to health. The bill doesn’t specifically address explicit bias either, which consists of overt and conscious acts of racial discrimination, which would be especially dangerous when potentially racist medical providers are responsible for the lives and health of people of color. When asked about addressing explicit bias, a spokesperson for Sen. Harris said in a statement that the legislation “would be a first step in the fight to reduce racial disparities in maternal health care and overall maternal mortality rates.”
While addressing disparities can be an easy talking point for politicians, some experts and advocates would like elected officials to look at these issues from a more holistic health equity lens, an approach which centers the patient as the expert in their own health needs. “Specific to Senator Harris’ bill—this is a program that is designed to reduce health disparities if its stated goals are met because it uses existing infrastructure which is inherently inequitable (based on insurance type, access to providers, etc.),” said Assistant Professor Monica McLemore at Advancing New Standards in Reproductive Health (ANSIRH) in an email to Rewire.News. “A health equity approach would begin with seeing the women experiencing the burden as experts and should be considered an integral part of the solution as opposed to privileging clinical providers.”
A health equity approach would recognize that systemic racism both within and outside of the health care system can have severe long-term effects on the physical bodies of women of color, which can increase pregnancy risks, even before a patient requires prenatal care. “Due to the groundbreaking work of Arline Geronimus of [the] University of Michigan, we know that this constant barrage of activated fight or flight mechanisms … creates an environment that she termed weathering, which contributes to accelerated aging and degeneration that can be detected at the cellular level,” McLemore said. But by addressing implicit bias early in medical training, Harris’ bill could help alleviate some of the issues with racial disparities in the rate of pregnancy-related deaths.
According to Wagner, sociological issues like implicit racial bias weren’t addressed when she was in medical school. But she thinks the grants created by Harris’ bill are something that medical providers might be eager to put to use. “I would hope that the majority of people in medicine would be interested in breaking down these barriers,” she said. “From my personal experience earlier on in my career at several institutions, people are really hungry for this information. I am hopeful that people will be receptive to implementing implicit bias training.”
Breaking Down Barriers to Care Through Pregnancy Medical Home Programs
The other key initiative contained in Harris’ bill is a pilot program, funded at $25 million annually through fiscal year 2023, to help those with at-risk pregnancies more effectively navigate the maternal health care system. Under the bill’s provisions, HRSA will distribute grants to ten states for pregnancy medical homes (PMH) programs which pair a care manager with pregnant people on Medicaid. Those care managers can help navigate the various integrated medical providers needed for a safe and successful pregnancy as well as assist with socioeconomic issues impacting pregnant people such as food insecurity or domestic abuse. While there are several local PMH programs in various states across the U.S., attempts at scaling the concept are relatively new, with North Carolina running the only statewide PMH program in the country.
“The [North Carolina] PMH program has been credited with the convergence in pregnancy-related mortality rates because the program partners each high-risk pregnant and postpartum woman that is covered under Medicaid with a pregnancy care manager,” Harris’ bill reads.
What has really impressed some experts about PMH programs is the level of comprehensive maternal care that PMHs can deliver to Medicaid recipients, who often can’t access quality care in the first place.
“What I think is really effective from my own view is that they require that they give any patient that comes in for their first prenatal visit an entire risk assessment. It’s really comprehensive, it’s medical, it’s obstetric, and it’s also psychological which is really important,” said Jacoby Altscher. “Something that North Carolina finds in their program is that a care manager really contributed to their success so the Harris bill includes a care manager. Someone who coordinates care and can refer you out if you need other services, [such as other] health care and social services.”
Many experts hope that scaling PMH programs on a multi-state basis would produce increased access to doulas and midwives for Medicaid recipients, a service often excluded from Medicaid’s current coverage, according to Bandele. “Women in Black communities are less likely to have access to doulas and midwives even though Black women were the first midwives,” she said recounting how historically Black women, many of whom were enslaved, delivered babies. Then, when maternal care moved to a corporate model, Black women couldn’t go to the hospitals because they were segregated. “Now it’s chic, right? Women who have resources are like ‘Oh yeah, I have my midwife and I have my doula,’ but women who need it in [Black] communities can’t afford it because Medicaid won’t reimburse it.”
According to Dr. Wagner, doulas and midwives can be critical in the effort to reduce the maternal mortality rate within communities of color. “The use of doulas is growing; I think we’re understanding in the medical community how important that is,” she said, explaining the ways in which doulas can make a large difference for the health of pregnant people. “They really can act as such a wonderful support for pregnant women because they know the system and they can also provide a lot of stress relief around just being pregnant in general. [They can] break down some of those barriers as far as how scary labor and delivery is, talk to you about what your birthing plan is, and then really be an advocate for you in the delivery room and even after delivery.”
While Harris’ bill addresses the immediate crisis of maternal death rates among people of color, advocates hope that introduction of the bill kick-starts a broader discussion about improving health within communities of color beyond just having healthy births. “The health of our communities demands that we be holistic in our efforts to truly embrace and empower healthy Black mamas, healthy children, and healthier communities,” Monica Simpson, executive director of reproductive justice group SisterSong, said in a statement. “We need to think about what it takes to nurture our families and ensure that parents are able to make a living wage and be in workplaces that offer adequate support and protections such as paid sick leave.”
“We are excited that this bill helps to open that conversation,” Simpson said. “It is a good start to moving towards a better future for us all.”