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The United States has one of the most abysmal maternal health records among industrialized nations, and Black women bear a disproportionate share of the burden.

U.S. women are two to three times more likely to die than women in Canada from the start of pregnancy to one year after delivery. The infant mortality rate for Black women’s babies was more than twice that of all races, according to 2017 data from the Centers for Disease Control and Prevention (CDC), and Black women are two to three times more likely to die from pregnancy-related causes compared with their white counterparts. In some places, it’s worse: In New York City, from 2006 to 2010, Black women were 12 times more likely than white women to die from pregnancy-related complications.

The reasons U.S. Black women have a higher risk of adverse maternal and infant health outcomes vary. Black women have the highest maternal mortality rate among women of all races in the United States, and their position doesn’t change with increased education level or income. Black women experience high levels of chronic stress produced by systematic racial bias and institutionalized racism structures, which have physiological consequences that can lead to higher health risks. Black women also encounter discrimination and bias in clinical and health-care settings from providers, contributing to the disparity in maternal care and fatality rates.

Even in states making gains in maternal health, Black women are suffering. The maternal mortality rate in California declined by 55 percent from 2006 to 2013, but the maternal mortality rates for Black women still remain far above average.

Thirty years ago, California created the Black Infant Health (BIH) program, a public health program to help pregnant Black women have healthier babies through a group-based and case-management approach. Recently, the program received a funding boost through California’s Perinatal Equity Initiative (PEI), which California Gov. Gavin Newsom signed last June.

The initiative is a result of the Dignity in Childbirth and Pregnancy Act (SB 464), introduced by California state Sen. Holly J. Mitchell (D-Los Angeles) to “actively fight the Black maternal mortality disparity in California.” The act includes the establishment of an implicit bias training program for perinatal care providers, reducing personal, interpersonal, institutional, structural and cultural barriers to health-care access, and requiring the California Department of Public Health to resume tracking of maternal mortality and morbidity. According to Mitchell’s press release announcing the act, although Black women make up only five percent of women in California, they account for 21 percent of pregnancy-related deaths.

The initiative is just one of more than 80 legislative efforts to address racial disparities in U.S. infant and maternal mortality rates. As Rewire.News reported last year, lawmakers in Illinois and Texas introduced bills that address implicit bias in their medical health-care systems (although the proposals appear stalled in the legislature) and ten states are proposing bills to expand doula care.

On a national level, federal lawmakers are hoping to reduce maternal mortality rates through improving provider training in bias, coverage and access to doulas, coordination and reporting among hospitals, and the adoption of best practices for improving maternity care with bills, including the Modernizing Obstetric Medicine Standards (MOMS) Act of 2019, introduced by Sen. Kristen Gillibrand (D-N.Y.), Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act, Excellence in Maternal Health Act of 2019, and Preventing Maternal Deaths Act.

The new legislative and fiscal support for BIH will support the program’s participants, women who must be at least 18 years old and up to 30 weeks pregnant at the time of enrollment. For 30 years, in counties with the highest birth rates of Black infants, including Los Angeles, Alameda, Fresno, and Contra Costa counties, the Black Infant Health program has shown to be an effective contributor in reducing rates of low birth weight and preterm births, as well as infant mortality, among participants.

In the program, health advocates, nursing support, and social and outreach workers support women throughout pregnancy and the first year of their infant’s life through home visits. BIH’s process to determine interventions include community-based focus groups, environmental scans, and needs assessments conducted by the organization’s community boards, which are composed of physicians, Black mothers and fathers, social workers, health professionals, early childhood experts, community members, and researchers.

With additional funding from the PEI, each county’s office will expand and bolster its process.

Natalie Berbick, coordinator of infant health programs for Contra Costa Health Services, tells Rewire.News that the reasons Black women experience these maternal outcomes are “multifactorial and dynamic.”

“What the Black Infant Health model is very clear about is that the drivers of these disparities, the responsibility or onus to change them, do not [lie] on the Black woman,” Berbick said. “You have to think bigger and broader as to why we are seeing these persistent disparities.”

As a result of such thinking, the BIH program now includes group support services, case management methods, and other evidence-based strategies, Berbick said. “We’re providing social support, stress reduction activities, and empowering women with information so they could feel they have some agency in their lives,” Berbick said.

In Contra Costa County, the Black Infant Health program will now increase coverage of and access to doula services, as well as create a program to increase fathers’ involvement in alleviating maternal stress. The fatherhood program is based on that of the Alameda County Public Health Department, which houses the state’s only family health services department to offer direct services that serve male partners, according to Christopher Gibson, family advocate for the Alameda County Family Health Services’ Fatherhood Initiative.

Gibson works as an advocate for fathers in the area of maternal and infant health; he is also lead facilitator for Cafe Dad, the county’s fatherhood support group that provides safe spaces for fathers to share their parenting experiences, challenges, and successes. Gibson said fathers play a critical role in promoting healthy Black mothers and infants.

“I really think that men do not have the information or the knowledge of the benefit[s] of other types of care when it comes to pregnancy and giving birth,” he tells Rewire.News.

He hopes the Perinatal Equity Initiative in more of California’s public health departments will result in greater male partner involvement, such as participation in prenatal visits, and push service providers to treat fathers “like they are part of the family.”

Sharon Goldfarb is dean of nursing at the College of Marin and sits on the community board of the Contra Costa Perinatal Equity Initiative. She says her decades of experience as a health educator and family nurse practitioner who has worked with homeless, undocumented, and other underserved populations, have shown it is important that nurses know to recognize and speak up about the racism embedded in the medical system. She cites the lack of training in conducting Apgar tests to or diagnosing measles in Black patients as examples of the sort of structural racism she urges her students to recognize and speak up about in order to improve maternal and infant outcomes.

“We have to have [nursing] students who say there are problems,” she said. “There’s inequality, and this is the field you’re going into. So go [into] the field with eyes wide open and be prepared to do something about it.”

The PEI-funded Black Infant Health programs are expected to launch in the spring and seem promising, Berbick said. Community-based organizations will be able to apply for funding to implement the models.

State-level initiatives such as California’s recent advancements are just one of many steps needed to improve maternal and infant health among Black women. Eradicating the systems that inherently undervalue Black people and expose Black women to structural barriers to resources and coverage, environmental risks, and chronic stress is critical to improving maternal health care in the United States. We can do this by amplifying Black-women-led solutions in the fight for social, economic, and political equity.