Tamara Etienne was 30 weeks pregnant when she learned she’d have to find a new doctor. It was 2017, and she had recently stepped away from her teaching job to pursue a master’s degree in health administration and raise her growing family. Etienne and her husband applied and qualified for Medicaid in Florida, so she thought she’d have no problem continuing her prenatal care. But the OB-GYN she was seeing couldn’t accept her new insurance.

“I got really stressed out because at this point I’m big pregnant, and I couldn’t find someone to take me on for care,” Etienne, now a mother of four, said. She called around for a couple of days before she found a birthing clinic in Miami that would see her. She said she felt surrounded by support from providers there, something she hadn’t experienced before as a Black woman seeking prenatal care in the South.

“It doesn’t have to be like this,” Etienne, a doula and executive assistant for Southern Birth Justice Network—a Miami-based nonprofit providing midwifery and doula training to Black and brown people—said of the state of the maternal health crisis. “In this wonderful country we live in, which is not a poor place, people should not have to go to risky alternatives for care during pregnancy. There should be more access to midwives and birthing centers.”

And yet, the maternal health crisis in the United States is showing no signs of improvement. In 2020, the Centers for Disease Control and Prevention (CDC) released maternal mortality data for the first time in over a decade, citing a rate of 17.4 maternal deaths per 100,000 live births. That still puts the United States far behind most developed countries. According to the March of Dimes 2020 report on maternal and infant health, the states with the highest levels of infant mortality and preterm births are mostly concentrated in the Southeast.

“We look at the Southeast as an area of the country that faces a lot more obstacles to mothers and babies being healthy than we see in other parts of the country,” March of Dimes President and CEO Stacey Stewart said.

The maternal health crisis is a multilayered problem, with deep roots in the history of racism and a continued foothold in lack of access to care—and it requires a multilayered solution.

The obstacles

A healthy pregnancy begins long before conception—it starts with the preexisting health of the woman.

“In Georgia, nearly 1 in 5 women of childbearing age are uninsured,” Stewart said, citing March of Dimes data. “That means 20 percent of women are already starting without the proper resources to manage their health.”

People with chronic health conditions like hypertension, diabetes, or obesity are at higher likelihood of risky pregnancies, especially if these conditions aren’t properly managed. Pregnant Black people face additional health challenges due to the chronic effects of racism-induced stress on their bodies.

When Charity Moore of Birmingham, Alabama, learned she was pregnant in 2017, she immediately knew what her risk factors might be—she feared that her polycystic ovary syndrome could put her at risk for preterm delivery. Sure enough, a blood pressure scare at 34 weeks sent her to the emergency room, where she delivered her son via cesarean section. (Moore believes this could have been prevented with better prenatal oversight by her doctor.) One day later, her baby was sent to the neonatal intensive care unit because his body temperature was dropping.

Desperate to help her son as much as she could, Moore pumped breast milk every three hours and had the baby’s father deliver it to the NICU. She later learned that the nurses had been feeding him baby formula, letting her breast milk sit unused in the hospital’s fridge.

“The NICU nurse was like, ‘Y’all don’t breastfeed as long anyway, so he might as well get used to formula while he’s here,’” Moore said. “And I’m like, ‘Who doesn’t breastfeed?’” The comment clearly had racial undertones, alluding to the fact that Black women breastfeed at lower rates than white women—yet another byproduct of Black women receiving subpar care.

Moore’s experience speaks to the way so many women, and especially women of color, feel ignored by their providers during pregnancy and childbirth—or worse, openly talked down to. This bias infects every corner of the U.S. health-care system, starting in medical schools. One 2016 study from the University of Virginia found that about a third of medical students believe Black people have thicker skin than white people and therefore a higher threshold for pain.

Former state Rep. Jennifer Carroll Foy, a Democratic candidate for governor of Virginia, recently shared her near-death experience in 2017 after she gave birth to twin boys at 22 weeks via c-section. Carroll Foy said her pain after childbirth was dismissed due to racism. Her trauma has now catalyzed her run for office and her plan to reform Virginia’s health-care system to better support Black mothers.

“This distortion of reality that simply because we produce more melanin, or because our hair is different, that somehow means we have thicker skin or a different shaped pelvis or different bacteria in our vagina, [these ideas] are deeply embedded in the South,” Dr. Joia Crear-Perry, founder and president of the New Orleans-based National Birth Equity Collaborative, said.

She said a refusal to reckon with history is partially to blame for the lack of progress in maternal health outcomes.

“The fear of having an honest and truthful conversation around the history and legacy of slavery, Jim Crow, mass incarceration, and today’s police violence as an undergirding to white supremacy culture has made it almost impossible for us to move forward,” Crear-Perry said.

It’s not as if pregnant people have much choice about where to go for prenatal services. Thirty-four percent of counties in the Southeast are maternity care deserts, and another 20 percent have limited access to care. According to March of Dimes research, around 717,000 women of childbearing age in the Southeast live in counties with no access to maternal health services. In all, according to the report, “7 million women of childbearing age live in counties without access or with limited access to maternity care. These women are giving birth to more than 500,000 babies a year.” That leaves pregnant people in the Southeast and beyond with few options when it comes to finding a trusting and culturally competent provider.

The postpartum period brings another set of challenges. “We’ve created an infrastructure that doesn’t even allow you to heal from having a baby,” Crear-Perry said.

According to the U.S. Bureau of Labor Statistics, only 19 percent of working people have access to paid family leave. Medicaid programs are required to cover women for just 60 days postpartum (this has been extended indefinitely during the pandemic), yet the CDC estimates that 1 in 3 maternal deaths occurs one week to one year after delivery.

Crear-Perry points out the undeniable correlation between lack of access to maternity care and lack of access to abortion—both problems that plague the Southeast.

“When you are desirous of control, you tend to have the same underlying ethos and worldview,” she said. “The worldview is, ‘Our job is to make sure you act right. Our job is to police and control your body and your decisions. We don’t really believe you will make good decisions on your own, so we need to do these things to make you safer.’”

The research backs this up: States with restrictive abortion laws are often the ones with the worst maternal and infant health outcomes.

Possible solutions

This compounded crisis won’t be solved without a dedicated investment in Southern communities, advised and led by people who know these communities well. Jamarah Amani, executive director of the Southern Birth Justice Network, believes midwives can play a crucial role in improving maternal health outcomes.

“Midwives have been the pillars of their community for as long as Black folks have been in this country, and have really provided care that fills in the gaps,” Amani said. The gradual medicalization of pregnancy and birth in the early 20th century—as seen in laws like the 1921 Sheppard-Towner Act—made it more difficult for many midwives to practice.

“It really institutionalized nursing and midwifery in ways that took it out of the community and made the education requirements unattainable for most Black folks,” Amani said. “And that still continues to this day.” Some insurance programs cover midwifery care, but the level of coverage varies by state and by plan.

Stewart also notes the role of implicit bias training in medical schools and hospitals.

“There has never been a time in this country where Black women and those who are descendants of slaves have been provided a level of care that is commensurate with their white counterparts,” she said. March of Dimes has implicit bias training programs available for health-care organizations to use for their staff. The most reliable way to achieve some of this change, though, is through policy.

March of Dimes is supporting a number of bills in various stages of development, including the Black Maternal Health Momnibus Act, introduced this month by Rep. Lauren Underwood of Illinois, Rep. Alma Adams of North Carolina, Sen. Cory Booker of New Jersey (all Democrats), and members of the Black Maternal Health Caucus. The bill would help fund community-based organizations working to improve Black maternal health outcomes across the United States.

“We have to be willing to fund these new models of care that can supplement what the health-care system is failing to provide to these women,” Stewart said.

Crear-Perry hopes recent elections in Georgia have shown people what is possible in the South moving forward.

“What Georgia shows us is that the South is not what our biases and perceptions are,” she said. The election of two Democratic senators in historically Republican strongholds shows the power of community-level organizing and activism, even in places where antiquated systems are deeply entrenched.

“We are no longer saying, ‘That’s just what they do and they’re going to keep doing that,’” Crear-Perry said. “There are millions of people who live in the South who want justice and joy, and who will fight when there is something worth fighting for.”