Research shows time and again that Black women are at least three times more likely to die from a pregnancy or childbirth-related cause than white women. Black infants are also over two times more likely than white babies to die before they turn one. Research also shows that people identifying as Black or African American prefer to see providers of their own race. And this racial concordance leads to better health outcomes. Yet, programs targeting race-based infant and maternal health disparities, including those increasing provider diversity, and therefore patient-provider racial concordance, are under attack as evidenced by the Supreme Court’s 2023 decisions ending race-based affirmative action. Innovative workforce diversity programs and public health interventions working to close the maternal health race gap are under threat, yet promising research-proven solutions and resilient communities persevere.
Maternal and Infant Health Disparities
Despite overall reductions, the U.S. still claims one of the largest maternal mortality rates among high-income countries, and women identifying as Black or African American carry a staggering proportion of this burden. Even when controlling for income [PDF] or other factors, a Black woman is more likely to die due to a childbirth-related cause than a white woman. Structural racism, bias in healthcare settings, reduced healthcare access, and economic inequalities drive and exacerbate these outcome disparities. Additionally, Black infants are 2.5 times more likely to die before their first birthday and two times more likely to suffer from low birthweight, which is associated with a lifetime of poor health outcomes. These maternal and infant health disparities are largely preventable, as illustrated by Baltimore having recently eliminated the Black-white infant mortality gap in several neighborhoods.
Maternal Workforce Diversity, Provider Concordance
Studies show that people identifying as Black or African American prefer Black health care providers, are more likely to receive preventive services [PDF] when seeing Black providers, and are less likely to delay care if seeing Black providers. Moreover, Black newborns cared for by Black providers are less likely to die in their first year than those cared for by a provider of another race, and Black residents of counties with more Black primary care physicians have longer lifespans than Black residents of counties with few Black primary care physicians. Additionally, Black primary care physicians, as well as other groups underrepresented in medicine (URM), are more likely to practice in federally-designated Health Professional Shortage Areas or Medically Underserved Areas than white primary care physicians.
Programs in Jeopardy
Despite these findings, Black physicians represent only 5.2% of all active physicians, despite 14.4% of the U.S. population identifying as Black or African American. Several programs are working to close this gap by widening pathways to medical school for Black or other URM populations. While it’s no surprise that Historically Black Colleges and Universities (HBCUs) are on the forefront of expanding medical school pathways, schools like the Perelman School of Medicine at University of Pennsylvania are forming innovative partnerships with HBCUs to recruit and foster a diverse medical student population. Yet, other workforce diversity programs result in lawsuits, some using the anti-affirmative action ruling as precedent. In January, Vituity, a physician-owned health care partnership, was forced to abandon its Black Physician Leadership Incentive program when a Florida judge ruled it discriminatory. Last year, an Arkansas district court ruled that the state Minority Healthcare Workforce Diversity Scholarship was unconstitutional.
Other lawsuits target programs aimed at reducing Black-white maternal health disparities. For example, a California program called the Abundant Birth Project offers Black and Pacific Islander women, who have the poorest birth outcomes in the state, a monthly stipend that recipients use for fresh food and transportation to prenatal appointments. However, a group called Californians for Equal Rights Foundation is suing the City and County of San Francisco to end the program, which it claims is discriminatory, despite clear data showing maternal health outcomes are very much associated with race. The list goes on, and experts believe these lawsuits will exacerbate racial health disparities in the U.S.
Closing the Gap: Centering
In the current environment wherein appointed judges threaten programs that target workforce diversity and improve maternal health, how can we improve care delivery and pregnancy outcomes? One program gaining popularity is CenteringPregnancy, which offers longer prenatal care visits in groups of 8-10 pregnant people, in addition to regular private provider time. Groups are led by providers, including obstetricians, pediatricians, and nurses, as well as support staff, increasing the likelihood a mother will encounter provider diversity. Centering programs have been shown to reduce preterm births and diminish preterm birth racial disparities, reduce NICU admissions, decrease the likelihood of Cesarean section births, and increase the odds of breastfeeding. Both patients and providers report higher satisfaction with care using the Centering model, with researchers espousing that Centering can reduce provider burnout and increase maternity care provider retention.
Midwives and Doulas
Another much-researched strategy to improve workforce diversity and reduce maternal health disparities is the continued support of midwives and doulas. In fact, Black midwives have long proven their skills, attending 80% of Black births in the 1930s rural South. Over time, the number of Black midwives has declined. In 2020, Black midwives only attended to 9% [PDF] of Black births. Research shows that midwife-led care is associated with lower preterm birth rates, lower infant mortality and miscarriage rates, higher satisfaction with care and lower costs than other models of maternity care. Additionally, Black midwife-led care has the potential to reduce exposure to bias in the healthcare system, reduce barriers to prenatal care, and improve quality of care. Strategies to reduce workforce barriers for Black midwives include supporting standalone birth centers and increasing coverage for Black midwives.
Black doulas tell a similar story. Doulas, professionals who provide support before, during, and after childbirth, are associated with improved maternal health outcomes. Benefits include decreased rates of preterm birth and low birthweight, particularly among low-resourced populations. Doula care also reduces racial healthcare disparities, increasing the likelihood of provider concordance and facilitating trusting patient-provider relationships. While doulas face workforce barriers similar to Black midwives, organizations like the National Black Doulas Association offer training, resources, and mentorships to reduce maternal mortality disparities and remove workforce barriers for doulas of color. Additional strategies to support doulas include increasing Medicaid and private insurance coverage and simply making women aware [PDF] these services exist.
Looking Ahead
While lawmakers and special interest groups continue to weaponize the courts against programs aimed at increasing workforce diversity, reducing maternal mortality gaps, or both, communities remain resilient. Increasing participation in programs like CenteringPregnancy, widening maternity care provider pathways, and supporting doulas and midwives are all proven strategies to improve maternal and infant health, particularly among Black women. As perfectly stated by the Black Mamas Matter Alliance, a group working for Black maternal health, rights, and justice, we should all “envision a world where Black mamas have the rights, respect, and resources to thrive before, during, and after pregnancy.”