Structural Racism and Black Maternal Mortality Rates in the Southern United States

By Kendahl Brown

    Structural Racism and Black Maternal Mortality Rates in the Southern United States

    About the Author

    Kendahl Brown
    Undergraduate Student
    Tuskegee, AL, US
    1 Article Published
    Kendahl Brown

    I am a 4th year social work major with a minor in sociology at Tuskegee University. At the end of Spring of 2023, I was tasked with writing and completing a research proposal. My interest in research stems from my goal to be a social worker and advocate for those who are unable to advocate for themselves.

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    Abstract 

    This study explores the maternal mortality rates of black mothers in the Southern United States. These rates are much (3x) higher than they are in mothers of other races (Taylor, 2020). Unfortunately, black women are commonly overlooked and dismissed when it pertains to them speaking up and expressing their concerns about healthcare. Along with being dismissed in healthcare settings, they are also more susceptible to various prenatal and postpartum illnesses such as high blood pressure, gestational diabetes, eclampsia or preeclampsia, cardiomyopathy, and others. It is likely that this common dismissal from doctors stems from structural or systemic racism, as there is a long history of black women being treated unethically in medical settings. Lastly, black women, especially those living in impoverished areas usually do not have access to proper prenatal healthcare, which could also lead to a fatal birth for the mother and/or baby.

    Introduction

    In 2020, Good Morning America shined a light on the issue of structural racism’s impact on black maternal deaths in “How maternal medical disparities affect women of color” How maternal medical disparities affect women of color – YouTube (Good Moring America, 2020). This essay will explore this issue, alongside how healthcare professionals and social workers can support social justice through strengthening access to diverse resources and culturally responsive strategies that may prevent birth deaths among black birthing mothers. A recent study (U.S. Government Accountability Office, 2022) found that more than half of rural counties lack obstetric services, and rural counties with more African American and low-income families were less likely to have hospital obstetric services. A maternity care desert is “a county within a state/city in which access to maternity health care services is limited or absent, either through lack of services or barriers to a woman’s ability to access that care.” It is important to include the voice of communities affected by these disparities when developing interventions for perinatal health, defined as women’s and infants’ health during pregnancy and the first year postpartum. Such interventions are considered a critical indicator of a nation’s overall wellness (Hansen, 2022; Office of Disease Prevention and Health Promotion, 2020; n.d.).

    At present, perinatal health in the United States is plagued by persistent and pervasive racial and socioeconomic disparities. Human rights in healthcare are a part of the principles of decision-making and patient-centered care in the U.S. However, some women’s voices or choices are not often heard by providers of healthcare. Unfortunately, black women are commonly overlooked and dismissed when it pertains to them speaking up and expressing their concerns in a healthcare setting. Along with being dismissed in healthcare settings, Black and Native American women experience an unacceptable and disproportionate risk for poor perinatal health outcomes (Martin et al., 2018; Peterson et al., 2019). These risks are discussed in an Evidence-Based Birth video (2017) on “Racial Disparities and Systemic Racism in Childbirth” (https://youtu.be/vUmqcRCXysM?si=H0Fvt4fR7cfp6Dvh). The at-risk populations are traditionally served by social workers and are the most likely to be affected by structural inequities and associated perinatal health adversity. Therefore, the social work perspective, which emphasizes diversity, cultural competency, equitable access and healthy families, serves as a source for advocacy for social justice in combating structural inequities and associated perinatal health adversity of black birthing patients in maternity care deserts.

    Social Injustice

    Evidence of perinatal health disparities began garnering attention at the beginning of the 20th century, when Hull House social workers emerged as advocates for reducing high rates of infant morbidity and mortality, particularly among the very poor (Sherraden, 2013). Within their role at the Hull House, social workers such as Jane Addams and Julia Lathrop conceptualized strategies to address infant mortality beyond the need for enhanced medical care. These early social workers situated their concerns with perinatal health in underlying conditions, including the “economic, social, civic, and family conditions” (Lathrop, 1918, p.1), such as inadequate housing, education, food safety, sanitation, and the overarching issue of abject family poverty (Sherraden, 2013).  A social workers’ professional role is to “enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers, 2017, p 1). Social workers undergo explicit training to provide services that address individuals’ social needs (National Academies of Science, Engineering, and Medicine, 2019). Through this training, social workers are poised to address clients’ challenges and concerns from a person-in-environment, bio-psycho-social-based perspective, which allows the profession to frame individual or community experiences as expressions of social inequity, and to work towards social justice using a broad approach to solution-building.

    Historical context

    In the United States, Black women are dying at a much higher rate– about 2-3 times higher– than any other ethnic group (Taylor, 2020). In the USA’s Deep South there are overwhelming health disparities. The Deep South is a descriptive category of cultural and geographic subregions in the southern states, including Alabama, Mississippi, Georgia, Louisiana, and South Carolina. Macon County is located in the southeastern part of the State of Alabama. The city of Tuskegee is the county seat for Macon County. The Black Belt designation originally described the rich soil and green landscape that drew whites as farmers and landowners to the area beginning around 1830. Over time, many settlers built large plantations to grow cotton as well as other agricultural products. After the Emancipation Proclamation of 1865, the region became known for its large concentration of African Americans who were previously slaves on the plantations and were left with an impoverished status that continues to this day. Over time, poor farming techniques saw the soil erode down to the limestone base, known as the Selma Chalk. By the middle of the 20th century, the rich black soil was gone, leaving behind large swathes of poor farmland occupied by descendants of the slaves that once farmed the land (Tullos, 2004). The Robert Wood Johnson Foundation, in their annual demographics report by county, indicated that out of 66 Alabama counties, Macon County ranked as the following: High unemployment rate (6.1%), moderate education (High School Graduation, 89%), poor quality of life (ranked 58th), length of life (ranked 64th); and poor health outcomes (59th) – County Health Rankings and Roadmaps Initiative (rwjf.org)

    In his 2018 report entitled “Addressing the Tangled Roots of Health Disparities,” John Arnst (2018) defined disparities as the study of “any condition disproportionately affecting one racial, ethnic or gender group.”  One of his most compelling examples is the correlation between poverty, income, and unequal access to health care and life expectancy.  He writes, “The richest 1 percent of American women and men live an average of 10 and 15 years longer, respectively, than the poorest 1 percent.” Rathmore and Krumbolz in the Institute of Medicine report titled “Unequal Treatment” discussed disparities as reported by Kilborne, Switzer, Hyman, Crowley-Matoka, and Fine (2006). The disparities include observed clinically and statistically significant differences in health outcomes or health care use between socially distinct vulnerable and less vulnerable populations that are not explained by the effects of selection bias, with an expanded definition that includes differences in health outcomes or health status and health care use.  As they discuss, disparities in health outcomes or health status may be caused or intensified by patient, provider, or system-level factors that result in differential treatment or by societal inequities such as differential power or socioeconomic status.

    Structural Racism Contextualized

    The American Medical Association describes structural racism as the entirety of ways in which society(ies) fosters racial discrimination through the operation of different systems such as housing, employment, and healthcare (Bailey et al., 2021). Similarly, the phrase “implicit bias” has been conceptualized as “thoughts and feelings that exist outside of conscious awareness and subsequently can affect human understanding, actions, and decisions unknowingly” (Bryant & Saluja, 2021). The correlation between structural racism, implicit bias, and black maternal mortality is not new information, and the effects of racism in the healthcare field are incredibly prominent. However, as modern-day medicine evolves, so does the subtlety of devaluing women of color (Taylor, 2020). Unfortunately, this pattern is blatant in impoverished areas where healthcare deserts are common. It is seen more frequently in rural parts of southern states such as Alabama and Mississippi, as well as rural parts of midwestern states such as Wisconsin and Michigan, among women of childbearing age (e.g., 20 to 35 years of age). 

    Despite its prominence, structural racism is a historic topic that many Americans still don’t acknowledge. Even if acknowledged, many Americans have little knowledge of how structural racism affects various parts of African Americans’ lives. Regarding healthcare, the views of African Americans have been shaped by disturbing historical experiences dating back to slavery and segregation. For example, Dr. J Marion Sims, the man who has been given the nickname “the father of modern gynecology” was a doctor who performed shocking and unethical experiments on his female African American slaves between 1844 and 1849 (Zellars, 2018). In one example, in an attempt to learn the correct process for surgically correcting vesicovaginal and rectovaginal fistula he operated on one woman 30 times over 5 years until he successfully figured out the correct process. With anesthesia not available in this time period (Zellars, 2018), one can only imagine the pain this woman was subjected to. More history about the importance and history of the topic is shared by PBS Vitals (2023) in “Why Pregnancy Is So Dangerous for Black Women | Perspective” at https://youtu.be/fiZYqWHgMjc?si=8_S0RjabL_nPA2-l (personal communication).

    Other incidents have contributed to a historical sense of medical mistrust among African Americans, including glaring instances in which African American research subjects have been mistreated such as the United States Public Health Syphilis Study of the Untreated Negro Male, and the case of Henrietta Lacks. In addition, the misjudgment of pain when it comes to African American women has been, and continues to be, problematic. Often attributed to structural racism throughout the healthcare field, other specific (preventable) health issues that black women are more susceptible to, both prenatal and postpartum, are often overlooked by doctors. These health issues/ complications include but are not limited to preeclampsia/ eclampsia, gestational diabetes, cardiovascular disease, hypertension, and postpartum depression. This 400-year history of racism, medical mistreatment, and mistrust is the context in which to understand black women’s contemporary poor maternal health and high maternal death rates.

    In contemporary times, the historical context is infused with further harsh realities. Overall, rates of maternal morbidity and mortality are particularly dire within the US. For example, in 2018, there were approximately 17.4 deaths per 100,000 (Hoyert & Miniño, 2020). In addition, for every maternal death, there are approximately 70 cases of severe morbidity (Fingar et al., 2018). Likewise, US infant mortality continues to remain far too high, exceeding the ranking of 46 other nations (World Factbook, 2020). Stark disparities persist concerning a wide variety of perinatal health conditions, including the disproportionate rates of unaddressed maternal mental and physical health conditions, preterm birth, low birth weight, and maternal-infant mortality (Centers for Disease Control and Prevention, 2019; Goldfarb et al., 2018; Mukherjee et al., 2016; U.S. Department of Health and Human Services Office of Minority Health, 2019). Research shows that among racial/ethnic perinatal disparities, the contrast between White and Black women’s pregnancy-related mortality is the starkest of all, with Black women dying at three to four times the rate of White women (Howell & Zeitlin, 2017; Peterson et al., 2019). Women who experience socioeconomic stress, mental health, and substance abuse conditions are also at a greater risk of experiencing perinatal health challenges (Blumenshine et al., 2010; Forray & Foster, 2015; Ross & Dennis, 2009). Often, women who experience complications during pregnancy are at risk for additional pregnancy-related mortality and morbidities (e.g., preterm birth, low birth weight, infant mortality, and poor maternal health) following birth (Goldenberg et al., 2008; Peterson et al., 2019).

    Location, Resources, and Preventative Care

    Alongside the history and preconceived notions health professionals have of black mothers, the health issues mentioned previously that black mothers are more likely to face also stem from living in rural, underserved areas. “At the patient level, black women have an increased prevalence of chronic diseases, including obesity, cardiovascular disease, diabetes, and asthma, all risk factors for pregnancy-related complications such as pre-eclampsia” according to Essian, Lasser, and Molina (2019), for the Journal of the National Medical Association. These diseases also are commonly seen in poverty-stricken, rural communities. For example, obesity, diabetes, and cardiovascular disease are consequences of the lack of proper and affordable groceries in grocery stores, and the influx of fast-food chains in these communities. In the medical system, having the privilege of being insured – either partially or fully – makes seeking and receiving primary care somewhat seamless. However, on the flip side, being under insured or having no insurance at all impedes access to critical primary care, which is necessary for pregnant mothers (Essian et al., 2019).

    Prevention Strategies

    To combat the rising mortality rates, preventative care must be made available to every young woman, pregnant or not. “Several studies provide evidence that black women do not receive enough timely, routine, and adequate preventive health care services” (Anachebe & Sutton, 2003). When discussing lowering maternal mortality rates, it is important to mention the term “upstreaming”. In terms of public health, “upstreaming” is an approach to care that examines and addresses root causes rather than symptoms, and it can improve long-term health outcomes and decrease healthcare costs. Better access to tools for upstreaming is needed. For providers, the use of the Reduction of Peripartum Racial/ Ethnic Inequalities Patient Safety Kit has proven to be beneficial. This kit could be much more widely distributed. Additional simulation or e-learning modules to train social workers and health care professionals about substance use disorder, including assessment tools information (e.g., SBIRT, other assessments), also are needed. In addition, Mental Health First Aid training may help close the gap in referrals to other supportive services for maternal and mental wellness.

    Another gap is addressing patient access to external healthcare resources to support black birthing patients with high-risk medical conditions, in which, telehealth or mobile health interventions that include a culturally responsive approach to care especially for black women may be useful. ABC News shared “Expectant Black mothers find support with doulas and midwives | Nightline” story (https://youtu.be/Qozewq0YvEY?si=XB7GFzKRORL_M1oI) that stresses the importance of midwifery and doula services to mothers (2022). Another important supportive resource is a social worker. It is known that some healthcare providers as well as local clinics may not have access to a medical social worker, especially in rural areas. This lack can limit continuity of supportive care, such as home visits for mental health and wellness checks with a nurse and social worker interdisciplinary team. Other interventions for those identified with substance abuse issues, who are reluctant to access care, may benefit from self-help health solutions paired with more access to confidential care for substance abuse intervention and treatment for perinatal risks. Improved access to health education resources, including hybrid events virtually and at primary care/public health agencies in local communities, specifically for preconception, inter-conception, prenatal, and postpartum resources, and the Hear Her campaign by the CDC also are needed. In addition, better resources for healthier pregnancies are needed to support patients with mental health or substance use issues, such as a self-help e-learning tool R1 Learning curriculum (e.g., mental health, substance use, and life skills), Cope Notes (daily mental health text message support), Talkable Communities, and/or Valued Minds The goal is to educate Black birthing patients about how to optimize their comorbidities before becoming pregnant and understand that pregnancy complications can translate to future cardiovascular, obesity, and diabetes health risks.

    How to Pursue Change

    The biggest change must first take place within the healthcare world. First, it is necessary to improve access to critically important resources for black mothers living under the poverty line. These resources include access to affordable reproductive healthcare centers, health screenings, and family support programs (TANF, SNAP) (Hamm et al., 2019). Another important way to decelerate mortality rates is by eliminating what is known as “maternity care deserts” (Hamm et al., 2019). Maternity care deserts are essentially places– usually lower-income locations–where maternal care is virtually inaccessible. Next, it is crucial to enhance the quality of care that black mothers receive (Hamm et al., 2019). For example, to rid the healthcare system of its structurally racist orientations and practices, an adequate method would be training providers on how to address racism and create diverse and equal workspaces (Hamm et al., 2019). Another approach to decelerating maternal deaths is addressing maternal mental health needs both prenatal and postpartum. Overall, in order to know that each mother is being properly looked after, (1) barriers to accessing mental health services must be demolished, and (2) the lack of comprehensive care must be addressed (Hamm et al., 2019).

    Social Workers are a voice for social justice at various levels of healthcare practice. This includes micro-level interventions that  assist individual clients with addressing social, physical, and mental health concerns during the perinatal period; Mezzo level interventions in which social workers provide support within communities (e.g., patient-centered medical homes [PCMHs] and health navigation) (National Academies of Science, Engineering, and Medicine, 2019), and at the macro level, social workers can act as key players in social and health policy advocacy across several domains including (1) enhancing equity related to underlying Social Determinants of Health (SDH); (2) promoting access to quality health services, such as the Council on Patient Safety in Women’s Health Care’s patient safety bundle on reducing peripartum racial/ethnic disparities (2016) ; and (3) naming and calling for the dissolution of policies that promote health environments characterized by stigma and discrimination. 

    Women’s perinatal care needs vary based on personal and cultural preferences (Coast et al., 2016). Social workers trained in reproductive justice and person-centered culturally competent care practices can use their professional knowledge to establish acceptable healthcare plans and community-based interventions for birthing mothers while helping to educate nurses, physicians, and other allied health providers on best practices for culturally responsive patient-centered care to decrease or prevent black maternal morbidity and mortality rates in the U.S.

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