What blame-the-mother stories get wrong about birth outcomes among black moms

Published on
March 14, 2018

Amid the recent media attention to the increases in maternal morbidity and mortality in the United States, many think pieces and editorials have inadvertently contributed to the phenomenon known as “mother blame.”

Mother blame is the notion that individual characteristics or behaviors such as smoking, late entry to prenatal care, being older during pregnancy, or other chronic health conditions during pregnancy are exclusively responsible for poor birth outcomes. More specifically, for black women, who as a group have the highest rates of maternal morbidity and mortality, people incorrectly assume that they become pregnant while being sicker, older and fatter, and so conclude they’re responsible as individuals for their adverse outcomes.

Such assumptions are incorrect and dangerous for three important reasons. First, addressing individual risk factors to improve pregnancy outcomes has not been shown to be successful or effective. In fact, epidemiologic data show that when studies control for factors such as education and income among black women, the same rates of adverse birth outcomes persist for rich and educated women as for poor women. The recent birth story told by Serena Williams highlighted was scientists have known for a long time — this is a problem that affects black women across the socioeconomic spectrum.

Second, focusing on a mother’s individual characteristics or behaviors avoids the uncomfortable truth that health care service delivery systems, namely hospitals and clinics and the people who work in them, contribute to these poor outcomes. As a clinician-scientist, I know both from my clinical work and my research that there are significant areas of improvement that the current workforce need to address. In particular, areas such as diversifying the health care workforce, expanding doula support, paying close attention to birth plans, and decreasing our reliance on the criminal justice system for pregnant people with mental health issues. Finally, there is nothing inherent about black skin that increases risks during pregnancy — except perhaps over-exposure to the real culprit, racism, which can harm a mother’s body in real, measurable ways.

Focusing on a mother’s individual characteristics or behaviors avoids the uncomfortable truth that health care service delivery systems, namely hospitals and clinics and the people who work in them, contribute to these poor outcomes.

Research on the social determinants of health has shown that several factors have a significant impact on health. According to the University of Wisconsin Population Health Institute, at the population level, health behaviors and clinical care only account for approximately 50 percent of health outcomes, while the other half is explained by social and economic factors as well as the physical environment in which people live.

So what is successful in lowering risk and improving pregnancy outcomes? Years of data that show that successful public health interventions such as Black Infant Health, Nurse Family Partnership and Centering Pregnancy improve birth outcomes. All of these programs are grounded in team-based approaches to support moms and deliver superior outcomes for both mothers and babies. These programs are built on several principles, including culturally relevant care, peer-to-peer learning, and establishing cohorts among the women. The emotional support and resilience skills developed when mothers learn from other mothers is one of the most valued parts of these programs.

But it’s important to remember that the health delivery system — and more specifically the people who provide that care — are part of the problem. Several studies and recent reporting from ProPublica and NPR have shown that black and brown pregnant women experience high levels of stress, disrespect, and racism during pregnancy, and these in turn are associated with poor outcomes such as premature birth, maternal morbidity and mortality, and increased risk of death for infants in the first 1,000 days of life. One factor that could help protect pregnant women of color from such stresses in the health care system is surveillance, which simply means that pregnant women are rarely or ever alone with health care providers. That in turn can decrease the chances that these women experience stressful interactions with staff, disrespect, or racism and its impacts.

To improve birth outcomes for black women, I would suggest that we begin listening to the needs of mothers. That’s why my recent work has focused on new methods such as having women generate, rank, and prioritize the research questions that matter most to them — this has allowed funders and researchers to hear from women at high social and medical risk for preterm birth to determine what their priorities for care are. We need to start partnering with patients to meet their social and clinical needs — particularly for women who have complex needs such as the coordination of specialists and specialty care. More importantly, we need to build a health care delivery system that keeps the needs of black and poor women front and center. Ultimately ensuring these women receive high quality, culturally relevant care throughout their reproductive lives should improve birth outcomes and help curb the shameful disparity that now exists.

Monica McLemore is an assistant professor in the Family Health Care Nursing Department at the University of California, San Francisco.