What we can learn from efforts to address the Black maternal health crisis during COVID-19

The dual pandemic of COVID-19 and structural racism has unleashed an ongoing reckoning over the nation’s failure to address deep-seated racial disparities in health and access to care.

But we have also learned that we are capable of circumventing a system that is inherently inequitable in the face of this dual crisis. For example, prior to COVID-19, the Black maternal health crisis in the United States had been well documented. As the pandemic hit the U.S. this spring, philanthropic organizations such as Tara Health Foundation, Yellow Chair Foundation, Ptizker Family Foundation, the Robert Wood Johnson Foundation and many others have rapidly mobilized to ensure that data on how COVID-19 is affecting pregnant people is both accurate and representative of Black, Indigenous, and people of color. Data from the PRIORITY study will in turn allow us to make evidence-based policy and clinical care decisions that are grounded in the latest facts.

Research has shown strong associations between disrespectful care from health systems and providers and poor reproductive health outcomes. The association between institutionalized and internalized racism and the health of Black women is clear. While it is difficult for many people to recognize that unequal access to resources such as health care is ultimately racist, the Black maternal health crisis makes this abundantly clear. The simplest example of this is the significant reduction in infant mortality observed in states that expanded Medicaid. In 14 of the states that did not expand Medicaid, Black people make up the largest population of those most likely to be eligible. Access to health insurance is known to reduce the burdens of disease and death in all populations, yet policy makers make this an economic argument, not a moral argument.

Fortunately, a new book makes that moral argument seem more urgent and relevant than ever. In “Know Your Price: Valuing Black Lives and Property in America’s Black Cities,” Dr. Andre Perry, a scholar and Brookings fellow, makes the case for investments that close the equity gap for Black people. This is a tall order given the depth and range of racism in this country, but he argues that in order to ensure Black futures, we must invest resources in solutions that affirm Black families and the Black community as assets — not deviations from a white standard.

So, how do we connect the dots? We offer three innovations that could be rapidly adopted to help achieve health equity.

1) Better research: Researchers need to do a better job of testing new interventions to address health disparities. Crucially, such studies need to be focused on the communities that suffer the greatest burden of these disparities. Research studies should also be designed to examine disparities that are not based on assumptions of inferiority due to comparisons to white norms. For instance, when designing studies to evaluate interventions that address maternal morbidity and mortality, a one-size-fits-all approach will not be helpful, especially when risk is not equally shared – Black women are equally at risk for dying from pregnancy related complications regardless of education, income, or other social determinants, but this is not true for other groups. Too often, researchers make assumptions that lay the blame for health disparities on Black people themselves instead of racism. Studies should not shy away from identifying racism as the root cause of health inequities and not race.

2) A more representative worforce: We believe that Black people experience disparities in health outcomes because existing health provider training programs do not do nearly enough to recruit and train a health care workforce that is from the community and that has an understanding of and a commitment to eliminating health disparities. For instance, at present there are far too few Black birthworkers, including nurses, ob-gyns and midwives. According to data from 2015, only 65.6% of the U.S. population is White, however, 83.2% of licensed nurses and 90% of certified nurse midwives are White. While the physician community is more diverse (49% White), only 4% of physicians are Black or African American, 4.4% Hispanic and 0.4% American Indian or Alaskan Native. While 93% of licensed nurses or certified nurse midwives are women, only 34% of physicians are women. In other words, Black people deserve Black health care providers and caregivers who believe that Black Lives Matter – and that is the floor, not the ceiling. Disparities in health outcomes observed in Black people are in part a result of not having providers and health scientists who not only look like them, but who also trust and believe them.

3) Improved coordination: Without a coordinated approach to addressing health disparities, disparities will persist. That’s why the for-profit, nonprofit and government sectors need to coordinate their investments and work if we’re to make progress. This moment has shown us that the government’s ability to provide basic public health infrastructure is woefully inadequate. That’s why now more than ever, we need to harness and amplify community wisdom and resources. For example, we could pair displaced students who are attending school virtually with retired people to further boost COVID-19 contact tracing.

If the efforts to address the Black maternal health crisis during the COVID-19 pandemic teaches us anything, it will certainly be an example of how we can better work together to address the root causes of the crisis. Such efforts have included mutual aid networks that were rapidly set up and deployed, bipartisan legislation for four COVID-19 relief packages after years of partisan gridlock, and crucial innovations in health care, such as finally allowing Medicare and Medicaid pay for telehealth visits. Foundation funders, for-profit health providers, and policymakers should view these rapid innovations in response to COVID-19 as just the beginning of reimagining what equitable and anti-racist health access and health care should look like for Black communities.

Researchers increasingly recognize that the health and well-being of our modern world is tied to the health and wellbeing of women and girls. In the United States, the lack of investment in Black communities and in reproductive justice are an existential threat to that wellbeing. If we are to eliminate Black maternal death and achieve health equity, we need to invest in new approaches to research and care that ensure the momentum from the anti-racist movement is not lost.

Monica McLemore is an associate professor in the Family Health Care Nursing Department at the University of California, San Francisco. Stephanie Bray is the president and CEO of United Way California Capital Region.