Why do so many Black women die of pregnancy-related complications?

Women in the United States die during pregnancy, childbirth and in the year that follows at a higher rate than in any other industrialized nation, and the crisis is especially acute for Black women. They are nearly three times more likely to die in childbirth than white women and have twice the rate of preterm birth and low birth weight. The statistics are bleak even for affluent, highly educated Black women: a college-educated Black woman has a greater chance of suffering complications or dying in childbirth or soon after than an 8th grade-educated white woman.

It is commonly assumed that “if you're educated, you're generally just going to do better all along the life spectrum, but it's not working for Black people,” said Roni Cary Rabin, an award-winning New York Times health writer who spoke on a recent panel at the USC 2023 National Fellowship in Los Angeles. Joining her was Karen Sheffield-Abdullah, a longtime certified nurse midwife and an assistant professor at the University of North Carolina School of Nursing. The Center’s manager of projects, Jacqueline Stinson, moderated the conversation.

Rabin, who wrote a series of articles on maternal health in the U.S., presented a graph showing maternal mortality rates declined through most of the 20th century, reaching their lowest point in 1990. Since then, the rate has increased across all groups and the racial gap, which always existed, has widened. 

Rabin noted that most maternal deaths don’t occur in childbirth but during the year that follows due to health problems that developed or worsened during pregnancy. While mental health, suicides and overdoses are the leading causes of maternal death in the U.S. overall, for Black women it is the development of cardiovascular problems. She said, “If you're already coming into [pregnancy] with strain on your body, with hypertension, with the strains of poverty or discrimination, that strain is much greater for someone who's got those problems, then they're more likely to progress and start exhibiting cardiovascular problems faster.”

A 2021 study in California revealed that Black immigrants have better birth outcomes than U.S.-born Black women. “There is something about the lived experience here in the United States for Black women that causes us to have the outcomes that we have.” Sheffield-Abdullah said. 

She explained the “superwoman schema,” developed by her mentor and colleague, Dr. Cheryl L. Wood’s Giscombé — the lens through which Sheffield-Abdullah views her research. Sociocultural and historical events in the U.S. have led many Black women to develop five hallmark characteristics: “emotional suppression, determination to succeed despite limited resources, maintaining a stoic exterior, resistance to being vulnerable and a caregiver role,” she said.

Sheffield-Abdullah takes these factors into account when she observes stress and anxiety in a Black woman around the time she gives birth. She asks: “What is stress for you? How do you define stress? Is there anything uniquely stressful about being pregnant? Is there anything uniquely stressful about being Black and pregnant?” Through her line of questioning, she seeks to create safe spaces for people to talk about their mental health and examine factors that may threaten it and, in turn, their maternal health.

Oftentimes patients say: “I'm just happy to be alive.” She finds this telling. “That's the bar — just living.”

Both panelists said that Black mothers and pregnant women consistently say doctors don’t listen to them. Whether they report pain or bad reactions to medication, they often aren’t taken seriously, or they are ignored. An analysis of physicians’ medical records confirms disparate treatment depending on race, Rabin said. Doctors were more likely to dominate the conversation with a Black patient instead of listening. Some research has shown doctor visits were shorter for Black patients than for white patients.

Rabin expressed the need to examine the mechanisms driving such dynamics.. “Where does that communication break down, how does that bias get placed, how can you train doctors or modify their behavior or get them to think about it in a way that is going to be helpful in practice?” she said.

For Sheffield-Abdullah, it is imperative to go beyond the numbers to find answers. Many Black individuals she spoke to hesitate to discuss their anxiety or psychological distress with their health care providers for fear of what the response might be: a call to Child Protective Services, mediocre care, undesired interventions, or callous dismissal.

Rabin observed similar experiences by mothers with infants in neonatal intensive care units. When one woman asked a nurse if there was a support group for mothers like her, the nurse did not offer suggestions but said she’d have to report that the mother requested that kind of information. 

Sheffield-Abdullah and Rabin suggested ways to improve maternal health and birth outcomes for Black individuals, other communities of color experiencing high rates of death and complications, and rural residents. Among the recommendations: training doctors to take the time to listen to their patients, utilizing new tests to identify potential pregnancy complications (such as preeclampsia), demedicalizing pregnancy and childbirth by turning to nurse midwives if the patient is low risk, providing blood-pressure cuffs to new mothers to monitor their hypertension, and providing better maternal health education to mothers when they leave the hospital. Sheffield-Abdullah also emphasized the need for diverse health care professionals and, for higher-risk patients, collaborative, holistic care by a team of physicians, social workers and mental health professionals.