July 14, 2020
July is Maternal Health Awareness Month: Black Mothers Deserve Equity
During the 2020 legislative session, the General Assembly enacted House Joint Resolution 111, which designates July as Maternal Health Awareness Month in Virginia. Creating awareness is an important step toward creating change. The resolution rightly acknowledges that there are significant racial disparities in maternal health and therefore a critical need for new policy solutions. Nationally, Black women are 2.4 times more likely than white women to die during pregnancy or within one year of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. In Virginia, Black women are 1.9 times more likely to die using the same measure than their white counterparts. It is time to build on recent legislative action and make sure that Black mothers have equitable opportunity to survive childbirth.
In June 2019, Gov. Northam ceremoniously signed a bill that codifies the Maternal Mortality Review Team in Virginia, and he also announced a goal to eliminate racial disparities in maternal health by 2025. Subsequently, several initiatives to address maternal mortality were considered during the 2020 legislative session and included in the 2020-2022 budget approved by the General Assembly in March. Funding was included to extend health coverage for women who receive Medicaid up to one year postpartum. Currently, Medicaid for pregnant women ends 60 days after a birth for women whose income is too high to qualify for traditional Medicaid coverage and yet, experts agree that the risks associated with childbirth often extend long after 60 days. The budget bill also included increased Medicaid reimbursement for home visiting services to help new families learn important parenting skills. Evidence suggests that home visiting programs promote healthy birth outcomes, enhance school readiness, prevent child abuse, and improve family self-sufficiency.
In response to the economic impact of the COVID-19 pandemic, these new investments have been paused or “unallotted” until the state budget can be reconsidered during a special session later this year. Thus, implementation of these promising new policies to address disparities in maternal health will depend on lawmakers making an intentional decision to reenact the new funding.
In addition to the new investments, a workgroup was also approved by the legislature and instructed to study and make recommendations regarding the state regulation of doulas and Medicaid reimbursement for doula services. A doula is a trained professional whose role is to provide tailored, patient-centered, non-clinical physical and emotional care to someone who is pregnant before, throughout, and after a pregnancy. Doula care has proven to be beneficial in helping women of color successfully navigate the stress and trauma that systems can often cause.
Those who receive doula care have lower rates of cesarean sections and are less likely to experience low-weight births, and some studies have found lowered risk for postpartum depression. Women with low incomes and from culturally diverse backgrounds have been found to benefit from doula care but have not always had access to or knowledge of these resources. This important workgroup study is set to be completed by December 1, 2020.
Racism & Black maternal health
Black women face a myriad of systemic issues, including racism and sexism, that impact opportunity and daily life. On average, Black women in Virginia typically make 60 cents for every dollar paid to white men. Virginia is 38th in the country for the amount of lost wages experienced by Black women as a result of this significant pay gap. And nationally in 2017, Black women were paid 21% less than white women. This diminished earning potential likely results in Black women needing to make difficult choices between resources like food, housing, and health care in order to support themselves and their family. According to the most recently available data from 2018 – prior to the implementation of Medicaid expansion – Black women aged 19-64 (12.1% uninsured) were less likely to have health insurance than their white counterparts (7.6% uninsured). It is essential that deliberate policy decisions are made to ensure increased and culturally sensitive access to affordable health care for Black women.
Regardless of income level or insurance status, Black women more often experience a lower quality of health care compared to white women. Additionally, the experience of discrimination and the stress associated with it, including while accessing health care, has been proven to lead to poorer health outcomes for mothers and their children during pregnancy. One recent study finds that 32% of Black women said they personally had been discriminated against because of their race when going to a doctor or health clinic, while 22% said they have avoided going to a doctor or seeking health care out of concern they would be racially discriminated against. The experience as well as the fear of discrimination may exacerbate negative health outcomes and create barriers to accessing the timely and regular health care that is critical during and after a pregnancy.
Furthermore, the implicit bias of medical professionals may negatively impact the care received by Black women. A study conducted at the University of Virginia found that half of the white medical students they studied endorsed at least one false belief about Black people being biologically different from white people and that these beliefs were associated with how those medical students assessed and treated pain experienced by Black patients. Those medical students were also likely to report lower pain ratings for the Black patient compared to the white patient experiencing the same medical issue. The students who had those false beliefs were also less accurate in their treatment recommendations for the Black patient compared to the white patient. Importantly, white medical students who did not hold a false belief about Black people did not show the same bias in treatment.
Much of these racist beliefs are passed down through generations. Similarly, Black women carry a history of negative interactions with medical professionals. J. Marion Sims – a pioneer of modern gynecology – made several discoveries by experimenting on enslaved Black women without consent and without the use of anesthesia. Black women across the country and in Virginia also endured decades of forced or coerced sterilization through state programs.
Virginia lawmakers should make it a priority to ensure that medical professionals receive regular and comprehensive implicit bias training, that there is deliberate intent to diversify the medical field, and that medical services are better equipped for diverse populations. This would benefit thousands of Black families and provide an increased opportunity for pregnant Black mothers to receive quality medical treatment.
The critical need for societal and structural change
In addition to re-allocating funding to extend health coverage in Medicaid after pregnancy and expand home visiting services, there exists a need for broader change to reduce maternal mortality and eliminate racial disparities in maternal health. These are some ways in which policymakers can create change:
- Reduce institutionalized racism in medical settings by ensuring facilities in Virginia are educating and hiring more Black medical professionals. In addition, policymakers can mandate regular racial bias education and training focused on patient-centered care within existing curricula and for current clinicians.
- Study the impact of policy on communities of color. Rather than solely focusing on the fiscal impact of a policy, each policy recommendation from the Maternal Mortality Review Team should include a racial impact assessment to determine anticipated impacts to women of color and Black women in particular.
- Establish a state paid family and medical leave program so that people can take extended time off to care for themselves and their loved ones after giving birth, without risking their financial security.
- Address the conditions which impact health. Black women live at the intersection of racism and sexism, and both have a profound impact on daily life. Addressing inequalities in areas such as education, housing, transportation, food access, and working to strengthen opportunities for economic prosperity are crucial for improving health, including maternal health.
During this Maternal Health Awareness Month we recognize that maternal mortality continues to be pervasive in Virginia and that significant racial disparities exist. Black women should have the resources and opportunities to safely survive pregnancy and childbirth, and a number of deliberate policy decisions can be made now and in the future to improve Black women’s maternal health and eradicate the disparity in mortality by 2025.