Improving Black maternal outcomes is at the heart of a Montgomery County, Maryland, program aimed at working with expectant mothers from their pregnancy.
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The maternal mortality rate for Black women was three times higher than the rate for white women, according to the most recent data from the National Center for Health Statistics.
A report from the center last year examined maternal mortality rates from 2023 and found the rate for Black women was 50.3 per 100,000 live births, which is also far higher than the rate for Hispanic women (12.4 per 100,000 live births) and Asian women (10.7 per 100,000 live births).
The data was published by the Centers for Disease Control and Prevention.
Montgomery County Health Officer Dr. Kisha Davis said the elevated frequency of negative outcomes for Black women is rooted in inequities related to health care access.
“So access to being able to find a doctor, having insurance coverage, differences in insurance coverage and private insurance versus Medicaid versus having no insurance,” Davis said.
She added that social factors, such as housing stability, transportation and economic opportunities, also play a role.
“Even when we control for those individual factors, like income and education, Black women still see worse outcomes. And so what this tells us is that this isn’t an individual problem, it’s a systemic one,” Davis said.
She said the data should prompt questions within the community of medical providers.
“We need to be thinking about, ‘How are we supporting women through their pregnancy? How are we making sure that they have access to the specialized medical care that they need? How are we making sure that they have access to insurance and doctors, and where those doctors are located?’” Davis said.
Doctors studying Black maternal health pay attention to something called severe maternal morbidity, Davis said, which includes precursor events that signal a worse health outcome.
“So those are things like cesarean birth, preterm birth, low birth weight, fetal mortality and infant mortality,” she said.
Existing health conditions can necessitate cesarean section deliveries, and Davis said that’s one reason expectant mothers need to have conversations with their health care providers about what to expect during birth and delivery.
Knowing what to expect ahead of time, and knowing what to expect in the event of complications, “can really help to bring some of that tension down,” Davis said.
“Everybody wants a one-stop solution. And I think the challenge with maternal health work is that there’s not really a one-stop solution,” she said.
Instead, Davis said a holistic approach is needed.
“It’s not just the OB department’s problem to solve. It’s the emergency department’s problem. It’s the outpatient prenatal department’s problem. It’s the people who are in the hall, running the code. Everybody has a piece of this issue,” she said.
Davis said Montgomery County has several programs directed at serving Black mothers, including Starting More Infants Living Equally healthy, or SMILE.
“I remind new moms that it’s OK to not be OK,” Davis said. “There’s a community and village that wants to stand up and support you. But sometimes we have to ask, and sometimes that can be the hardest part.”
One provider’s experience with childbirth
Nina Ashford is the chief of public health services for Montgomery County’s Department of Health and Human Services.
She credited her health care provider for addressing challenges that arose during and after pregnancy.
“I had a provider who listened to me, who heard me, who was actually integral in being able to diagnose and really advocate for me and getting me the care that I needed for postpartum depression,” Ashford said.
When it comes to mental health issues associated with pregnancy, the statistics again show a disparity in how they affect Black women.
“We know that Black women are twice as likely to get diagnosed with a perinatal mood and anxiety disorder, but they’re only 50% as likely to get care and treatment,” Ashford said.
Having a provider who listened to her and acted on her concerns, Ashford said, was critical, especially when she had her second child. Her first son was delivered by C-section, and the plan was to have a vaginal delivery with her second son.
“But my Spidey senses, a week before, were like, ‘I don’t know if that’s the right move,’ so I decided to schedule a C-section.”
Ashford said it was clear to her that her health care provider was concerned that she had changed her mind, since C-sections can result in negative outcomes, but supported Ashford’s decision to have a second C-section.
“And come to find out, I had a ton of scar tissue from my first C-section. And so, if anything had gone wrong, they wouldn’t have been able to get my son out in time,” Ashford said.
“I share all of that to say that I think what really matters is providers that listen to women, and listen to women when women are trusting their instincts, when they’re trusting their guts.”
When it comes to providing health care for Black mothers, Ashford said her message to her peers in the health care field is to acknowledge their patients’ fears. Women are told that becoming a parent and giving birth is a joyful experience.
“And it should be joyful,” she said. “But I don’t know any Black mom that doesn’t know that she is more likely to die than her non-Black friends who might be pregnant at the same time, and just having an upfront conversation about that, acknowledging as a provider that you know this is an issue and you are committed to equitable care … is the advice that I would give to providers.”
Black moms are not alone when it comes to facing societal pressure to uphold childbirth as a picture-perfect and positive process.
“I think this is a universal pressure put on all moms, to be quite honest with you,” Ashford said.
And it’s something that can also contribute to postpartum depression, which Ashford said she experienced.
“When you have a baby, they tell you that the moment they place them in your arms, the skies open and unicorns prance across the clouds and sunshine beams shine down, and then when they place your baby in your arms, and that doesn’t happen, you’re like, ‘What is wrong with me?’” she said.
New moms aren’t wrong for feeling things are hard, Ashford said, adding they should seek help if they have symptoms that might indicate something more is happening.
And for Black moms, Ashford encouraged them to speak up if something seems off.
“As a mom, one of your biggest jobs is the advocacy for your child, and that doesn’t just start once they’re born,” she said. “And so, you’re not just advocating for you. You’re advocating for your child. If something doesn’t feel right, if you don’t understand, ask questions, demand answers.”
An easy way to do that, Ashford said, is to make a list of questions before an upcoming doctor visit so you can get your concerns addressed.
But how do you even know what to ask? Ashford suggested using artificial intelligence — not for medical advice, but to help mothers think through potential issues to bring up with their provider.
“It is helpful to have. I always joke and say ChatGPT is like having a free consultant, but like a free consultant that can help you think through the questions to ask so that you don’t miss anything,” she said.
SMILE: A program designed to address Black maternal health
Iye Kanu, nursing supervisor for Montgomery County’s SMILE program, said the program was designed for Black women who live in the county. It provides care from pregnancy through a child’s first birthday.
SMILE offers free childbirth education classes for expectant mothers at least three times a year, Kanu said. As a result, it sets them up to be able to self-advocate “during a very critical, fragile and important time of their life.”
Among the services provided by SMILE are regular check-ins with nurses, transportation to health care providers and assistance in coordinating referrals, scheduling appointments and with questions around insurance. The assistance continues after delivery, with breastfeeding support and networking and support-group links.
For any patient, getting their questions answered can be challenging. So Kanu said SMILE teaches another acronym: BRAIN, which stands for Benefits, Risks, Alternatives, Instincts and Nothing.
Kanu said the first two letters help moms to understand the benefits and risks in any course of care. They’re also encouraged to ask about alternatives to a given course of action. Paying attention to instincts, Kanu said, allows a patient to ask, “What does your gut tell you?”
Nothing is a question she said that people often don’t consider, she said. But it’s important to ask, “What happens if we do nothing?”
“We teach our moms how to self-advocate,” Kanu said.
Kanu didn’t start off in the area of maternal health, but said she was drawn to it over time.
“It’s just really a very special time and very delicate time in a woman’s life, in a family’s life,” Kanu said. “You really, truly have an opportunity to make an impact.”
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