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EDITORIAL

To save mothers’ lives, reduce racism in obstetrical care

Racial disparities in maternal health are trending in the wrong direction.

A doctor used a hand-held Doppler probe on a pregnant woman to measure the heartbeat of the fetus in 2021, in Jackson, Miss. Long-term, it will be important to diversify the workforce — including hospital boards and C-suites — by recruiting and training professionals who can relate ethnically, culturally, and linguistically to their patients.Rogelio V. Solis/Associated Press

Nneka Hall gave birth on her 37th birthday. But instead of looking forward to years of shared celebrations, Hall mourned the loss of her stillborn daughter.

Hall says she raised concerns with her obstetrician during pregnancy, but her doctor did not take her seriously. Since then, Hall has made a career out of advocating for improved maternal health care for Black women. “I wouldn’t be doing this work if my daughter hadn’t died,” Hall said.

Black women like Hall have long reported that their pregnancy concerns are ignored by providers. That is one reason why the statistics about women’s health during childbirth — in particular Black women’s health — released this month in a report by the Massachusetts Department of Public Health were devastating and disheartening but unsurprising.

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For every 10,000 women who delivered babies in 2020 in Massachusetts, 100 women experienced unexpected complications in labor or delivery that had significant consequences to the woman’s health, nearly double the rate reported in 2010. Between 2011 and 2020, Black women were 2.3 times more likely than white women to experience severe maternal morbidity, with 146 complications per 10,000 deliveries, compared to 63 among white women. Racial disparities increased over that time, and differences persisted when controlling for age and weight.

Disparities are not new. The Department of Public Health reported that between 1998 and 2019, Black women were 1.9 times more likely than white women to die during pregnancy or within one year postpartum, and national figures are worse.

As Dr. Hafsatou Diop, director of DPH’s Division of Maternal and Child Health Research and Analysis, said, “It has been long recognized that racism — not race — is the risk factor, as it leads to discriminatory beliefs and behaviors toward Black non-Hispanic birthing people.”

The problem is multifaceted and solutions will be too. But two clear needs are to directly address racism in obstetrical care and to expand affordable access to different types of care providers, particularly doulas.

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The Legislature formed a Commission on Racial Inequities in Maternal Health, which released a 74-page report in May 2022. The report cited recent studies that identified racial bias in health care — for example, medical students agreeing with false statements like Black skin is thicker than white skin, a belief correlated with assumptions about pain tolerance.

Charles Anderson, president and CEO of the Dimock Center, a Roxbury health center, said providing quality care involves connecting with patients in ways they understand and building trust. “People come into an interaction with their own set of biases, misconceptions, preconceptions. It often influences the way they deliver information and more importantly how they hear information,” Anderson said. “It might be an assumption based on what that person might think the family structure is like. It could be based on inability to see them the same way you’d see someone who reminds you of your sister or aunt or mother or grandmother.”

The report stressed the need for antibias training for clinicians. That should be paired with concrete tools to minimize bias — including the use of a Centers for Disease Control and Prevention tool to evaluate risk and match women with appropriate care, and the distribution of materials that educate patients about pregnancy and care. Providers also have to recognize that tools like screenings may have been developed with white people in mind, and they need to make sure they are using culturally competent checklists to ask women about their health. For example, questions intended to measure stress during pregnancy might fail to ask about discrimination.

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Ndidiamaka Amutah-Onukagha, director of the Center for Black Mental Health and Reproductive Justice at Tufts University School of Medicine, supports wider use of maternal health “safety bundles,” medical protocols that define, for example, what constitutes a hemorrhage and how to treat it. Amutah-Onukagha said the problem is not that providers don’t know what to do but that they don’t do the same thing for everybody. Having protocols, she said, “reduces the likelihood of subjectivity and bias and racism that leads to delays in treatment.”

Long-term, it will be important to diversify the workforce — including hospital boards and C-suites — by recruiting and training professionals who can relate ethnically, culturally, and linguistically to their patients. But meanwhile, there are solutions.

For example, Baystate Medical Center, Brigham and Women’s Hospital, and Boston Medical Center are piloting remote blood pressure monitoring for women at risk of hypertensive disorders. Dr. Christina Yarrington, division chief of maternal fetal medicine at Boston Medical Center, said the hospital started the initiative after it realized in 2021 that the biggest racial differences in pregnancy outcomes at BMC were around women with high blood pressure-related complications. Now, all women who meet certain criteria are offered a blood pressure cuff with a device that sends measurements to a nurse, who can catch problems early. So far, the program has corresponded with a decrease in Black women’s hospital readmissions for high blood pressure.

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Another needed improvement is in access to doulas, who provide nonmedical support during childbirth.

Doulas are associated with reduced rates of complications and fewer medical interventions. But, except for a few hospital-based programs, doulas generally cost $800 to $2,000 and are not covered by insurance.

MassHealth is exploring reimbursing for doula support. Lawmakers are considering a bill requiring MassHealth to cover doulas while creating a fund for workforce development and a framework through which doulas can advise DPH. This should be paired with efforts to standardize their credentialing and training. State standards could help clients understand a doula’s qualifications and enable broader insurance coverage.

This initiative isn’t simple. Lorenza Holt, who coleads the Massachusetts Doula Coalition, said there is a need to ensure doulas are adequately compensated by MassHealth and money is available to professionalize the industry — for training doulas, helping them form business cooperatives, and helping them meet certification standards. “Everyone wants to improve birth outcomes, everyone agrees things are dismal, nobody wants to pay what it’s actually going to cost,” Holt said.

Licensing certified professional midwives and making it easier to open freestanding birth centers would also expand care options.

There is no silver bullet, and there are myriad other ideas worth examining — ensuring insurance adequately covers maternal care, experimenting with postpartum medical home visits, expanding authority of the state’s Maternal Mortality and Morbidity Review Committee, and creating a fetal and infant mortality review board.

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With the numbers trending in the wrong direction, policy makers and medical professionals must focus on solving the problem.


Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.