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NEMA / Uncategorized  / Protecting Your Birth: A Guide For Black Mothers

Protecting Your Birth: A Guide For Black Mothers


The data is heartbreakingly clear: Black women in America have more than a three times higher risk of death related to pregnancy and childbirth than their white peers. This is regardless of factors like higher education and financial means, and for women over 30, the risk is as much as five times higher.

While the recent national dialogue created in response to the data has been a critical leap forward, it has also brought up a lot of fear and questions from Black women about how we can prevent these outcomes.

Last year, we sought out resources to help Black women navigate their prenatal and postpartum care in light of this knowledge, but came up empty when looking for a resource that explicitly called out encountering racism during this time and how to tackle it.

As a result, we partnered to create an education guide that would offer pregnant Black women agency when planning their care (which, in most cases, would be with white care providers). We felt it required an allied, intersectional perspective that acknowledged the importance of care providers and health educators working together on behalf of patients.

We aimed to have a discussion with medical racism and antiracism at the center, especially since increasing evidence points to the effects of structural racism as the reason for this mortality inequity. Medical racism is present whenever health care professionals or institutions alter the diagnostic or therapeutic care provided because of a patient’s race, particularly if the decision puts the patient at an increased risk of poor outcomes.

We wanted to inform Black women of the unique risks they could encounter during their pregnancy, birth and the postpartum period, as well as what they could do to prepare for them. This guide is meant to help Black women feel safer, and to provide a modern framework for medical providers to actively address their own racism.

Here’s what you need to know:

Step 1: Acknowledge Race and Racism In The Room

Discussions of race can bring up anxiety for all involved, but addressing it is a necessary step toward creating safety and combating implicit bias. Implicit bias means our subconscious associations based on characteristics such as race, ethnicity, age and appearance. Social psychologist and prejudice expert Patricia Devine has likened this bias to a habit, and like with any habit, becoming aware of it and being motivated to change are important first steps.

For Pregnant Black Women

If you feel comfortable, you can share your fears through the lens of statistics about race and its impact on maternal care with your care provider. The following sample language could help: “I recently read that Black women like me have a much higher chance of death related to pregnancy and childbirth than white women. That’s really scary. What do you think about these statistics, and how we can work together to prevent that from happening?”

For Care Providers

Ob-Gyns, midwives, nurses and medical assistants must actively work to check their own implicit bias (check out Project Implicit) by learning about the oppressive history of Black women’s health and using strategies to actively combat stereotypes. Care providers must acknowledge that not only do we treat people differently based on race, but that this distinction affects their risks and experiences of care.

Care providers must also cultivate the mental habit of focusing on the things that make people individuals. One strategy: Take a “camera lens” approach to separate what we are seeing (for example, a reproductive-aged woman with a toddler) and what we are interpreting (a single mother), so that we do not place a negative value judgment on the patient. Another strategy: mentally change the race/ethnicity of your patient, then challenge yourself to see if you would do or recommend anything differently.

Step 2: Create a Care Plan Anticipating That Racism May Impact Pregnancy

Research suggests that people who experience systemic racism may internalize this into physical manifestations, including higher blood pressure (hypertension) and higher rates of heart disease.

57 percent of Black women have hypertension compared with 37 percent of white women. This difference persists in pregnancy, when Black women have higher rates of hypertension and heart disease, as well as more severe disease, regardless of education level, socioeconomic status or where they live.

Pre-eclampsia is a high blood pressure-related disease that only occurs in pregnancy, and can lead to organ damage and seizures (called Eclampsia) if not treated. In fact, the leading causes of maternal death among Black women are heart disease-related complications, which can include high blood pressure and pre-eclampsia. This has been unchanged over time, and persists in all age groups and socioeconomic levels.

Approximately 1 in 6 Black women in America will have a preterm delivery which increases risks to newborns, as nearly two-thirds of all newborn deaths to Black women can be attributed to prematurity. Women with a history of preterm birth are more likely to have another preterm delivery. If you’ve had a preterm birth before, talk to your care provider about what monitoring and treatment may be appropriate for you.

New recommendations from the American College of Obstetricians and Gynecologists suggest that women with risk factors should have additional cardiovascular screening prepregnancy and during pregnancy, as well as close follow-up (within 7-10 days postpartum) with a cardiologist or primary care provider in addition to an obstetric care provider.

For Pregnant Black Women

  • Do whatever you need to do to feel safe and supported. For appointments, bringing a support person or hiring a birth doula to accompany you can bring a sense of community to the experience, and provide you with someone knowledgeable to reflect with afterward.

  • Mental health support through connecting with a therapist or faith leader, as well as physical support through acupuncture, massage or regular low-impact exercise like walking and yoga, can also help to alleviate daily stress.

  • Have your blood pressure regularly monitored before, during and after pregnancy. The first few weeks following delivery are particularly important as up to 65 percent of maternal deaths from high blood pressure, including pre-eclampsia, occur 10-426 days postpartum. The following sample language could help: “I know that Black women like me are more likely to have problems related to blood pressure in pregnancy. How are we going to monitor my blood pressure so that I am safe?”

  • Be aware of the symptoms of heart and blood pressure problems in pregnancy. Report to your provider if you experience any of the following: severe headache, vision changes, shortness of breath, asthma not responsive to your usual medications, more difficulty breathing when you lay down flat, heart palpitations, chest pain or increased swelling, particularly in the hands, face and feet. These symptoms could also be signs of pre-eclampsia, which affects up to 15 percent of pregnancies worldwide. When Black women have pre-eclampsia, it often presents earlier and is more likely to be more severe than with white women.

For Care Providers

  • Consider that coping with both systemic racism and sexism is a risk factor for your patient — if not formally, at least in how you support and manage their care.

  • Acknowledge that Black women have higher rates of hypertensive disease in pregnancy, and monitor their blood pressure more closely during and in the weeks after pregnancy, the same way you would anyone with additional risk factors.

  • Learn about the benefits of doulas and support systems, particularly for Black women, and encourage your practice to support connecting patients to doulas.

  • Consider consultation with maternal-fetal medicine or cardiology providers for any abnormal results or persistent symptoms

Step 3: Identify How Racism May Impact Labor

Many studies have demonstrated that medical professionals have perceived Black people as having higher pain tolerances, leading to disparities in pain management that cannot be explained by perceived lesser pain. This is one of the many ways that the history of slavery impacts the treatment that laboring mothers receive. It is important for patients and providers to be aware of and actively combat these assumptions.

With your support team and provider, think through pain options you might want ahead of your delivery. Ask what you should do if you feel that your pain is being inadequately treated. The following sample language could help: “I know that research has shown that Black women are more likely to have their pain under-treated. I am worried about being in pain and not receiving appropriate treatment. How can we make sure that doesn’t happen?”

Non-Hispanic Black women have higher rates of primary (first-time) cesarean delivery. While it is not completely clear why this is happening, one thing you can do is ask about primary cesarean delivery rates at your hospital and with your care provider team.

For Pregnant Black Women

  • Take a birthing class to learn about the basics of labor and delivery, and what options are available to you.

  • Talk to your doctor about why she would advise you to have a cesarean birth and how it would be performed. The following sample language could help: “I am concerned about data showing that Black women like me have higher rates of cesarean delivery. What is your cesarean delivery rate, and why would you advise me to have one?”

  • Create a birth preferences document, and work with your support team to help you decide what options might be best for you.

For Care Providers

  • Acknowledge that research has shown that the medical profession still under-treats pain in Black patients, particularly Black women. Overcompensate for this fact by making sure you are paying particular attention to this topic in prenatal care and laboring patients.

  • If you are involved in research, examine ways in which racial biases can be accounted for or at least acknowledged in your data collection and analysis.

Step 4: Identify How Racism May Impact Postpartum

The postpartum period is critically important and often overlooked. Up to 45 percent of maternal deaths happen in the weeks after delivery, a time where people are generally more removed from medical care and their regular support systems. Also, those affected often don’t have insurance coverage. In the United States, the postpartum time period is commonly thought of as the six weeks after delivery due to insurance coverage changes at that time. However — medically and physiologically — it is at least the entire year after birth, as this is how long the physical changes of pregnancy persist.

As of 2018, The American College of Obstetricians and Gynecologists (ACOG) recommends that women see their providers within three weeks of delivery. Women who have had more complicated pregnancies, including problems with blood pressure like pre-eclampsia, should be seen within a week of delivery, ideally a few days after leaving the hospital, for a check-in that includes a blood-pressure evaluation.

For Pregnant Black Women

  • Create a “Postpartum Preferences Plan” (resources like “Nurture,” “The Fourth Trimester” and “The First Forty Days” can help). Similar to birth preferences, a postpartum plan should include discussions of support teams, preferences (for example, do you want to breastfeed on demand overnight or have someone help with nighttime feedings) and planned check-ins with your care provider.

  • Ask questions about how you can best prepare for your postpartum experience. The following sample language could help: “I know that many of the scary things that happen in pregnancy, particularly to Black women, happen after delivery. I want to be as prepared as possible for postpartum recovery. Can we make a plan to keep me safe and healthy during my postpartum care?”

For Care Providers

  • Help all your patients create a “postpartum preferences plan,” either using the resources above or by tailoring your own for your practice.

  • Change your practice so that all patients are seen sooner in the postpartum period. ACOG now recommends that everyone be seen before three weeks postpartum.

  • Pregnancy-induced hypertension is a risk factor for cardiovascular disease. Follow new guidelines suggesting that women with a history of gestational hypertension or pre-eclampsia meet with a cardiologist or primary care physician within two weeks of delivery, for continued cardiac evaluation.

New ACOG guidelines suggest that all women with cardiovascular risk factors should meet with a cardiologist or primary care physician for a screening exam within three months of delivery. This includes Black women who had gestational hypertension or pre-eclampsia.

To lessen the burden and build the groundwork for Black women around these difficult conversations, we have created a list of antiracist prenatal and postnatal care preferences, which you can print out and share with your Ob-Gyn or midwife.

By Erica Chidi and Erica P. Cahill, M.D.

  • Oct. 22, 2020