By Christina Johnson MD, PhD and Judy Banks, MD
As we work to bring the challenges of black maternal health into greater focus this week, we recently listened to stories of several women - African American health care workers who experienced negative outcomes related to their pregnancies.
As clinicians, we can say that while the words change slightly, we’ve heard these stories many times. Too many times.
“Each time I saw a doctor with these complaints, the response was ‘oh, it's nothing’. The look that they would give me was as if I was crazy … It took about three days from the time I first called with the complaints of headache and elevated blood pressure for me to be admitted to the hospital for treatment.” – Patient 1
“Then I started swelling. Even my eyelids had swollen. I remember calling the doctor, and pleading ‘this is not normal, this is not me! … The nurse gave me her cell phone number and told me to take a picture of her of my feet and send it to her. I thought that it would definitely help me to be seen. She texted back and said it was normal.” – Patient 2
“I explained to the on-call doctor that I was 20 weeks, I wasn’t feeling right, and I was seeing floaters. I said I had preeclampsia before so I kind of know what it's like. His response came across as arrogant – he seemed annoyed. He said ‘you're only 20 weeks and it can't be happening in your 2nd trimester. If you want, you can go to the emergency room.’ I felt dismissed.” – Patient 3
These are not the kinds of memories that women and families are supposed to have of pregnancy. Unfortunately, in certain populations, specifically African American women, they are all too common. Rather than being a special time for women and their families, many of these stories involve uncertain or even deadly outcomes.
The gap between health outcomes for pregnant African American women has widened. African American women are 3.5 times more likely to die from pregnancy or birth complications than non-Hispanic white women. Heart diseases and blood pressure disorders like cardiomyopathy and preeclampsia were the leading causes of death in African American women – a rate 5 times that seen among white women. In addition, during and after pregnancy, African American women are 2-3 times more likely to die of severe bleeding (hemorrhage) or blood clots (embolisms) than white women.
We need to close this gap.
Know the Signs and Symptoms
Most pregnancy related deaths are due to heart disease, bleeding, and blood clots. It is important that pregnant women know the symptoms associated with each of these. Before pregnancy, patients should inform their doctors about high blood pressure and diabetes, and work with their physicians to get these well controlled.
- leg or facial swelling
- nausea and vomiting
- abdominal cramping
- vaginal bleeding
- lightheadedness or dizziness
- chest pain
- trouble breathing
- severe fatigue
Another important cause of pregnancy related death and poor outcomes is mental health disorders. Before, during and after pregnancy, women should see their doctors if they feel sadness, or if they lack interest in or feel as if they want to hurt themselves or their newborns.
The Doctor-Patient Relationship
First and foremost, patients should find a trusted clinician with whom they can establish a partnership. While the obstetrician is the first point of contact for a woman during pregnancy, gynecologists, family medicine and internal medicine doctors all treat adults and may see women before, during and after their pregnancies. These clinicians are trained to help in medical emergencies and to recognize alarm signs for pregnancy-related complications.
This trust is crucial. It’s what will make the difference when a pregnant woman gets the headache that won’t go away, or the swelling that seems abnormal, or simply when a woman needs to know her concerns are being heard.
Physicians and other clinicians, like the rest of the population, may have attitudes, beliefs and behaviors which negatively influence their interactions with patients even if the clinician is not aware of acting on these beliefs. These beliefs are called implicit biases. Biases about patients based on their age, gender, socioeconomic status, race and ethnicity may impact communication and lead to differences in treatment decisions.
For example, there are false beliefs about pain tolerance relating to pregnant Black and Hispanic patients. First perpetuated in the antebellum south, the belief that African Americans were intolerant to pain led to differences in availability of curative medications, treatments for common illnesses and justified physical violence. To this day, this carries over into medicine, with less use of epidural anesthesia for African American and Hispanic women during delivery, as well as more cesarian births, which are associated with more birth complications.
These disparate outcomes for racial and ethnic groups can be linked to our shared history of systemic racism. Access to jobs, quality education, healthy neighborhoods and quality health care were historically governed by race. African American, Native American, and Hispanic/Latinx communities were explicitly disadvantaged through laws and societal structures like segregated neighborhoods and hospitals. Today, these inequities have contributed to persistent differences in outcomes for pregnant women along those same racial lines, as well as the unequal outcomes seen in chronic diseases like diabetes and heart disease, as well as infant mortality and certain cancers.
As clinicians, we need to take a more mindful look at the way health care is delivered. Clinicians at every level need to investigate their patient outcomes to determine, what, if any disparities exist in how they are treated, and their communication with the patient. If any differences are found, it is important to address these outcomes and uproot what may be biased behavior.
Together, we can improve black maternal health outcomes.
Don’t just look – see me.
Don’t just listen – hear me.
- Marian F. MacDorman, Marie Thoma, Eugene Declcerq, Elizabeth A. Howell, “Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017”, American Journal of Public Health 111, no. 9 (September 1, 2021): pp. 1673-1681. PMID: 34383557
- Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022.
- Saluja B, Bryant Z. How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States. Journal of Women's Health (Larchmt). 2021;30(2):270-273. doi:10.1089/jwh.2020.8874
- Addressing Inequities in Cardiovascular Disease and Maternal Health in Black Women
- Enhancing Reviews and Surveillance to Eliminate Maternal Mortality