African-American women experience the highest maternal death rate, at 2.5 & 3 times their European-American and Hispanic counterparts respectively.
Believe it or not, the death rate in the US for pregnancy-related deaths is the highest among any developed nation. Those nations include western, African, and eastern-European countries. According to the CDC, there’s an average of 700 women who die per year, with nearly 50,000 women being seriously injured from pregnancy-related issues. More than half of those cases are completely preventable (CDC, 2019). The numbers are even more staggering for African-American women. The death rate for a college-educated Black woman is 5x as much as a White woman with no high school diploma.
This health disparity is unlinked to socio-economic status, as Black women with money, education and in good health die at a higher death rate than their White counterparts from lower socio-economic statuses. There are several way to address this problem, but by doing sosial assessment and situational analysis it is clear that social stigma and discrimination is at the root of the issue. Discrimination, though an important risk factor, is not easily addressed through an intervention that will prevent loss of life in the short term. According to Edberg, picking one’s battles includes assessing the rationale behind the intervention. Although a program based on the Risk and Protective Factors Model could be designed to change health worker’s perspectives to prevent further loss of life, based on the history of American attitudes towards race, it would not be a very timely intervention.
Following the PRECEDE-PROCEED model, after social assessment and situational analysis the next step is an epidemiological assessment. The purpose of this assessment is to uncover “The nature and extent of a health problem or problems, patterns and trends, and the affected populations (Edberg, 2015).” An article from The National Partnership for Women and Families outlines the fact that when Black women enter the hospital to give birth, they are already at an increased risk for complications. This is due to a greater likelihood of having fibroids, preeclampsia and physical weathering. These health conditions, if properly assessed and managed during the prenatal period, need not lead to death if women are properly cared for. “Seventy-five percent of Black women give birth at hospitals that serve predominantly Black populations. Black-serving hospitals have higher rates of maternal complications than other hospitals. They also perform worse on 12 of 15 birth outcomes, including elective deliveries, non-elective cesarean births and maternal mortality” (NationalPartnership.org, 2018). This evidences that there should be a 3-fold target of an intervention program: pregnant Black women, Black women seeking to become pregnant, and Black women who present with health risks prior to/during pregnancy. The intervention should address who handles their prenatal and postpartum care.
A behavioral/environmental assessment reveals that not only do pre-existing conditions affect the health outcomes of the women, but the attitudes of the health workers do too. According to the American Medical Association, the “quality of prenatal delivery and postpartum care, as well as interaction between health-seeking behaviors and satisfaction with care may explain part of this difference [between outcomes]” (Flanders-Stepans, 2000). The environment in which the women choose to give birth directly affects their outcomes. The same report by the National Partnership for Women and Families confirms that although the women may go to Black servicing hospitals, the risk spans all income and education levels. This assessment is closely tied to an Educational and Ecological Assessment, as it reveals the attitudes and beliefs of the healthcare workers contribute to the high morbidity and mortality death rate of their Black patients. Therefore, an intervention should address where Black women choose to deliver.
To be successful, the intervention would need to be affordable, as “pregnant women who lack insurance coverage often delay or forgo prenatal care in the first trimester, and inadequate prenatal care is associated with higher rates of maternal mortality” (NationalPartnership.org, 2018). Even those with health insurance coverage tend to receive lower quality reproductive health care or prenatal counseling. This can be attributed to Black women’s attitudes regarding medical professionals. Many women are reluctant to advocate for themselves and do not question their healthcare professionals. Connecting Black women to healthcare professionals that genuinely care about their outcome and the health of their families is paramount to reducing the disparity and number of lives lost.
A realistic intervention program would target Black women, with or without preexisting health issues, who are seeking to become or are currently pregnant. The intervention should address where they receive prenatal and postpartum care, and particularly, where they choose to deliver their babies. An administrative and policy assessment reviews the “ resources available to support the development and implementation of a health promotion program” (Edberg, 2015). Key members of the community who could contribute to the success of preventing further loss of life would be Black doulas and midwives committed to the health of the African-American community. Beginning an initiative that educates Black women about the benefits of working with a midwife could help change the perspective of the profession. Birth outcomes are substantially better for those using a midwife than giving birth at a hospital. Furthermore, midwives connected with an OB also have success with high risk pregnancies, as most nurse-midwives have masters or doctorate degrees in nursing. Nurse-midwives- according to Dr. Kelly Kasper of Indiana University Health, “offer the same standard tests as doctors do” for their patients but also offer quality postnatal care as well (Scanlon, 2016). The benefit of working with a midwife or doula, is that the high-risk pregnant mother will have a well trained advocate at her side, should she choose to give birth at the hospital. For those choosing to deliver at a free-standing birth center, The Department of Health and Human Services requires Medicaid offer coverage for midwife services in all states. This intervention would connect qualified doulas and midwives with pregnant women in their area and provide the resources to pay for their services, in order to improve the health outcome of Black mothers throughout the US, and especially in the cities with the highest mortality rates.
Black Women’s Maternal Health: A Multifaceted Approach to Addressing Persistent and Dire Health Disparities. (2018). The National Partnership for Women and Families. Retrieved on February 20, 2020 from: https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html
Edberg, Mark. (2015). On health and behavior - An Introduction. Essentials of Health Behavior Social and Behavioral Theory in Public Health. (2nd ed). Burlington, MA: Jones & Bartlett Learning, LLC.
Flanders-Stepans M. B. (2000). Alarming racial differences in maternal mortality. The Journal of Perinatal Education, 9(2), 50–51. https://doi.org/10.1624/105812400X87653
Pregnancy Related Deaths. (2019). Centers for Disease Control and Prevention. Retrieved on February 20, 2020 from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm
Scanlon, P. (2016). Is a Midwife Right For You? What They Can—and Can’t Do.. Riley Hospital for Children at Indiana University HealthRetrieved on February 20, 2020 from: https://www.rileychildrens.org/connections/is-a-midwife-right-for-you-what-they-can-and-cant-do
Shahul, S., Tung, A., Minhaj, M., Nizamuddin, J., Wenger, J., Mahmood, E., & Talmor, D. (2015). Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia. Hypertension in Pregnancy, 34(4), 506-515. Retrieved on February 20, 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4782921/