The recent intense media focus on high rates of maternal mortality in the U.S.—especially for African-American women—has been a mixed blessing. It has raised much-needed awareness about the rising rates of maternal deaths and disability happening during pregnancy, birth and postpartum. Yet those startling statistics have added more stress and burden on women who absorb this “new news” and are left feeling disempowered, frightened and at the mercy of our struggling maternity care system.
Millions of dollars are spent annually on maternity care alone, and there is deep dysfunction within a system dedicated to maintaining the corporate bottom line. This creates a conundrum on many fronts, as evidenced by our abysmal maternal and infant mortality rates. Particularly egregious are the vast disparities between African-American and Native-American women when compared to their white counterparts. Currently, three to four times as many black women die or “nearly die” during pregnancy, birth or postpartum. African American college-educated women, including those with supposed good insurance, are more at risk of a poor outcome than a white high-school dropout. This illustrates the impact of racism when personal and/or institutional biases factor into the quality and safety of health care delivery.
In my work as a midwife and women’s health advocate for the last four decades, I coined the phrase “materno-toxic” as a way to describe the life-threatening impact on mothers living in areas where a lack of equitable investment in business and infrastructure has not happened in decades; where grocery stores and decent housing are scarce; where loans and support for home ownership are non-existent; and where violence and strife prevail.
In the United States today, so many zip codes, both urban and rural, are not conducive to raising families or protecting their health. However, not all materno-toxic zones are geographical or defined by zip code or economics. You could equally be exposed as a black woman living in an affluent area, with a high income and “the best” gynecologist in the area. Where a person lives, works, plays or worships may negatively affect their health, but the social determinants of health also include the effects of racism, classism, sexism and conscious and unconscious biases, perpetrated personally or institutionally to the point of ill health, or even death.
Essentially, mothers can suffer and experience the effects of being in a living, breathing, materno-toxic zone all of their own, based on other people’s response or reaction to their race, socio-economic status, citizenship or by being “othered” while pregnant, delivering their baby or in the postpartum year, regardless of location.
Take someone like Ashley, for instance. She was a young white mother with commercial insurance who was rapidly approaching the last trimester of her second pregnancy. She was “let go” from her obstetrician’s office because she couldn’t produce the $2,000 deductible lump-sum amount required to finish out her prenatal care and delivery with her chosen provider. She was on her own, even as her baby continued to grow and thrive in her uterus, without a referral, without hope of finding any other provider, consigned to head to an emergency room when labor ensued.
Or how about Akila, an African-American substitute teacher with “managed-care Medicaid” insurance, who searched diligently but couldn’t find a provider willing to accept that particular insurance plan. She also had no referral or advice on where to go next. Her continued use of the emergency room due to early pregnancy complications left her frantic, belittled and uninformed as to how to find reassurance about her safety and that of her baby. So, even though her insurance covered her emergency medical bills, she had no access to prenatal care.
Both mothers were blamed for circumstances that are created by our broken maternity system, and even when inside of the purported “safety” of the hospital or clinical setting, judgment and bias, unconscious or otherwise, is condoned and acceptable. Such bias—based on race, socioeconomics, or gender—plays a large role in what decisions are made or procedures performed, or whether mothers are listened to or even afforded the dignity and respect of being human.
On the other hand, recent studies have shown that states that are supportive of and have integrated midwifery care have better birth outcomes. It seems that the historical and deeply embedded systems-wide inequities—racism, classism, sexism—woven into our systems of health and social wellbeing, including the lived-experience of not being white while pregnant or parenting, or living in or being continually exposed to materno-toxic environments, is what has us at this impasse. These are the reasons why we have such disparate treatments, responses and protocols that have been acceptable institutionally, sometimes personally and quite often historically, while evidence-based practices have been mostly ignored, circumvented or implemented erratically at best.
No, we should not blame the mothers, nor can we blame the providers and supporters who are on the front-lines of this crisis. Those looking for solutions must remember how their passion and compassion once drove them to serve in this perinatal arena. We have to consider that it is likely that burnout caused by institutional and structural barriers sometimes creates yet another materno-toxic environment for healthcare workers. We must support the supporters, the men and women taking a stand and saving lives both inside and outside of our medical institutions.
It is imperative that we recognize that community-based and community-led organizations are “the village” that former First Lady Hillary Clinton popularized so many decades ago—in fact, they always have been the safety-net and continue to serve to this day.
Vast numbers of perinatal professionals such as community doulas, childbirth educators, lactation educators, community health workers, home visitors and health navigators are already aware, active and deployed (compensated or not) in materno-toxic zones reaching communities in need with practical and purposeful maternity care, advice, support and education. Their efforts, although extremely effective and essential to building safety into our maternity care systems are not readily embraced, acknowledged, funded or sustained, despite data showing their efforts lead to improved perinatal outcomes.
We must actively support the training and workforce development for culturally sensitive providers and community-based perinatal professionals while building a pipeline to future career paths in midwifery, nursing, medicine and health care administration.
And we must remove the toxicity that may reach or surround a mother or mother/ baby pair so that an American woman’s zip code or her color won’t put her at greater risk of death or disability giving birth in the U.S.A. today.
Jennie Joseph is the Executive Director of her own non-profit corporation, Commonsense Childbirth Inc., and the founder of the National Perinatal Task Force, a grassroots organization whose mission is the elimination of racial disparities in maternal child health in the U.S. A British-trained midwife, Jennie creates access to comprehensive maternity healthcare for all, while fostering safe, respectful, patient-centered care and support for women in areas that she terms “materno-toxic zones.”