COMMENTARY

'I'm Confident': Solutions to Reduce Maternal Health Disparities

Monique A. Rainford, MD

Disclosures

September 04, 2020

Monique A. Rainford, MD

I was enamored with a certain Bible passage early in my teenage years. I had drawn on it for a successful debate I participated in at the time, and it has stuck with me:

What good is it, my brothers, if someone says he has faith but does not have works? Can that faith save him? If a brother or sister is poorly clothed and lacking in daily food, and one of you says to them, "Go in peace, be warmed and filled," without giving them the things needed for the body, what good is that? So also faith by itself, if it does not have works, is dead.

–James 2:14-26 (English Standard Version)

I think about this passage often, especially when I reflect on all the work that must be done to address racial inequities in the United States, particularly those that lead to the health disparities affecting Black women. Those health disparities read like a laundry list: a higher pregnancy-related morbidity and mortality rate, higher infant mortality rate, shorter life expectancy, and higher rates of obesity, diabetes, cardiovascular disease, cervical cancer, and breast cancer.

Add to that list the disparities apparent in the COVID-19 pandemic, which has also disproportionally affected Black pregnant women.

It has been well established that these disparities have little to do with genetic variations between White and Black people in America. The question is, if we really want to eliminate these disparities, what would that look like? Can it even be done?

I firmly believe that the answer is yes. It won't happen overnight, but I believe that it can be done in a finite period of time. It will require genuine commitment and investment of both human and monetary resources.

Solutions will need to target different issues individually, but we probably would see some overlapping benefits. We don't need to reinvent the wheel but rather intensify the support of proven strategies and interventions.

Successful Approaches

Let's start with "The JJ Way." I first learned about this approach in 2017 when I heard the brilliant TED talk by writer Miriam Zoila Pérez. The program is named after Jenny Joseph, who founded the Florida clinic Birth Place. Her organization has made considerable strides in reducing disparities and improving outcomes by focusing on prenatal bonding through "respect, support, education, encouragement and empowerment."

Group prenatal care also has shown some promise. It is associated with increased patient satisfaction, higher breastfeeding initiation rates, improved knowledge, and lower preterm birth weight, particularly for Black women.

Doulas have also demonstrated a positive impact on birth outcomes. Doula-assisted mothers were four times less likely to have a low-birthweight baby, two times less likely to experience a birth complication, and significantly more likely to initiate breastfeeding.

Common threads for these three approaches include a supportive environment with strong social support and education.

Addressing Biases

Another issue that needs to be addressed is clinicians' implicit bias — when someone believes that they are not racist but exhibits some discriminatory behaviors and language. Training on implicit bias can't be restricted to checking a box after watching a 30-minute video. Clinicians should be challenged to take a test for implicit bias such as the one developed by Harvard. All should be given access to effective interactive training.

Additional resources will be required to reduce disparities, which may prompt some skeptics to ask whether it's fair to allocate more resources to the care of Black pregnant women than to others. But think about how America allocates resources now. A premature baby of any ethnicity needs significantly more expensive care than a full-term baby. There is no argument about the fair allocation of resources in that situation.

How about food? In my experience, women tend to be highly motivated to improve their health habits while pregnant. But if they live in a food desert, how can they get healthy food? Organizations such as Hungry Harvest or Feeding America potentially could provide fresh food.

How about housing? A few years ago, I cared for a hospitalized pregnant Black woman who was told to stop work as a driver because of her seizure. She was distraught about stopping work, and her nurse was somewhat critical of her apparent lack of concern for the unborn baby. I went into the room and had a discussion with her to better understand the barriers. She explained that if she didn't work, she would lose the housing she fought long and hard to obtain.

Housing and childcare support needs to be available for disadvantaged pregnant women, who are disproportionately Black. This should extend at least through the baby's first year of life, and new mothers should be offered education, job training, and placement.

There are substantial data to show that such investments yield high outcomes.

I am confident that these investments will produce benefits that far exceed the long-term cost, possibly even in the short term by reducing indices such as preterm birth and morbidity. Moreover, America can move closer to its ideal of equality by ensuring health equity for all of its citizens.

Monique Rainford, MD, is chief of obstetrics and gynecology at Yale Health in New Haven, Connecticut. She is also the author of the book Please God, Send Me a Husband. Follow her on Twitter

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