Pregnancy and childbirth can be deadly in the United States, especially for people who are Black. The maternal mortality rate in the U.S. is significantly higher than other high-income countries such as the Netherlands, Germany, and Canada. And the problem is growing worse. According to a recent report from the National Center for Health Statistics, the U.S. maternal mortality rate nearly doubled between 2018 and 2021, fueled in part by the pandemic. Mortality rates for Black women were significantly higher than rates for white and Hispanic women. This report and others have found that Black women are two to three times as likely as white women to die of pregnancy-related complications.
Nationally, the top three underlying causes of maternal deaths vary by race:
· Mental health conditions, including deaths due to suicide and overdoses (23% of deaths overall; most common in Hispanic and non-Hispanic white people)
· Excessive bleeding/hemorrhage (14% of deaths overall; most common in Asian people)
· Heart and coronary conditions (13% of deaths overall; most common in Black people)
“According to the CDC, 80% of maternal deaths are preventable,” says Kaitlyn Rabb, a policy analyst at Rhode Island KIDS COUNT and the primary author of its recent issue brief, Racial and Ethnic Disparities in Maternal, Infant, and Young Children’s Health in Rhode Island. When people die from pregnancy-related complications, Rabb says, “it could be due to poor timeliness of care, poor quality of care, or inadequacy of listening to patient’s needs.”
Statistics can be numbing. Stories convey the stakes. In January 2019, a 27-year-old pregnant Black woman, Lashonda Hazard, died at Women & Infants Hospital. According to screen shots of text messages she sent to a friend that were shared on Facebook, Hazard went to the hospital seeking help for severe abdominal pain, but was sent home. Her death a day later sparked outrage online and in the community, and galvanized efforts on multiple fronts to improve maternal care and outcomes for Black women and other birthing people of color in Rhode Island.
There are five birthing hospitals in Rhode Island, but 80% of babies in the state are born at Women & Infants Hospital, according to Joseph Wendelken at the Rhode Island Department of Health. Since coming on board in February 2021 as chief of obstetrics and gynecology at Women & Infants, Dr. Methodius Tuuli has led a multiprong approach to end racial disparities and improve maternal outcomes. “Training, combined with continued vigilance, feedback, and accountability are ways of moving forward,” he says.
Women & Infants now offers hospital-wide training in how to recognize implicit biases, the unconscious stereotypes and prejudices that can affect how patients are treated. “Training alone is not enough to make progress, but it is a beginning,” Tuuli says. “If nothing else, you remove the excuse of ignorance.”
The hospital is also tracking all patient outcomes, complications, and patient experiences, and breaking them down by race and ethnicity. “We have quality meetings where we review where we are with these outcomes,” Tuuli says. “Every year we set targets and then try to improve year over year.”
This involves more than talk.
“Say there was a bad experience in Labor and Delivery. We dig into the incident and give feedback to the provider involved,” Tuuli says. “Sometimes that includes retraining, a warning, or even termination. We have multilevel interventions to hold ourselves accountable.”
In terms of improving outcomes, “maternal mortality is actually the tip of the iceberg,” Tuuli says. “Most of our work focuses on morbidity, the complications that may happen around childbirth. If we are tackling those, we are tackling mortality.”
One example is addressing food insecurity, lack of access to sufficient food, which can adversely affect outcomes. The hospital has partnered with Meals on Wheels of RI and the insurer Point32Health to develop a program to identify pregnant patients with food insecurity to provide nutritionally appropriate meals. “Meals on Wheels delivers meals to the family until we are able to connect them with a more sustaining source of food.”
Another innovative program tackles a leading cause of maternal morbidity and mortality in Black people: postpartum hypertension.
“Blood pressure normally peaks four to five days after delivery,” Tuuli explains. “But at that point our patients are home.” The typical approach is to have patients return to the hospital to get their blood pressure checked or ask them to measure it at home. “But they have a new baby,” Tuuli says. “There may be transportation issues. They may not have the resources to take their blood pressure at home. So we designed a program to tackle these barriers.”
The Hypertension Equity Program is offered to all patients who deliver at Women & Infants and have a diagnosis of blood pressure disorders such as chronic or postpartum hypertension, preeclampsia, HELLP syndrome, or eclampsia. Nurse practitioner Danielle Simmons and bilingual community health educator Maria Mejia Castillo meet with eligible patients to explain how the program works, provide blood pressure monitors, and instruct them on how to take their own blood pressure. Patients are asked to take their blood pressure daily for six weeks and upload their results through an electronic portal or by calling them in.
“If they don’t call, we follow up with them,” Tuuli says. “Based on the results, we decide who needs treatment and who needs continued monitoring. At the end of the program, the patients are connected to primary care, because we know patients who develop high blood pressure during pregnancy are at risk for other complications.” The program launched in November 2022. By early May, the program had enrolled approximately 490 patients.
SISTA Fire, a network of women and nonbinary people of color, has been involved in making these changes and others, such as ensuring that the hospital offers translation services on an opt-out basis rather than an opt-in basis, and that it develops pathways that support increasing the number of staff and providers who are Black, Indigenous, and people of color.
“It’s been a journey through multiple leadership changes at Women & Infants, as well as the Covid-19 crisis,” wrote Ditra Edwards, executive director of SISTA Fire, in an emailed statement. Shannon Sullivan became president and chief operating officer at Women & Infants in June 2020. “The depth of our engagement improved with the leadership of Shannon Sullivan and Dr. Tuuli,” Edwards wrote. “This work continues, and we have received regular updates on their implementation of new practices.”
But Edwards says it’s important to focus on more than one hospital.
“In order to see true reproductive justice in Rhode Island, there needs to be a transformation of our medical systems and our social and economic systems,” Edwards wrote. “We need alternative, community-led solutions to the structural racism that has produced ever-growing debt, a lack of jobs paying a living wage, a lack of safe and affordable housing, and the daily challenges of meeting our most basic needs around food and childcare.”
Rabb at Rhode Island KIDS COUNT agrees.
“Healthcare only impacts about 10 to 20% of your overall health and well-being,” she says. “The other 80% is determined by social determinants of health, such as economic stability, education access, and the neighborhood and environment that you live and work in.”
Encouraging the use of doulas is another focus of advocacy by SISTA Fire and other organizations—among them the Umoja Nia Collective, Our Journ3i, and Doulas of Rhode Island. Doulas are nonclinical trained professionals who provide physical, emotional, and educational support during pregnancy, childbirth, and postpartum. In 2022, Rhode Island became the first state to mandate reimbursement for doula services both by private insurance plans and Medicaid. The law provides up to $1,500 in reimbursement for doula services, including three prenatal and three postpartum visits, and labor and delivery.
Research shows that doulas improve maternal health outcomes and the experience of giving birth. For example, one meta-analysis of 26 randomized controlled trials found that doulas who provided support during labor reduce the rates of cesarean delivery and improved women’s ratings of their birthing experience. An observational study of low-income women (41 percent of them Black) found that mothers who received support from doulas were two times less likely to experience a birth complication. In Medicaid beneficiaries, one study showed that women supported by doulas during labor and childbirth were less likely to have a cesarean delivery, while another showed that the money saved by avoiding cesareans made doula services cost effective.
It’s particularly important for Black women and birthing people to have access to Black doulas, says Latisha Michel, a certified perinatal doula in Rhode Island and mother of six who founded Ready Set Latch Go. “Although we don’t know each other before meeting as doula and client, we have shared experiences. We know what we’re up against when we go into these spaces where we may not be treated equally. We may not be heard. But people know their bodies.”
Michel sees herself as an educator and advocate.
“I want to make sure that the birthing person is heard and is well informed about different options so they can make the best decisions for themselves and their baby, throughout their whole birth process,” she says. That means providing childbirth education and staying with clients from the start of labor until their babies are born. Michel also offers post-partum care, such as help with breastfeeding or bottle feeding.
Michel is one of the coordinators of the Doulas of Color Network at SISTA Fire. “We hold space for emotional support because this work is not easy,” she says. “We provide additional trainings of interest to the doulas. And we skill-share with each other, because doulas have different expertise. It’s just a safe space for doulas of color to do this work in solidarity.”
The Urban Perinatal Education Center offers another safe space.
“Black women aren’t dying because they were born Black,” says Quatia Osorio, a doula and community health worker who is executive director of UPEC. “My race is not a risk factor. What is a risk factor is my treatment and care.” She says it’s time to shift the narrative: “Instead of asking, why are Black women having bad outcomes, the question should be, why are these systems causing these women to have poor outcomes?”
One reason is systemic racism, she says. “Historically, Black and brown people have been told that we are not good parents,” Osorio says. During the “crack baby” hysteria of the 1980s and 1990s, which has since been discredited, “Black women were told they were bad mothers, or not seen as fit.”
And those stereotypes continue today, Osorio says. “Now nurses ask, do you smoke pot? All these inferences about drug use.” That’s why, “in building UPEC, we wanted to remove the bias and judgment.”
Staff at UPEC affirm pregnant women and birthing people rather than disparage them. “We provide culturally matched, congruent care,” Osorio says. UPEC offers classes on pregnancy, postpartum, and newborn care in both English and Spanish. Educators who speak Creole and Portuguese are also available. The organization also runs the statewide hotline to match women and birthing people with doulas.
“We ask a lot of questions when people first approach us about how they want to be served,” Osorio says. “We want to know what we can do to make their birth journey better.”
Although initially UPEC provided services online, the organization moved last year into a permanent location in Pawtucket. The center is open until 9 p.m. several days a week, so that people who work can attend classes and receive services.
“Parenting is hard, and people are vulnerable and scared,” Osorio says. “At UPEC, we believe our role is to make their journey better. That is the type of care we give them. And they flourish.”
For more information or to find a doula:
Statewide doula hotline: 1-833-RI-Doula
RI Birthworker Co-op (searchable by insurance plan)