By Hannah Lambalot and Tomi Sontan, MS
Essential hospitals stand apart for their commitment to serve people who face structural barriers to care and experience persistent disparities in outcomes, which are strikingly evident in maternal health care.
The truth is that the obstetric outcome of non-Hispanic Black patients is two to three times more likely to end in the death of the birthing patient or the infant than if the patients were non-Hispanic white, and the data bear this out. In 2020, the U.S. maternal mortality rate stood at 23.8 deaths per 100,000 live births, an increase from 2019. In 2020, the maternal mortality rate among non-Hispanic Black women was 55.3 deaths per 100,000 live births, compared with 19.1 deaths per 100,000 live births among non-Hispanic white women.
The infant mortality rate is even more staggering, with 5.58 deaths per 1,000 live births in 2019. The data also reveals deep racial disparities. The infant mortality rate for non-Hispanic Black infants was 10.62 deaths per 1,000 live births, compared with 4.49 deaths per 1,000 live births of non-Hispanic white infants.
Today, many physicians and scholars, including those at essential hospitals, are working together to reduce maternal health disparities and drive down the disproportionate mortality rate among people of color. That work recognizes that the cause for the disparity between obstetric outcomes as structural and interpersonal racism, not race-based biological differences.
A History of Mistrust
Historians outline how the racism that causes such staggering disparities in maternal and infant mortality is not new but inherited from days of chattel slavery in the United States. Many of gynecology’s current clinical practices, such as the caesarean section and surgical techniques used to repair obstetrical fistulas, were developed by slaveholding physicians François Marie Provost and James Marion Sims. They unethically experimented on Black people who were enslaved to produce tools and techniques that leave Black birthing patients today wondering who to trust.
For patients perceived as Black, discrimination in a health care setting increases the probability of a poor outcome, because the perception of someone’s race can affect their access to care and the quality of care they receive. In a 2019 study examining the relationship between perceived discrimination through racial microaggressions and delayed prenatal care, 24.8 percent of the 1,410 Black, African American women interviewed experienced delays in prenatal care. Moreover, the researchers found that delays were tied to skin tone, noting the effect of colorism on access to care.
Structural Racism Causes Physiological Stress
The stress of living in a racist society affects more than the physician-patient relationship. Allostatic load is the measurement of chronic stress through multiple biomarkers of different physiological systems, such as blood pressure and cortisol levels. The incredible allostatic load of Black people — Black women, even more so — leads to an earlier deterioration of health than among white people. This social stress on health, termed “weathering” by Aline Geronimus, ScD, leads to the increase of stress-related diseases, such as hypertension.
Hemorrhage and hypertension disorders, cited as two of the top five causes of pregnancy-related deaths, relate directly to iron-deficiency anemia, a condition that, until recently, was diagnosed and treated using race-based algorithms. When patients present to the hospital for or after birth, their hemoglobin levels are tested to ensure an appropriate level, and the previous threshold for triggering iron treatment for anemia in Black patients — hemoglobin levels lower than 11.0 grams per decaliter (g/dL) in the third trimester — was higher than the threshold for non-Black patients — 10.2 g/dL. Varying anemia-related thresholds based on race decreased the likelihood of having the necessary medical supplies ready in case of a hypertensive or hemorrhage event, a glaring example of how outdated research has created structural barriers that continue to compromise care today. The American College of Obstetricians and Gynecologists (ACOG) in 2021 removed the racially based guidelines defining the threshold for iron-deficiency anemia in pregnancy.
Essential Hospitals Act
ACOG’s previous race threshold is but one example of structural racism Black birthing patients face today. The Centers for Disease Control and Prevention state three in five pregnancy-related deaths could be prevented. With that in mind, and recognizing the high maternal mortality rates of Black birthing patients, 12 members of America’s Essential Hospitals are working to reduce morbidity and mortality for Black pregnant or birthing patients through a new essential hospital learning collaborative. Their work to improve obstetric outcomes focuses on improving hemorrhage and hypertensive disorders for pregnant and birthing patients within and outside the hospital walls.
Alameda Health System, in Oakland, Calif., is improving hypertension care by using text messages to facilitate remote blood pressure monitoring twice a day among birthing patients.
JPS Health Network, in Fort Worth, Texas, is focusing on hemorrhage prevention by conducting a patient-centered, mixed-methods research study to understand care preferences and barriers. The health system is also launching systematic screening for social determinants of health to identify appropriate interventions for each birthing patient.
The University of California, San Diego Health, in San Diego, is improving access to home blood pressure cuffs, increasing the frequency of anemia screening, and standardizing the use of intravenous iron infusions. Additionally, the health system is expanding patient education and mandating staff training focused on caring for Black maternity patients.
We urge association members to join these hospitals, among others, in responding to the maternal health crisis in the United States. Learn more at America’s Essential Hospitals’ annual conference, VITAL2022, where essential hospitals will share their innovations in obstetric care and work to combat structural racism. This year, leaders from association member St. Joseph’s Health, in Paterson, N.J., will discuss how they are restructuring power dynamics to elevate patients’ voices and develop systemic change in perinatal health. Also, consider registering for our preconference workshop, “Developing an Infrastructure to Combat Structural Racism.” Plus, gain further insight into improving population health, policy and finance, and executive leadership lessons.
Our Essential Communities website houses programs, resources, and tools to aid in your hospital’s journey to community-integrated health care. Consider showcasing your hospital’s work to target social determinants of health on our program map or in our resource center.
Also, consider joining the America’s Essential Hospitals Combating Structural Racism Interest Group. Together, we examine organizational practices and policies to better understand how structural racism affects their work and to make changes that promote diversity, equity, and inclusion.
We meet the first Tuesday of the month, from 2–3 pm ET, to collaborate and share valuable tools and reference resources in three core areas: culture, policies, and clinical processes.
If you’re interested in joining, email Health Equity Associate Tomi Sontan, MS, at firstname.lastname@example.org.
 Owens DC. Medical Bondage: Race, Gender and the Origins of Gynecology. Athens, Georgia: University of Georgia Press, 2017.