For too many Black women, pregnancy is fatal. These birth workers could help

Between 2013 and 2018, a startling 73% of pregnancy-related deaths in Philadelphia were in Black women—yet they accounted for only 43% of births. According to a 2020 report from the Philadelphia Department of Public Health's Maternal Mortality Review Committee, over half of the 26 pregnancy-related deaths could have been prevented.

Saleemah McNeil and her team of Black birth workers at Maternal Wellness Village, a Jenkintown-based collective, didn't need a report to tell them just how dangerous pregnancy could be for Black women. After all, many of them had gone through their own birth traumas.

To improve these "fourth trimester" outcomes for pregnant people across Philadelphia, they're collaborating with researchers at Temple University to study how having access to community support services—including Black doulas, lactation consultants, therapists, and more—can improve health outcomes for pregnant Black people.

"When you listen to community members, this is what they want," said Aasta Mehta, medical officer of women's health at the Philadelphia Department of Public Health.

The 2020 report also found 46% of all pregnancy-related deaths were due to heart conditions. With the help of a $6 million grant from the nonprofit Patient-Centered Outcomes Research Institute, the partnership will focus on improving heart health before and after giving birth.

"When we look at the statistics of black women dying three to four times higher than our white counterparts and we try to figure out why, a lot of [medical] things are listed," said McNeil, program director at Maternal Wellness Village. "But we don't talk about the racism that's attached to it."

During pregnancy, the heart works overtime to circulate the mother's blood throughout her body and the fetus. This means it has to pump more blood and faster. Childbirth only places additional stress on the already strained muscle.

This means preexisting heart conditions that were controlled outside of pregnancy—or those that went undetected—can become more dire as the heart is pushed to its limits. Women may also develop new heart arrhythmias or other malfunctions, and studies show that blood flow isn't the only burden to blame: lack of access to nutritious food or exercise, inadequate or culturally insensitive medical care, stressful events, social isolation, and depression contribute to cardiovascular disease in Black women even outside of pregnancy.

As in many other parts of the medical system, racism and implicit bias can keep doctors from recognizing signs of heart complications in pregnant people of color or dissuade patients from seeking care. In focus groups conducted by AccessMatters, a Philadelphia organization that supports reproductive health, researchers found that many Black parents felt disempowered during the birthing process.

"There have been consistent messages that Black people are unfit, neglectful, and irresponsible parents and that their reproduction is to be managed or controlled rather than nurtured," said India Blunt, deputy director of training and capacity building at AccessMatters.

But research has shown that other types of supplemental support can improve outcomes. One study found that doulas halved low-income mothers' risk of pregnancy complications.

"When a relationship is built with a doula … birthing people often do find newfound motivation," said Naima Black, director of the community doula and breastfeeding programs at Maternity Care Coalition, a Philadelphia-area organization. "With that comes, oftentimes, a different focus on health, wellness, and nutrition."

Black women are also less likely to be screened for mental illness, even though depression can create physiological changes that promote cardiovascular disease. Lactation, however, can actually reduce risk of hypertension by increasing the production of hormones that dampen blood pressure.

While past studies have shown that support resources can improve birth outcomes, they haven't specifically looked at the benefit for heart health in pregnant people, said Sharon Herring, associate professor of medicine and director of the Program for Maternal Health Equity at the Lewis Katz School of Medicine at Temple University, who is co-leading this study with McNeil.

"What they find from this study will really help inform the kinds of activities that we can implement more broadly to really make a difference," said Mehta.

Next year, the team will start recruiting more than 400 Black patients from Temple practices who will be assigned to two groups. Both groups will receive a set of resources to support heart health that have slowly rolled out citywide: text-message-based tips on nutrition, physical activity, and breastfeeding, home blood pressure self-monitoring, and care from a physician who has gone through antiracism training.

The second group will also have access to other services offered by Maternal Wellness Village, which is based at Oshun Family Center, a Jenkintown-based program dedicated to providing racially concordant care for Black patients, particularly those undergoing transitions such as birth. A community-based Black doula will visit them at home six times prior to delivery, be present at delivery, and visit again eight times after the baby is born. Follow-up appointments will be scheduled at key times, concentrated in the immediate postpartum period, when the new mother needs the most support, then tapering off over the course of a year.

Additionally, lactation consultants will help prepare for breastfeeding and offer tips to ensure child and mother are getting enough food. Mothers' mental health will also be assessed before and after birth.

It is especially important that mental health professionals understand Black experiences, Herring said, because many standard diagnostic tools are designed for white people.

"My people want therapy, they just don't want to go to people who don't look like them, can't relate to them, and cannot on a base level know or understand what it's like to be Black in America," said McNeil, who is a licensed psychotherapist. "There's a trust factor that goes into play."

To measure how effective the community support interventions are, the researchers will compare participants' blood pressure and weight six weeks and one year after giving birth. Mehta said that data will provide compelling evidence when advocating for making these services permanent and covered by insurance.

Systemic change is the ultimate goal, McNeil and Herring said. Based on the study's findings, the team will assemble a tool kit of best practices to share with hospitals nationwide, and will do video and social media outreach to inform Black pregnant people of the support systems they might benefit from.

"That's such a key piece that's often missed in these interventions," Herring said. "Often we forget about ... the issues with systemic racism that occur at the institutional level."

McNeil advocates for a "top down and bottom up" approach: validating the efforts of community birth workers like herself at the bottom level, while promoting change in the top-level institution to recognize the structural obstacles that Black birthing people face that increase their risk of medical complications. Recognition that socioeconomic disparities might limit mothers' ability to engage with some services is also important when designing these programs, Blunt added. For example, even if they receive text reminders, they may not be able to afford nutritious food or dedicate time to exercise.

Medicaid and insurance reimbursement is one kind of institutional change that these data might encourage, Mehta said. Currently, not all insurance plans cover the cost of community health workers, which limits who can access the services. Mehta added that another major obstacle is connecting patients to these kinds of services.

"I think [community-based support] should be incorporated as the standard of care so everyone has access to the same services," McNeil said.

Although the study is still in a nascent stage, local maternal health organizations expect that the results will prove the effectiveness of community interventions to improve Black mothers' heart health.

"Getting that data is going to be huge, because what gets measured gets managed," said Marianne Fray, CEO of Maternity Care Coalition.

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