Utilizing Community-Centered Approaches to Address Black Maternal Mortality

Abstract

The rise of Black maternal mortality rates throughout the country demonstrates a great need to utilize innovative frameworks to craft solutions that improve health outcomes for Black birthing people. Previous research and interventions have examined individual- and policy-level factors to reduce maternal mortality; however, these methods may lack a true community-centered approach to understanding the experiences of Black birthing people in local communities that have been disproportionately impacted. In addition, certain research methods may not recognize other marginalized intersectional identities (e.g., Black transgender men) who experience inequities in Black maternal health. This commentary aims to provide recommendations for utilizing community-centered strategies on Black maternal mortality informed by community-based participatory research principles.

While the United States is commonly regarded as one of the leaders in health care and medical innovation, maternal mortality portrays a striking narrative. The United States has one of the highest maternal mortality rates among developed countries around the world (Tikkanen et al., 2020). According to the Centers for Disease Control and Prevention (2020), maternal mortality is defined as the death of a woman “while pregnant or within one year of the end of pregnancy from any cause related to the pregnancy” (p. 1). From 2000 to 2020, the national maternal mortality rate has increased from 9.8 to 23.8 deaths per 100,000 births, despite advancements in medicine (Hoyert, 2022). This indicates that maternal mortality is a serious public health crisis. Maternal mortality is even further exacerbated when examining racial and ethnic disparities in the United States (Tikkanen et al., 2020). Black women have a likelihood of maternal mortality that is between 3 and 4 times higher than non-Hispanic White women (Hill et al., 2022; Roeder, 2019). Moreover, more than half of all maternal deaths are completely preventable, with a large proportion of these preventable deaths being Black women (Roeder, 2019). Considering the concerning statistics that exist for all mothers in America, the fact that Black women experience much more loss necessitates great reflection and action toward health equity. Previous research on maternal mortality has examined genetics, personal lifestyle choices, and health care access as drivers for disparities (Hobgood, 2020; Moaddab et al., 2018). However, it has become increasingly apparent that components of these disproportionate death rates may be rooted in discrimination and racism (Greenwood et al., 2020). For example, historical practices of redlining have resulted in disparate access to maternal health care services for Black women, resulting in Black mothers having a higher likelihood of having a preterm delivery (Matoba et al., 2019). In addition, because of redlining, Black mothers are more likely to reside in socioeconomically deprived neighborhoods than their White counterparts, and prior literature suggests that this is linked to disparities in breastfeeding as well (Morrow et al., 2021). Beyond housing inequity, multiple forms of discrimination result in poorer maternal and prenatal health outcomes and disparities, which limit the extent to which individual changes impact one’s health. Recent studies have demonstrated that these racial disparities in maternal health remain even after controlling for socioeconomic status and access to prenatal care for Black women (Hardeman et al., 2022). Research also shows that individual and structural racism act as social determinants of health, contributing to adverse pregnancy outcomes via reduced health-promoting behaviors, increased poverty, and reduced educational opportunities (Hailu et al., 2022). Furthermore, the impact of these issues varies based on one’s community environment, often leaving pregnant and postpartum people feeling disempowered (Eftekhari et al., 2013; McLeroy et al., 2003). Yet, community-centered approaches to these issues show promise in ameliorating maternal health disparities by empowering birthing people to play a key role in improving their health and to create applicable solutions on a larger scale (Wallerstein & Duran, 2010). Therefore, to achieve health equity in maternal health outcomes, we provide recommendations to address Black maternal mortality using community-centered strategies that address individual, community, and institutional level factors. Through approaches like these, it is possible to tackle the multiple levels of discrimination that lead to maternal health disparities.

It is also important to note that maternal mortality mainly centers cis-gender women, even though there are people of different gender identities who can become pregnant and give birth. Therefore, to be inclusive, we will also use the term Black birthing people to refer to all Black individuals who can give birth.

Researcher Positionality Statement

All the authors of this article are cis-gender women of color (five identifying as Black, one identifying as Indian, and one identifying as Latina). Six of the co-authors were graduate public health students at the time of writing this commentary, and the senior author is an assistant professor of public health at a predominantly White institution (PWI). We come from a range of cultural, geographic, and socioeconomic backgrounds, and some of the authors have lived experiences with mistreatment and discrimination within the health care system. However, we acknowledge we are not the experts on the lived realities of Black birthing people. We acknowledge that while we have elements of privilege given our social location (e.g., students and faculty at a PWI), some of us do share similarities with Black birthing people. We are also aware that our identities and experience may contribute to biases and have taken steps to be cognizant of our views and reflect on our positionality. Each of us has a personal connection to the area of Black maternal mortality as women of color with increased susceptibility to maternal mortality. Through some of our personal experiences, we understand both the overt and subtle ways that health care providers can disrespect or ignore the needs of patients which can lead to maternal mortality disparities. Our experiences drive our passion to address these disparities.

Key Recommendations

Our key recommendations stem from successful results in studies that have incorporated community-centered and community-based participatory research (CBPR) strategies in their work on reducing maternal mortality. CBPR is a collaborative and partnership approach to research that equitably involves community members, leaders of organizations, and academic researchers in all aspects of the research process (Israel et al., 1998). It enables all partners to contribute their expertise, with shared responsibility and ownership as well as allowing for the integration of data and knowledge gained with action. In line with community-engagement and CBPR principles, we provide three key recommendations that are essential to improving health outcomes for Black birthing people.

Engaging Key Stakeholders and Building Capacity

Solutions to reducing Black maternal mortality require input from those most impacted: Black birthing people. In some cases, disparities in maternal mortality can be attributed to health care providers failing to effectively communicate and listen to the concerns of Black birthing people and those that work closely with them (Green et al., 2021). Forming advisory boards and partnerships between researchers, practitioners, and community members is necessary to understand and address the concerns of the community. For research projects designed to reduce Black maternal mortality, community-based doulas, Black mothers, and Black birthing people should be included as co-investigators and/or consultants so they can provide direct input in the design of the research process and the analysis of the data.

At the local level, doulas who directly engage with birthing people inside and outside of the health care system would be able to share their perspectives on how their services are effective and how they can be supplemented by certain resources or supports. In Syracuse, New York, Black Community-Based Doulas (CBDs) utilize a Reproductive Justice (RJ) framework within their practice to center their lived reproductive experiences (Rivera, 2021). These doulas center care practices and discourse with clients around sexual autonomy, gender freedoms, and reproductive liberty, which provide Black birthing people with safe spaces to make decisions about their birth journeys (Rivera, 2021). Such insight can guide researchers on the gaps that exist within the community in terms of resources, guiding research projects, and what interventions can be introduced to address the gaps for Black birthing people. While efforts have also been made to incorporate the work and expertise of doulas in the discussion of reducing maternal mortality, these have either been calls to action about investing in and incorporating community doulas into the health care system (McCloskey & Bernstein, 2021) or improving on current doula-based community programs by getting feedback from doulas and clients (Marshall et al., 2022).

Black mothers also lend an important and critical perspective as experts in research studies pertaining to Black maternal health. For example, the Consortium to End Black Maternal Mortality, which included Black mothers as members, conducted listening sessions with Black mothers in Rochester, New York, to identify factors of the pregnancy and birthing experience that contribute to maternal mortality and morbidity disparities (Alio et al., 2022). The results of the study suggested interventions targeting mother-provider communication through training providers in culturally competent care in addition to improving health literacy would best address maternal mortality in the context of the Rochester community (Alio et al., 2022). Encouraging Black mothers to serve as leaders of research can have a direct impact on project questions, study design, and interpretation of the data.

Community-Centered Approach to Data Collection

While researchers must have access to the most up-to-date statistics on Black maternal mortality, we must recognize the diverse forms of data that are present within communities and how that can contribute to new findings. Using mixed methods design can be ideal in understanding the complexities of Black maternal mortality as a public health issue and developing data-informed solutions. For example, local data sources like DataHaven, which provides local data on social, health, and economic indicators throughout the Greater New Haven, Connecticut region, can be used to understand the epidemiology of maternal mortality trends and prevalence rates. Such an approach allows for resources to be specific to residents’ needs (CT DataHaven, n.d.). In addition, while quantitative data are often used to assess community needs, qualitative data provide opportunities to understand the experiences of Black birthing people themselves (Borba et al., 2015). Qualitative data collection allows birthing people the freedom to share their complete stories (Renjith et al., 2021; Sofaer, 2002). It is important that researchers move away from viewing participants as merely data points and begin to understand the lives of marginalized individuals and communities. A qualitative study explored the social determinants of maternal health among Puerto Rican women using focus group methodology and found that perceived poverty, food insecurity, lack of access to quality education, and unsafe environments were all major factors that affected maternal health (Tapp et al., 2013). Furthermore, qualitative and CBPR studies examining the experiences of prenatal care among Black birthing people have identified meaningful ways of improving both the actions of practitioners and revamping policies in integrating health infrastructure that may help to reduce maternal care inequities in specific communities (Nypaver & Shambley-Ebron, 2016; Peahl et al., 2022). In addition, qualitative studies that explored self-care practices among Black mothers identified key sources of interpersonal and societal stress that can inform the design of health promotion interventions (Nichols et al., 2015). Findings from qualitative work have the power to provide unique insight on how to engage in culturally informed policy work that can reduce disparities in maternal health.

In addition, as data are being collected, researchers must also consider who may not be included or represented in data collection (Lett et al., 2022). Using intersectionality as a lens provides persons whose identities or experiences are tied to maternal mortality but are left on the margins, such as Black transgender men and non-binary individuals, to be included. Intersectionality is defined as

a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender identity, sexual orientation, socioeconomic status) intersect at the micro-level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism).

(Bowleg, 2021, p. 1267; Collins, 2000; Crenshaw, 1991)

It is important to consider that people who are most at risk of maternal mortality, do not all identify as women. For example, Black transgender men who give birth may be at high risk of dying during or after pregnancy due to discrimination or often lack providers that understand transgender health (Bauer et al., 2009; Unger, 2015). Therefore, we call for the inclusion of all Black birthing people in understanding their unique intersections in future mixed methods studies through an intersectionality (Abrams et al., 2020).

Dissemination Rooted in Community

Community-based perspectives must also inform how information is distributed and disseminated. Existing literature demonstrates that physician bias and inadequate prenatal care are among the key contributors to racial maternal mortality disparities (Borders et al., 2015; Howell, 2018). Creating and relying on community advisory boards (CABs) consisting of diverse stakeholders including Black birthing people, health care providers, and family members affected by Black maternal mortality can help translate research findings into practical applications. For example, the Office of Bronx Borough launched the Bronx Black Maternal Mortality Task Force (BMMTF) in Fall 2020 (Diaz et al., 2021). The BMMTF was formed to bring health care professionals together to advocate and identify interventions that address Black maternal mortality across the Bronx and the greater New York City area. The BMMTF worked to combine various expertise and identify interventions to address Black maternal mortality, with the focus being on young Black mothers living in the Bronx, New York. In addition, researchers can train CAB members in data collection processes, analysis, and grant writing, to provide the infrastructure that can be used to maintain long-lasting results for the community without relying on researcher resources, which allows for sustainability. This way, trusted members of the community can collect data to better inform Black maternal mortality prevention efforts. Specifically, CABs can help ensure resources on preventing Black maternal mortality are accessible in terms of language, literature, and the types of resources detailed. Community-specific methods of information dissemination are vital to addressing the systemic barriers that contribute to Black maternal mortality—as experts of different lived experiences can help ensure all resources are relevant and targeted.

CABs can also be utilized to facilitate change on a clinical level for Black birthing people. CABs can work with the research team to conduct in-depth interviews with health care providers at local hospital systems to understand (a) hospital workflow processes and (b) determine the feasibility and acceptability of integrating doula service referrals within the hospital processes. Upon building a stronger community presence, the CAB can advocate alongside community members and policymakers for systemic change to allow for greater coverage of antenatal care services under insurance providers like Medicaid.

Conclusion

Using community-engaged strategies to reduce maternal mortality among Black birthing people is key to ending racial disparities in maternal mortality. CBPR alters the research landscape and promotes meaningful partnerships between academic partners and community members. By centering the voices and concerns of those most affected by disparities in maternal health and mortality, and acknowledging intersecting identities among Black birthing people, CBPR-based approaches offer the opportunity to reduce the mortality and morbidity of Black birthing people. Despite the current research and committees addressing Black maternal mortality, Black birthing people still suffer exceedingly, so we must utilize new methods and theories to address this epidemic. CBPR-based approaches to decrease Black maternal mortality must ensure that they truly embrace the key components of CBPR not just in theory but also in practice. Interventions to reduce Black maternal mortality must center the voices of Black birthing people and call upon their expertise to create meaningful solutions. In addition, we must expand the lens through which we view Black maternal mortality to address this issue. By utilizing CBPR practices and bringing in voices of all Black birthing persons, we can work to be more inclusionary in our efforts to truly make an impact in eliminating maternal mortality.