“The Convergence of COVID-19 and Systemic Racism: An Evaluation of Current Evidence, Health System Changes, and Solutions Grounded in Reproductive Justice.”

INTRODUCTION

The United States is currently experiencing the confluence of two deadly pandemics, that of systemic racism and of COVID-19. Both are widespread, deeply intertwined, and disproportionately affect Black, Indigenous, Latinx, and other people of color. The intersection of these two pandemics produces a perfect storm for people of color who are pregnant. Their already higher rates of pregnancy and birthing complications, including maternal mortality,¹ coupled with their increased risk of COVID-19 infection and adverse sequelae,² combine to potentiate these disparities.

Midwifery care has the potential to deliver effective and innovative solutions to the twin pandemics of systemic racism and COVID-19, thus being a fundamental part of healthcare initiatives targeting disparities. Specifically, there must be intentional efforts focused on the expansion of the racial and ethnic composition of midwives across the various domains of the midwifery workforce. To do this, midwifery care in the United States must grow to the fullest version of itself, one which moves beyond healthcare provision to embrace both advocacy and allyship within the political arena, healthcare organizations, educational institutions, and communities.³ In this version of midwifery care, midwives can best focus their efforts by using a reproductive justice lens centered on the voices of families, community-based organizations, healthcare providers, and researchers of color.⁴ Reproductive justice is a human rights- and social justice-based framework that recognizes the intersectionality of reproductive oppressions and advocates for individuals to have the right to decide when and how they become pregnant, if and how they want to parent, and the right to parent those children in safe and healthy communities.⁵ Across the United States, people of color, including those who are pregnant or birthing, midwives, community organizations, and researchers are already doing the work of reproductive justice. It is time for all midwives to follow the lead of these experts, partnering with them to face the urgent needs further laid bare during the COVID-19 pandemic.

The objectives of this commentary are three-fold. First, we will review the newest evidence about the intersection of systemic racism, COVID-19, and perinatal disparities. Second, we will explore how changes in healthcare delivery made in reaction to COVID-19 may exclude people of color who are pregnant and potentially exacerbate these disparities. Finally, we will discuss strategies by which midwives and the care delivery system might be reimagined within a reproductive justice framework during this time to better meet both the immediate challenges of COVID-19 and the longer-term need to address entrenched systemic racism.

SYSTEMIC RACISM, PERINATAL DISPARITIES, AND COVID-19

It is well known that people of color in the United States carry a disproportionate burden of COVID-19. Across the spectrum of COVID-19 infection, hospitalization, and death, people of color have higher risks compared to non-Hispanic white persons. A September 2020 commentary published in the Journal of the American Medical Association noted that, “racism, not race, drives inequity across the COVID-19 continuum.”⁶ In other words, COVID-19 inequity is caused by systemic racism, including differences in people’s housing, education, economic opportunities, diet, air quality, health care, and other factors; not by any inherent biological difference between people of different race or ethnicity. Systemic racism is defined as the “totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice.”⁷

In the presence of systemic racism, the social determinants of health, or the social, economic, environmental, and educational circumstances in which people are born and live, are profoundly affected.⁸ Among people of color, differences in the social determinants of health are implicated in the stark and long-lasting racial and ethnic disparities in perinatal outcomes,^1,9 although few investigators to date have focused on systemic racism when examining racial disparities in perinatal outcomes.¹⁰ The COVID-19 pandemic demonstrates yet again that disparities in health outcomes are a direct reflection of deep systemic inequalities and systemic racism.¹¹ For example, in a cohort study from two southeastern US hospitals, prevalence of COVID-19 infection was highest among pregnant people who were Hispanic, did not have medical insurance, or who lived in high-density neighborhoods.¹² This study highlights the importance of underlying social determinants in driving both the disproportionate burden of poor perinatal outcomes and COVID-19 infection in people of color.¹²

Although rates of maternal and neonatal mortality related to COVID-19 infection are not yet known, recent findings from the CDC indicate that there is an increased risk for adverse outcomes in pregnant compared to non-pregnant populations with COVID-19 infection.^13,14 Additionally, researchers have noted COVID-19 related increases in preterm birth (12.9% among 4442 pregnant people with COVID-19 infection compared to 10.2% in the general population in 2019).¹⁴ Increases in the rate of preterm birth among those with COVID-19 compared to the 2020 general population may actually be more profound than when comparing to the 2019 population. As first revealed in studies conducted in Europe, rates of both iatrogenic and indicated preterm birth were lower in 2020 than in 2019, possibly due to increased social support experienced by some pregnant people during COVID-19 lockdowns.¹⁵ Similar reductions were reported in some areas of the United States; for example, at a single institution in the northeast United States, preterm birth rates fell during the first three months of the pandemic compared to the previous year (9.9% vs 12.6%; OR, 0.76; 95% CI, 0.58–0.99).¹⁶ However, these reductions in preterm birth rates were not observed in a large hospital system in Massachusetts.¹⁷ Thus, the influence of COVID-19 on rates of preterm birth are inconclusive, and the benefit observed in some populations of lower preterm birth rates during COVID-19 lockdowns may not have been equally shared by people of color, who are disproportionately represented in conditions that increase risk for COVID-19 infection, including frontline work and denser housing conditions.²

A report from Zambrano and colleagues analyzing the outcomes of 400,000 US women of childbearing age with symptomatic COVID-19 highlights the disproportionate mortality faced by pregnant persons of color.¹³ Whereas non-Hispanic Black or African American (Black) women made up 14.1% of the cohort, they represented 37.4% of the deaths in the entire cohort and 26.5% of the deaths among pregnant women. Hispanic women of any race not only experienced a disproportionate risk for COVID-19 infection during pregnancy, but also had a 2.4 times higher risk for death, compared with nonpregnant Hispanic women.¹³ Similar findings of non-white ethnicity as a risk factor for severe COVID-19 disease in people who are pregnant were reported by researchers after a systematic review and meta-analysis of 77 cohort studies from across the globe.¹⁸ In addition to increased risk for more severe COVID-19 disease course for people of color,¹³ the cumulative impact of COVID-19 atop existing racial disparities in pregnancy outcomes such as maternal morbidity and preterm birth is of particular concern.^1,9 Additionally, systemic racism, disrespect, and legitimate concerns about dying within the traditional healthcare model may alter the trust that people of color feel in their care providers, leading to delays in care with resulting negative influences of disease progression.¹⁹

Some researchers theorize that the interaction between COVID-19 and systemic racism-associated psychosocial stress may function to worsen pregnancy outcomes in communities of color.²⁰ It has been proposed that COVID-19 produces a hyperinflammatory state resulting in hypoxic injury and vascular changes in the expression of angiotensin converting enzyme-2.²¹ These changes in inflammatory and cardiovascular physiology may indirectly increase mortality risk via the development of health conditions known to be associated with maternal mortality that are commonly identified in populations of color, including preeclampsia and cardiovascular disorders.²² Supporting this theory, in a recent study of 978 COVID-19 cases in a Brazilian population of people who were pregnant, researchers determined that cardiometabolic outcomes such as obesity, diabetes, and cardiovascular disease were the primary contributors to maternal death, and white ethnicity had a protective influence on these outcomes.²³ Similarly, Allotey and colleagues found in a recent systematic review and meta-analysis of 77 COVID-19 studies that elevated BMI, chronic hypertension, and preexisting diabetes were associated with more severe COVID-19 symptomatology in pregnancy, although these findings were not examined by race or ethnicity.¹⁸

The simultaneous occurrence of the maternal mortality and COVID-19 pandemics may increase the vulnerability of birthing people of color. As such, midwives must actively address systemic factors and larger social issues including racism, which disproportionately influence these communities. Given the multifaceted and complex nature of these risks, interventions will require a variety of diverse and actionable strategies that focus on addressing social determinants of health.

COVID-19 RELATED PERINATAL HEALTHCARE SYSTEM CHANGES AND IMPACTS ON PEOPLE OF COLOR

Numerous changes are occurring in prenatal, intrapartum, and postpartum care due to COVID-19 that disproportionately impact people of color and may exacerbate pre-existing health disparities.¹⁹ Prenatally, providers are spacing out appointments and shifting to include virtual video or telehealth prenatal visits.²⁴ Although remote pregnancy care appears to be safe and effective compared to traditional in-person care for low risk clients,²⁵ inequitable access to and health literacy needed to use home monitoring devices, such as blood pressure cuffs, is a concern in regards to the safety of remote care in higher risk clients. In addition, a digital divide exists in much of the United States wherein there are disparities in access to the internet or technological literacy, with inequitable access to these remote services for the most vulnerable clients.²⁶ Moreover, fewer visits also lead to decreased opportunities to screen for both pregnancy complications and address social determinants of health that disproportionately affect people of color such as food or housing instability, intimate partner violence, and perinatal mood disorders, all of which are on the rise during the COVID-19 pandemic.²⁷

Changes in intrapartum care during the COVID-19 pandemic may also have the potential to disproportionately affect people of color. Restrictions on the number of support people allowed to be present during labor and birth forces birthing people to labor without the protective element of social support or doula care.²⁴ Continuous labor support has been shown to decrease cesarean rates, instrumental vaginal birth rates, use of analgesics and regional anesthesia, and increase satisfaction in birth experience.²⁸ Given that people of color are at higher risk for negative birth experiences,²⁸ and other outcomes such as cesarean birth,²⁹ banning labor support disproportionately impacts these populations.¹⁹

The COVID-19 pandemic is also impacting the provision of postpartum care, with some visits converted to virtual or telehealth format and in person visits restricting accompanying children or partners, both of which may unduly burden people of color. Postpartum care is imperative for reducing maternal mortality, screening for and treating perinatal mood disorders, supporting breastfeeding, initiating family planning and pregnancy spacing, and optimizing health by providing a bridge to primary care to manage chronic health conditions.³¹ Underlying disparities in the provision of postpartum care have existed prior to the COVID-19 pandemic with people of color being more likely to miss postpartum visits,³² less likely to breastfeed,³³ less likely to get highly effective contraception such as long acting reversible contraceptives (LARCs),³² less likely to receive treatment and referrals for health conditions such as hypertension and gestational diabetes,³⁴ and less likely to receive treatment for perinatal mood disorders.³⁵ Virtual or tele-health postpartum visits may increase access to prescribed contraceptives,²⁷ but it will not provide access to hands on breastfeeding support or access to more effective contraceptive options such as LARCs and postpartum sterilization.³⁶ Given the technology divide, this may unduly impact people of color. Due to the syndemic burden of COVID-19 and systemic racism on perinatal outcomes in people of color, birthing people who end pregnancy at highest risk for postpartum issues may also most in danger of not obtaining access to vital resources and follow up care.

While the COVID-19 pandemic has forced health systems to adapt and innovate, many of these innovations may exclude the most vulnerable populations of people of color who are pregnant. Moreover, pandemic adaptations in healthcare provision may decrease providers’ ability to address the social determinants of health, rooted in systemic racism, which are the underlying causes of perinatal disparities during the pandemic and beyond. It is crucial that midwives put into place immediate solutions that address COVID-19 specific needs for people of color who are pregnant, giving birth, or in the postpartum period. However, it is equally imperative that as a profession, midwives move towards long term solutions to address persistent underlying causes that impact health outcomes for people of color.

MIDWIFERY STRATEGIES TO ADDRESS PERINATAL DISPARITIES DURING COVID-19 AND BEYOND

Midwifery care is centered on the birthing person. Midwives aim to partner with clients to recognize their individual life circumstances and needs. Thus, midwifery care has the potential to be an ideal model of care to address COVID19 and pregnancy disparities, which are rooted in the social determinants of health. Midwifery care has been shown to reduce preterm birth rates and reduce rates of cesarean birth; both of these perinatal outcomes disproportionately impact people of color.³⁷ Individuals who have midwifery-led care also report less discrimination and more positive birth experiences.²⁹ Although beneficial, midwife-led care alone is not enough to improve racial and ethnic disparities in perinatal outcomes. Midwives must be willing to radically confront the well-documented racist history of nurse midwifery in the United States. Additionally, there must be an intentional dismantling of the underlying structural racism that produces disparate outcomes, along with the prioritization of initiatives to center the voices of midwives, community organizations, researchers, and birthing people of color.

A midwifery model of care that re-embraces strategies to address individual, institutional, and systemic factors during pregnancy and beyond (Table 1), while instituting care initiatives grounded in a framework of reproductive justice (Table 2) may prove beneficial in addressing COVID-19 outcomes. These strategies are also important to address other health inequities that predated the pandemic and will likely persist long after COVID-19 is controlled. The tradition of caring for birthing people with expert clinical knowledge, while also addressing social determinants of health, has always been the heart of midwifery. This is particularly true for midwives who provide care to marginalized and underserved communities. Addressing the social determinants of health is not an extraneous but rather an integral part of midwifery care that is focused on dismantling systemic racism.

Table 1:

Addressing Changes in Provision of Perinatal Care During COVID-19

Topic	Recommendation	Resources
Prenatal
Social Determinants of Health	Screen at every visit for food insecurity, IPV, housing instability Compile COVID-19 specific resources for testing, food, housing, IPV	Davidson KW, Mcginn T. Screening for Social Determinants of Health. JAMA. 2019;322(11):1037–8. doi:10.1001/jama.2019.10915
Digital Divide	Screen for internet or phone access and evaluation of technology literacy Develop individual prenatal care plan taking into account medical need, access to technology, feasibility, and patient preference Prioritize in person visits for those with barriers to participating in virtual care	Eruchalu, C.N., Pichardo, M.S., Bharadwaj, M. et al. The Expanding Digital Divide: Digital Health Access Inequities during the COVID-19 Pandemic in New York City. J Urban Health 202; 98:183–186. https://doi.org/10.1007/s11524–020-00508–9 Peahl AF, Smith RD, Moniz MH. Prenatal care redesign: creating flexible maternity care models through virtual care. Am J Obstet and Gynecol. 2020;223(3):389.e1–389.e10.
Exposure Reduction Measures	Screen for exposure risk in home and work settings Provide education on mitigating transmission risk (ie, masks, hand washing, social distancing) Provide education on options for out of hospital birth, home prenatal or postpartum visits	If You Are Pregnant, Breastfeeding, or Caring for Young Children. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html. Backes EP, Scrimshaw S. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: the National Academies Press; 2020.
Prenatal Social Support	Transition to virtual group prenatal care Make exceptions to allow one support person at important visits such as ultrasounds, taking into account current location-specific community acquired infection risk	Coronavirus and Centering. Centering Healthcare Institute. https://www.centeringhealthcare.org/covid-19.
Intrapartum
Access to Community Based Birth and Labor Support	Improve access to and insurance coverage for out of hospital birth Allow hospital visitation for doulas as members of healthcare team Support transition to virtual doula support	Backes EP, Scrimshaw S. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington, DC: the National Academies Press; 2020. HMHBGA Toolkits & Reports. Virtual Doula Toolkit. Healthy Mothers Healthy Babies Coalition of Georgia. https://hmhbga.org/education/toolkits-reports/.
Postpartum
Breastfeeding	Support skin to skin, rooming in, and breastfeeding, even for SARs-CoV-2 positive birthing people if taking transmission precautions	If You Are Pregnant, Breastfeeding, or Caring for Young Children. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html.
Mental Health	Screen and refer for perinatal mood disorders and social support systems Continue to screen for food insecurity, IPV, housing instability	Onwuzurike C, Meadows AR, Nour NM. Examining Inequities Associated With Changes in Obstetric and Gynecologic Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol. 2020; 136(1):37–41; doi:10.1097/aog.0000000000003933 Davidson KW, Mcginn T. Screening for Social Determinants of Health. JAMA. 2019;322(11):1037–8. doi:10.1001/jama.2019.10915
Contraception Access	Increase access to post placental LARCs Prioritize sterilization procedures during hospitalization Prioritize in-person postpartum visits for clients desiring LARCs	Nanda K, Lebetkin E, Steiner MJ, Yacobson I, Dorflinger LJ. Contraception in the Era of COVID-19. Glob Health Sci and Pract. 2020;8(2):166–168. doi:10.9745/ghsp-d-20-00119

Abbreviations: IPV, intimate partner violence, LARCs, long acting reversible contraceptives

Table 2:

Midwifery Strategies and Resources to Address Disparities in Perinatal Outcomes Beyond COVID-19

Strategy	Recommendations	Resources
Individual
Anti-Racism Education for White Midwives	Participate in the ACNM Inclusion Conference for anti-racism training for practicing midwives	2020 ACNM Inclusion Conference: Dare to Think Different. http://inclusionconference.midwife.org/.
	Access ACNM Opportunities for Anti-Racism Work in Midwifery	Anti-Racist Strategies for White Midwives: Tools for Self-Examination and Action. ACNM. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000007979/Antiracist-Strategies-Resources.pdf.
Institutional
Support Midwifery Students of Color	Increase recruitment of and support for students of color	Serbin JW, Donnelly E. The Impact of Racism and Midwifery’s Lack of Racial Diversity: A Literature Review. J Midwifery Women’s Health. 2016;61(6):694–706. doi:10.1111/jmwh.1257
	Encourage participation in the Black Midwives Alliance Mentorship Program	Power. National Black Midwives Alliance. https://blackmidwivesalliance.org/power.
	Provide information on access to financial assistance, such as the National Association to Advance Black Birth Scholarships and the	Midwifery Scholarship. The NAABB. https://thenaabb.org/midwifrey-scholarship/.
	Carrington-Hsia-Nieves Doctoral Scholarship for Midwives of Color	The A.C.N.M. Foundation, Inc. Scholarships and Awards Applications. American College of Nurse-Midwives. https://www.midwife.org/Foundation-Scholarships-and-Awards.
Increase Diversity in Midwifery	Promote recognition of and reconciliation for history of racism in midwifery	Serbin JW, Donnelly E. The Impact of Racism and Midwifery’s Lack of Racial Diversity: A Literature Review. J Midwifery Womens Health. 2016;61(6):694–706. doi:10.1111/jmwh.12572
	Increase diversity in midwifery faculty	Waite R, Nardi D. Nursing colonialism in America: Implications for nursing leadership. J Prof Nurs. 2019;35(1):18–25. doi:10.1016/j.profnurs.2017.12.013
	Become familiar with the ACNM Anti-Racism Roadmap for Change	Anti-Racism Roadmap for Change. ACNM. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000008166/ACNM-Anti-Racism-Roadmap_Feb2021.pdf.
	Promote an Anti-Racism curriculum in midwifery education, with critical examination of midwifery curriculum and practices in midwifery education that marginalize or harm students of color	Burnett A, Moorley C, Grant J, et al. Dismantling racism in education: In 2020, the year of the nurse & midwife, “it’s time.”. Nurse Educ Today. 2020;93:104532.
	Promote midwifery educational institutions like Commonsense Childbirth Institute that are led by people of color	The JJ Way. Commonsense Childbirth Inc. https://commonsensechildbirth.org/jjway/.
Support Safe Spaces for people of color	Support Black owned midwifery practices and birth centers like CHOICES Memphis	CHOICES. Memphis Center for Reproductive Health. https://memphischoices.org/.
	Promote group prenatal care models such as that created by JJ Way	The JJ Way. Commonsense Childbirth Inc. https://commonsensechildbirth.org/jjway/.
Facilitate Provider and Patient Racial Concordance	Refer to the SisterSong Women of Color Reproductive Justice Collective registry of Black obstetric and midwifery care providers for clients where appropriate	Mapping Birth Work Across the South. Sister Song Reproductive Justice Collaborative. https://www.sistersong.net/mapping-birth-work-across-the-south.
	Utilize the Irth App to find racially concordant and racially unbiased perinatal care	Irth. as in Birth But We Dropped the “B” for Bias. Irth. https://birthwithoutbias.com/.
System
Support for People of Color-led Disparities Research and Advocacy	Support the National Birth Equity Collaborative	National Birth Equity Collaborative. NBEC. https://birthequity.org/.
	Become familiar with the Sacred Birth Study on Obstetric Racism	SACRED Birth During COVID19. SACRED Birth. https://sacredbirth.ucsf.edu/.
	Support the Black Mamas Matter Alliance	Advancing Black Maternal Health. Black Mamas Matter Alliance. https://blackmamasmatter.org/.
Legislative	Support the MOMNIBUS Act to improve Black Maternal Health	U.S. House. 116th Congress, 2nd Session. H.R. 6142, To end preventable maternal mortality and severe maternal morbidity in the United States and close disparities in maternal health outcomes, and for other purposes. Washington, Government Printing Office, 2020.
	Support the call for a White House Office of Sexual and Reproductive Health and	Call for Office of Sexual and Reproductive Health and Wellbeing. NBEC. https://birthequity.org/call-for-OSRHW/.

CONCLUSION

The COVID-19 pandemic has laid bare the direct ways that systemic racism influences social determinants of health leading to both the disproportionate burden of COVID-19 and long standing poor perinatal outcomes for people of color. Addressing these pandemics requires a two-pronged approach to meet the immediate perinatal needs of people of color during the pandemic while also building longer term solutions to address underlying disparities. Longer term, health care for birthing people should be grounded in reproductive justice, radically centering people of color. In this way, disparities might be eliminated, resulting in better outcomes for all. This unique moment in history calls for personal, professional, institutional, and systemic change. Midwives are uniquely situated to answer this call if all are willing to deeply examine their profession, the systems within which they function, and to reimagine and recreate a world that centers people of color. Although systemic racism is disproportionately experienced by people of color, all people are affected. By addressing this issue, midwives have the opportunity to create safer, healthier, spaces for all birthing people during COVID-19 and long afterwards.