The US has some of the highest maternal morbidity and mortality rates, with Black women disproportionately affected. Time and time again, we’ve heard that to improve maternal health outcomes in the U.S. for Black women, we must get rid of racial bias and discrimination. This goal, while important, will not happen in my lifetime. Current racial bias training in hospitals, schools, and workplaces are superficial fixes to a deep-rooted systemic problem in this country. Racist beliefs and systems will take generations to change, and we need solutions in the now that can lead to substantial progress in Black communities and the hospitals that serve them.
Community-based primary health care
Directly involving the community in primary health care can be one of the more effective ways to minimize racism, discrimination, and bias in the medical system. Black et al. illustrate how community-based primary health care (CBPHC) effectively prevents child and maternal deaths. Within these CBPHC programs, paid Community Health Workers (CHW) are instrumental in connecting mothers to maternal and child health resources. CHW programs are most effective in rural communities where physically accessing health services proves a burden. They deliver health education services, including nutrition and physical education, chronic disease management, family planning, and insurance basics. They can educate fellow community members about risk factors before, after, and during pregnancy in underserved and isolated areas. However, CHWs can still face resistance due to the complex diversity in the community, even when they come from it. CHWs must navigate trust between community members and the health systems that serve them. Therefore, sufficient training is crucial: proper instruction on counseling skills and trust building in settings with teaching and practicing opportunities is when the most benefit from CHWs is seen.
Large-scale CHW programs are only as strong as their communities, and careful design and implementation must be taken for every community program. Under proposed legislation such as the Justice and Jobs Act, large-scale CHW programs would be supported by implementing partners, including state health departments, non-governmental organizations, and churches, all driven by financial incentives dependent upon meeting various goals and objectives each year. Partnering with these different organizations can help to empower CHW programs and the communities they work with by providing an additional support system. These partners can help host workshops and educational services for the CHW program participants. Workshop participation can be incentivized with vouchers for food, diapers, and other pre- and post-natal needs.
Too often, community programs with low participation are due to a lack of interest or mistrust from within the community. To mitigate this problem, the community should be engaged in goal setting for these programs, with different goals being prioritized based on a community-specific needs assessment. Standardized indicators would measure the short-term usage of educational and social services within CHW programs and common risk factors for maternal mortality and morbidity, such as high blood pressure and obesity. Such a system would enable CHW programs to adapt to their communities’ needs, inform policy and political leaders to take action to strengthen the community, and ultimately benefit all races within them.
Better health care facilities must be combined with such Community Health Worker programs; otherwise, Black mothers will not benefit suitably. Provider and system failures are a major driving factor of Black maternal mortality and morbidity. Differential outcomes by race in maternal mortality and morbidity persist even when controlling for comorbidities and when pregnant Black women obtain care in high-quality hospitals. Investing in the quality improvement of Black-serving hospitals will benefit all races and ethnicities, as White patients in these hospitals also have elevated rates of severe maternal mortality and morbidity. Such investment, however, will need to be systematic and structural. A required course in racial bias is not enough; hospitals in poor neighborhoods need more quality control and supervision to attract diverse staff, training, and financial resources to improve their infrastructure and workforce. Hospital care must be standardized and adapted to the population’s specific needs. Furthermore, CHWs can be advocates for black mothers, potentially lowering the disrespect and abuse they experience in the system. Simply busing Black mothers to better, predominantly White hospitals, for example, constitutes a very shallow solution.
A call to action
The Black community is, in many ways, broken due to a legacy of slavery and a consequence of racism, redlining, and resource allocation. We should hold hospital systems accountable and involve the community by calling our political leaders to invest significantly in these communities and create a plan that can lead to tangible action. In 2020 the Black Congressional Congress launched the Jobs and Justice Act Plan, which included policy solutions to “promote revitalization, [support] small businesses, [and] job creation in historically-underserved communities…” among other things. This omnibus would have acted as a Marshall Plan for underserved communities with millions in meaningful funding. It failed in Congress, but its efforts should not be in vain. With substantial federal funds from legislation like this, Black communities across the country can begin implementing Community Health Programs that focus on functioning primary health care.
Racism is a complex social system that differentially allocates resources and opportunities and has no simple solution. One-time training, be it racial bias or other topics, is insufficient, and so is admitting selected minority women to high-functioning health care facilities. Much progress has been made, but we need a substantial reform of health care provision and a significant redistribution of funding to prioritize action based on the needs of today. Involving the community in primary health care is crucial to improving the quality of care an individual receives. Healthcare systems and providers must be the first to embrace accountability and open the door to communities. Our leaders must fund and invest in these underserved communities and their hospital systems to improve maternal health outcomes for all and create change that we can see in our lifetime.