Black women in New York are three times as likely as white women to suffer from life-threatening complications during childbirth, and 12 times as likely to die from pregnancy-related causes. Strikingly, racial disparities persist even when usual risk factors, including education and poverty, are accounted for; college-educated black mothers have worse health outcomes than white women without high school degrees. The New York City Health Department is tackling this racial inequity head-on with multiple clinical and community-based initiatives, including a scheme offering black women support from “doulas”; non-medical helpers who provide emotional and physical support. It has also implemented the US’s first citywide data collection and surveillance system for severe maternal health complications to focus attention on racial inequities and their causes.
Results & Impact
New data has highlighted the acuteness of the problem. While about 30 women in New York City die each year of a pregnancy-related cause, around 3,000 women almost die during childbirth, and Black women face greater risks on both counts. Most of the solutions the city is implementing are new, so results are yet to be seen. However, through one initiative in Brooklyn, doulas have supported more than 700 families. According to a recent report, women with doula support are 39% less likely to have a c-section and 15% more likely to give birth without needing drugs or labour-inducing techniques.
New York City Health Department, The Fund for Public Health in New York City, Healthy Start Brooklyn, Merck for Mothers, CityMatCH, American Congress of Obstetricians and Gynecologists-District II, Community Engagement Group on Sexual and Reproductive Justice, Nurse-Family Partnership
The data collection system was built by the New York City Health Department and Fund for Public Health. Data is collated from birth certificates, which include demographic and medical information on the pregnancy, and inpatient hospital discharge data. Life-threatening childbirth complications are identified from this data with an algorithm developed by the Center for Disease Control and Prevention. To combat racial disparity in maternal health, the state is using targeted universalism. This means looking at policies that will enable all women citywide to have the healthiest pregnancy possible, and then prioritising neighbourhoods with the worst outcomes. Key new initiatives include activities around chronic health problems and stress (from exercise classes to mental health support), the doula program, home-visiting programs, family wellness suites in neighbourhood health centres, and a clinical advisory team of obstetricians and gynaecologists to translate the data into clinical solutions.
Women and girls, children, low-income people, ethnic minorities
Cost & Value
The data collection system was built over three years with a $650,000 grant from Merck for Mothers. The doula initiative has an annual budget of about $250,000 and now employs 13 doulas. Maternal ill health is itself costly: from 2008 to 2012, extra costs related to severe maternal morbidity in New York exceeded $17 million each year.
Running since 2010
Racial disparities in maternal health outcomes have persisted for decades and have complex and deep causes. Issues of structural racism, such as the concentration of Black communities in areas with worse public services and the daily stresses and challenges faced by women of colour, cannot be decisively addressed by short-term community or clinical initiatives.
Baltimore is also starting a doula support initiative inspired by Brooklyn’s program.
New York is taking pioneering steps to confront stark racial inequalities in the health outcomes of its mothers.
Through its own improved data collection – the nation’s first citywide surveillance system for severe maternal ill health – the city has drawn attention and focus to the depth of the problem. From 2008-2012, Black women were three times as likely as white women to suffer from life-threatening complications during childbirth. And from 2006-2010, black women were 12 times as likely to die from pregnancy-related causes. While about 30 women in New York City die each year of a pregnancy-related cause, around 3,000 women almost die.
Strikingly, racial disparities persist even when the usual risk factors, including low education, poverty, and obesity, are accounted for. In fact, college-educated black mothers have worse health outcomes than white women without high school degrees.
“We know that there are two major immediate drivers that lead to such stark racial disparities,” said Dr. Deborah Kaplan, Assistant Commissioner for the Bureau of Maternal, Infant and Reproductive Health. “One is women’s health before pregnancy – that is the strongest predictor of whether you have a healthy baby and whether you yourself have complications. The other is what we call ‘toxic stress and trauma’, meaning chronic exposure to racism, violence, poverty, unemployment…. Those factors that poor women, and particularly women of colour, face day in and day out in society and that lead to chronic conditions and stress, putting a woman’s body in a state of constant fight and reaction, and affecting her ability to have a healthy baby,” said Kaplan.
While the challenge is immense, the New York City Health Department is not shying away and is tackling maternal racial inequities with clinical and community initiatives. It is using targeted universalism: which means that policy should be universal in its goals, but targeted in its strategies to reach those goals. The idea is that a policy that seems universal on the surface will have differential impact in practice because the underlying structure – the starting point – is not equal.
“We’re using targeted universalism; we’re looking citywide at which policies will create an environment where all women have the opportunity to have the healthiest pregnancy outcomes possible, and then we’re prioritising the neighbourhoods where there are the worst outcomes. Those are neighbourhoods in the South Bronx, East and Central Harlem, and North and Central Brooklyn, as well as in two neighbourhoods in Queens. That is where we are putting particularly intensive resources,” said Kaplan.
Some of the new community-based initiatives in the pipeline include activities around chronic health problems and stress reduction (such as exercise classes and mental health support), along with family wellness rooms in the city’s new neighbourhood health centres. The city is extending its home-visiting program, the Nurse-Family Partnership, in which nurses visit pregnant women and new mothers in their homes every one to two weeks, offering guidance. The aim is to reach the city’s most marginalised women, including teen mothers in foster care, women who are incarcerated or involved in the justice system, and homeless women and teens.
Perhaps the most established initiative is Brooklyn’s By My Side Birth Support program, which provides free and comprehensive doula care to women in need, and has been running since 2010. Doulas are non-medical helpers, providing emotional, physical, and organisational support to women before and during birth.
African-American women have a long history of using doulas; during the Jim Crow era, many hospitals denied access to pregnant women, meaning many had to deliver at home. Doulas have now been shown to improve maternal health outcomes; according to a recent study, women with doula-type support are 39% less likely to have a c-section and 15% more likely to give birth without needing drugs or labour-inducements.
“Multiple studies have shown that women who are assisted by doulas have fewer caesarean deliveries and medical interventions, have higher rates of satisfaction with their birth experience, higher rates of breastfeeding initiation and duration, and are less likely to develop postpartum depression. And newer research in the past year or two suggests women who receive extensive prenatal doula support have lower rates of preterm birth, a large factor in infant mortality,” said Gabriela Amman, Program Manager of By My Side.
Brooklyn’s doulas have attended more than 580 births and supported more than 700 families since 2010. More than 60 doulas have been trained and 13 are currently employed through By My Side. The initiative, part of the federally-funded Healthy Start program, has an annual budget of about $250,000. And it is now catching attention of other states; Baltimore is building its own doula program inspired by Brooklyn.
On the clinical side, the City Health Department is working with obstetricians, gynaecologists and hospitals to improve labour and childbirth. In 2016 it convened a meeting of experts – obstetricians, nurses, midwives and physicians – to share best practices. The next step is to convene a maternal mortality/morbidity advisory team to gain a holistic understanding of the data and translate it into actionable strategies.
The future is looking brighter, with drive and focus on this issue through the Health Department up to the Commissioner and Mayor. However, racial disparities in maternal health outcomes have persisted for decades and have complex and deep structural and behavioural causes, meaning there is no one simple or short-term fix.
“We’re looking at what we can do to improve women’s health, but also at the underlying factors that drive this, particularly structural racism. We have had inequity built in from the beginning of our country… Our neighbourhoods were formed by very intentional policies that have moved people of colour, and particularly black people, into segregated communities that have been underinvested in, meaning people are living in environments with factors like poor housing, less access to healthcare, and less exercise, that impair their health and increase the likelihood of poor birth outcomes,” said Kaplan.
Solving maternal health inequity will require long-term solutions and focus. Therefore, a critical part of future planning is a continued effort to keep improving data, to retain focus and attention on the problem and its causes.
New York’s Severe Maternal Morbidity surveillance system is the first in the country of its kind. Data is collated from children’s birth certificates, which include demographic information and a medical report on the pregnancy, and from inpatient hospital discharge data. Occurrences of life-threatening childbirth complications are identified by an algorithm developed by the Center for Disease Control and Prevention.This system was built with a $650,000 grant from Merck for Mothers.
The data collected so far has also highlighted the strong economic case for confronting maternal ill health. The City Health Department’s Severe Maternal Morbidity report found that from 2008 to 2012 the total extra costs of severe maternal health problems in the city exceeded $17 million each year. This means that tackling the causes of these health problems could end up saving a lot of money and more than paying for itself.
(Picture Credit: Flickr/Rob!)