Finding out that you’re going to have a baby can bring joy and excitement. For women of color, it can also bring serious concerns about the higher maternal mortality rates in some groups, especially among Black women. Maternal mortality rates are nearly three times higher among Black women than white women in the U.S.
While many of the reasons for that are bigger than any one person, learning what you can say and do to address this risk can help empower you during and after your pregnancy.
“Our babies are often born too small, too sick, or too soon,” says Kimberly Seals Allers, a maternal and infant health advocate and creator of the Irth app, which allows mothers to rate doctors, hospitals, and birthing centers.
It’s important to be informed and ask providers point blank what they are doing to minimize risks of severe illness for babies and mothers – especially for Black women, says Lisa Nathan, MD, chief of obstetrics at the Columbia University Medical Center and co-chair of the Maternal Mortality Review Committee for New York City’s Department of Health and Mental Hygiene.
“There are very real, very large risks unfortunately associated with being Black in this country and being a woman and being pregnant,” Nathan says. “It’s important not to be afraid to have some of these discussions early on so that you know you’ve found the right person and that you have good communication moving forward.”
Bring It Up Directly
The first step is to discuss the impact of racism on the systems of care during pregnancy and postpartum, says OB-GYN Erica P. Cahill, MD, a clinical assistant professor at the Stanford University School of Medicine.
(For more on this issue, listen to WebMD's Health Discovered podcast episode with Tonya Lewis Lee on her new Hulu documentary, Aftershock.)
It might not be easy. But “pregnancy care providers have conversations around fears and concerns all the time,” Cahill says. “The language around racism is what's different here.”
Since 2019, she’s collaborated with doula Erica Chidi to develop and enhance Centering Anti-Racist Education for patients and providers, also known as the CARE pregnancy tool. Chidi, based in Los Angeles, is co-founder and CEO of LOOM, a nonprofit that offers evidence-based sexual and reproductive health education.
You can start the conversation with your care team by saying: “I know that there are lots of risks for Black women, and I'm concerned. What are you doing to try to reduce risks for patients like me?”
Here are other questions and steps to consider to take care of yourself and your baby.
How soon should I begin planning for a baby?
Start this as early as possible – long before you try to conceive or as soon as you find out that you’re pregnant.
This will help you and your doctor develop a care plan earlier. They’ll want to know about your family’s health history and may recommend tests and look for fibroids in the uterus. Uterine fibroids disproportionately affect women of color and sometimes cause complications, says OB-GYN Francesca M. Rogers, MD, who specializes in high-risk pregnancies at Woman’s Care at the Pavilion in Burbank, CA.
Early planning also makes it easier to find an OB-GYN who’s a good fit for you in terms of care and communication – even if you need to switch doctors.
“If you go to have your pap smear and you don't like their attitude, you probably don't want them to deliver your baby,” Rogers says. “Some people like being told what to do; some people like making their own decisions.”
Every woman deserves health care providers who listen well and answer questions. But that doesn’t always happen.
For Black women in the U.S., implicit and overt bias date back to slavery. While many hospitals and providers now try to acknowledge it and make improvements, it hasn’t gone away and it leads to maternal problems that cut across socioeconomic lines, Nathan says.
You may recall that Serena Williams said she was ignored after a C-section in 2017 when she asked for blood-thinning medications because of her history of clots. She ended up with more surgery, blood clots, and a ruptured incision from intense coughing.
“What happened to the tennis superstar provided a clear-cut case study of discrimination in health based on race – not class,” says Linda Villarosa, author of Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation.
What can I do if my concerns aren’t being heard?
If you feel that you aren’t being heard, you have options – even if it’s too late to change doctors or you’ve already given birth and you’re still in the hospital.
“You can always say, ‘I would like to speak to someone at the next level in the chain of communication because I have some concerns’,” Nathan says.
“I'm big on everyone getting a second opinion,” Rogers says, “and you can always ask your OB-GYN to send you to a maternal fetal medicine specialist.”
What if I’m at risk of preeclampsia?
"Preeclampsia is a problem of high blood pressure in pregnancy that disproportionately affects Black women,” Cahill says.
Consider getting a blood pressure cuff to use at home, Cahill says. She notes that preeclampsia signs include blood pressure that’s above 140 for the first number, above 90 for the second number, or if you suddenly have increased swelling around the eyes and in the hands and feet. Your care team can also test your liver and kidney function as part of diagnosing preeclampsia, Cahill says.
It’s not just a pregnancy problem.
“Preeclampsia can also happen postpartum, so it’s important to watch out for that,” Cahill says. She emphasizes having a postpartum care plan for support, food, and sleep. “There's so much more all new parents need.”
Should I use a birthing center or hospital?
Talk about this with your doctor so you know what each type of facility offers – and how prepared they are if something goes wrong – and what is best for you.
“Women who have uncomplicated pregnancies can deliver at a birthing center, but anyone who has a high-risk pregnancy should deliver at a hospital with a good neonatal intensive care unit, or NICU,” says Rogers, who has delivered babies in both settings.
Hospitals with Level III and IV NICUs are better prepared to handle complex cases and emergencies affecting babies as well as mothers, Rogers says.
Even if you don’t live near such hospitals, you can look for doctors who have admitting privileges at the hospitals you would want to go to if you had to. “Admitting privileges” means that the doctor has the right to admit patients to a certain hospital.
You want to understand who’s on your birth care team, what the plan is, and what happens if the plan has to change.
“Discuss what's important to you about birth with your care team during prenatal visits,” Cahill says. “Ask questions about what's typical in this practice, [and] what the process of changing the plan looks like.”
How do you plan for pain control? What are my options?
Pain has a long history of being undertreated in women, especially in Black women. It still happens, Cahill says. Her advice: Talk about this directly with your care team.
False perceptions that African Americans have a higher threshold for pain persist as shown in a 2016 study that included medical residents. Such beliefs have resulted in pregnant women being shortchanged on pain management or ignored in other ways.
If I’ve had a C-section, is it safe for me to deliver vaginally?
The answer depends on several things including your current risks, previous complications or scarring, and your doctor’s comfort level, Rogers says.
If your care team determines that it’s safe, a vaginal birth after cesarean delivery (VBAC) offers health benefits including a shorter recovery, less blood loss, and lower chance of infection, according to the American College of Obstetricians and Gynecologists.
C-sections are more common among Black women compared with other women in the U.S. Of all babies born to Black women in 2020 in the U.S., 36.3% were delivered by C-section, compared with the national average of 31.8% across all women, CDC figures show.
But if you’re looking at a doctor’s or hospital’s C-section rates as a quality measure, both Nathan and Rogers say to keep that information in context.
“It doesn't necessarily mean that there's something going on that's not OK,” says Rogers, who has many older and high-risk patients who request and/or need C-sections. Nathan says that the same is true at Columbia’s medical center, where she works.
Sometimes I feel overwhelmed. How can I make this experience more manageable?
“Pregnancy brain is a real thing,” Rogers says. She suggests writing down questions and keeping a journal. “It's hard to remember when you're pregnant. That's why having someone with you to keep track of things is very important.”
Tap into support systems and lean on your family and friends, advises Brittney Lemon, an OB-GYN nurse at Mount Carmel St. Ann’s in Columbus, OH, who has worked with moms at hospitals around the U.S.
If people offer help, take it. This isn’t the time to say “No,” Lemon says, especially right after your baby is born, when the risk of life-threatening maternal complications is highest.
Birthing classes can help you feel more prepared. Parenting groups like Mocha Moms can extend your circle of support. Lemon and the other experts recommend that you consider professional support, such as a doula who can be with you every step of the way during your pregnancy and especially during the critical postpartum period.
Doulas can be expensive. But you can ask your doctor or a hospital social worker about financial support, Nathan says. Some moms turn to crowdfunding sites or ask friends and family to chip in toward the cost of a doula instead of buying gifts for baby showers.
Don’t minimize the emotions that you might feel during and after pregnancy, Rogers says. Share them with your care team, especially if you feel stressed out, depressed, or anxious. Your provider should monitor your mental health from the start, Rogers says, and recommend therapy or other treatment if needed.
What else can I do to educate myself?
Use credible websites from reputable medical organizations and institutions like the CDC. Rogers also recommends books like Pregnancy Day by Day. For postpartum, Cahill recommends the books Build Your Nest and The First Forty Days.
Allers also offers reviews of providers and hospitals through her app, called “Irth.” It’s named for birth “without the B for bias,” Allers says.
Another app in development is called PM3 (Preventing Maternal Mortality Using Mobile Technology). It’s being designed for and with Black women to help them manage their health and connect to social support and community resources. Researchers from Emory University, Morehouse School of Medicine, and Georgia Tech are collaborating on the app, which is being used in clinical trials in Georgia.
Above all, use what you learn to empower – not frighten – yourself. As Nathan tells her patients, you are the most important member of your team.