Spring 2020 Journal: Mitigating Black Maternal Mortality

April 13, 2020 bppj Race, Reproductive Justice, Social Justice 0

This article is the fourth article featured in our Spring 2020 journal. For the complete journal, please see the “Journal Archive” tab above.

by Angélica Marie Pagán, Vanessa Quintana, and Jenine Spotnitz

Edited by: Lisa McCorkell, Annie McDonald, and Sana Satpathy

Black women are dying at a rate three times higher than that of white women both during and after pregnancy [1]. This state violence against women will persist unless an intersectional analysis is used to parse out and address the root causes of black maternal mortality. This article analyzes the dire issue of black maternal mortality by looking at its racial components, gender components, class components, and the intersections of all three. Through doing so, we are able to recommend solutions that will address the crisis. We recommend that the Department of Health and Human Services: 1) subsidize mental health treatment for black women and low-income communities of color; 2) provide resources to develop community health workers that provide culturally relevant birth support (e.g., doula services); 3) incentivize and regulate the doula industry to be more inclusive of black women; 4) subsidize the cost of doula care and provide free doula services to the most vulnerable women; and 5) improve organizational operations procedures.

Black Maternal Mortality Crisis

The United States has the highest maternal mortality rate among affluent countries in the western world [2]. In comparison to their counterparts in Canada, Australia, New Zealand, and countries throughout Europe, women in the United States report the highest rate of chronic illness, hold the greatest financial burden for health care costs, are the most likely to miss health appointments due to costs, and are the least pleased with their health care [3]. Pregnant women in the United States increasingly have chronic illnesses that increase the risk of pregnancy complications, such as hypertension, diabetes, and cardiovascular disease [4]. Moreover, cardiovascular conditions have steadily increased. Consequently, women in the United States are most prone to complications during pregnancy and childbirth. According to the Centers for Disease Control and Prevention (CDC), the rate of maternal mortality has continuously increased since data started being collected. As of 2016, there were 16.9 maternal deaths per 100,000 live births—a drastic increase from 7.2 deaths in 1987.

Disaggregating the data reveals a grim picture of the appalling racial disparities of the maternal mortality rate. According to the CDC, per 100,000 live births, there were 14.1 deaths among Asian women, 30.4 deaths among Indigenous women, and 42.4 deaths among black women, in comparison to 13.0 deaths among white women. It is imperative to note that Indigenous women have over twice the maternal mortality rate of white women and black women have over three times the maternal mortality rate of white women.

Given the increased complications due to chronic conditions, it is notable that 44 percent of black women over the age of 20 have hypertension [5]. Meanwhile, nearly one in 10 black women are uninsured in the United States [6]. All people of color are in dire health conditions compared to their white counterparts; however, black women fare the worst. As maternal mortality rates continue to rise, it is imperative America reckons with the loss of life that occurs disproportionately in the black community.

Intersectional Analytical Framework and Black Maternal Mortality

Kimberlé Crenshaw notes that the mutually exclusive application of race and gender leads to the demise of black women within the contexts of law, feminist theory, and antiracist politics.7 In order for equitable outcomes to be achieved, she argues that “the single-axis [framework] that distorts [the experience of black women]” and perpetuates discrimination needs to be replaced with a multidimensional analysis [8]. A multidimensional analysis, also referred to as an intersectional analysis, addresses the unique experience of black women that causes them to be vulnerable within a white supremacist patriarchal power structure and is further exacerbated by capitalism for poor, black women.

The issue of black maternal mortality can only be remedied by policies that reflect an  intersectional analysis and are informed by both the history of black women dying during pregnancy and childbirth and the lived experience of black women navigating the health care system. This approach draws upon black women’s expertise and ensures that their identities are centered in the development of health programming. However, current analyses focus only on the racial aspect of black maternal death and fail to account for the impact of gender as well as the impact of race and gender simultaneously on black women’s lives. This single-axis analysis erases black women’s identities as racialized and gendered beings both individually and simultaneously, which results in the lack of critical analysis of the black maternal mortality crisis that has been a topic of research and discussion since the 1980s [9].

Race and Maternal Mortality

Black women confront the compounding effects of racialized trauma in a white supremacist society. Researchers and doctors increasingly acknowledge the “inescapable atmosphere of societal and systemic racism… [that creates] toxic physiological stress” for black women [10]. This phenomenon, known as weathering, has a detrimental effect on the human body over the long-term and leads to the destruction of the metabolic and immune system [11]. The trauma that accompanies being black in a country founded on and continuing its legacy of white supremacy makes black people’s health, and consequently black women, vulnerable to the point of death.

This vulnerability on the basis of race is evident within black maternal mortality rates because the compounded experiences of racism put black women giving birth at a greater risk of dying than their white counterparts. The trauma and stress black people repeatedly experience due to personally mediated, internalized, and institutionalized racism accumulates and takes a toll on black people’s physical and mental health [12, 13]. Consequently, black people have higher stress levels than white people, and this difference continues to increase with age [14]. The heightened stress levels of black women, due in part to experiences of racism, discrimination, and bias, increase their likelihood of complications and death during and after pregnancy.

Furthermore, high blood pressure (hypertension) is one of the leading causes of maternal death [15]. Black people have a greater risk of having high blood pressure and have earlier onset of hypertension [16]. As a result, it is plausible that black women are more susceptible to maternal mortality because racial disparities in hypertension persist without remedy. Research suggests that racism contributes to these disparities: personally mediated and institutionalized racism, in the forms of residential racial segregation and incarceration, may increase risk for hypertension [17].

Gender and Maternal Mortality

Our analysis of the pronounced black maternal death rate must also take into account gender inequity and gendered stereotypes that affect all women, but markedly impact black women because of their racialized and gendered identities. Women as a class are “relatively ineffective influence agents in domains or contexts” that are gender neutral or masculine because of gender stereotypes [18]. Thus, it can be expected that women’s concerns are less likely to be taken seriously by doctors than men’s. A 2012 national study found that 21 percent of black mothers reported that hospital staff treated them poorly due to their race, ethnicity, or cultural background [19].

It is no surprise then that within the context of medicine, a white male-dominated industry, black women’s health concerns and symptoms during and after pregnancy are dismissed. In this male-dominated field, women “typically have the extra burden of establishing their competence” in order for their concerns to be addressed [20]. This burden is especially compounded for black women due to their race and gender when highlighting symptoms or concerns during pregnancy and childbirth. Thus, the experience of dismissal that some black women endure during pregnancy and childbirth is representative of racist, sexist, and classist ideals that thrive in our patriarchal society, and more specifically affect the experiences of women of color within the health care industry.

Race and Gender and Maternal Mortality

In order to address black maternal mortality rates, we must move beyond an analysis that centers on the most privileged of oppressed classes—white women—and instead focus on those that are most vulnerable [21]. Although the single-axis frameworks of gender and race are valuable in beginning to understand black maternal mortality rates, an intersectional analysis is needed to fully understand the scope and breadth of the problem because it takes into consideration all modalities of oppression. Black women are some of the most vulnerable patients in health care, especially in obstetrics and gynecology, because of both their race and gender in a field that has historically been riddled with white supremacy and sexism.

The trauma of experiences associated with being both black and a woman manifests itself in the high stress levels of black women, regardless of income and educational attainment [22]. While socioeconomic status is an important determinant of access to quality health care, research demonstrates that race significantly impacts maternal mortality independent of socioeconomic status [23]. Black women have higher stress loads than both white women and black men, the privileged classes of oppressed groups [24]. These heightened stress levels can be attributed to the extra barriers and burdens black women face constantly throughout their lives because of their gender, race, and identity. The impact of this heightened stress is especially precarious for black women since high stress during pregnancy can lead to preeclampsia (high blood pressure developed during pregnancy). Black people are already predisposed to high blood pressure and heart disease, two of the leading causes of maternal death [25].

The heightened stress levels of black women cannot be mitigated simply through the mainstreamed “meditation and ‘me time’” often espoused in response to stress. The chronic stress of black women is not the result of a one-time or periodic experience, but rather the accumulation of experiences in a patriarchal, white supremacist world [26]. Research demonstrates the link between racism and post-traumatic stress disorder (PTSD), which may be one mechanism through which gendered racism contributes to black women’s increased risk of maternal mortality, as PTSD is associated with cardiovascular disease and earlier mortality from any cause [27]. Thus, an important intervention to reduce black maternal mortality rates is to subsidize and increase access to quality mental health treatment focused on healing trauma and managing stress for black women.

Race, Gender, and Class and Maternal Mortality

Despite black maternal mortality rates existing in epidemic proportions for all black women regardless of income or education level, black maternal health is particularly difficult to improve when one lacks income. Given structural oppression, poor women are left without access to obstetric care systems and emergency obstetric care which can be detrimental, especially for black women who face compounded oppression. Women of modest means face many barriers to care because of an inability to “pay for services, as well as failure to seek services because of prior negative experiences (e.g., receiving culturally inappropriate and unsatisfying services, reproach and sanctions for poor health habits), and lack of transportation” [28]. In our capitalist society, money affords individuals opportunity, access, and life.

Model Doula Program

An effective solution to maternal mortality rates is doula care. Doulas support women throughout their pregnancy, birth, and first year of the child’s life. Doula care reduces cesarean births, decreases mortality and other adverse outcomes, and improves quality of life for the first and second child [29]. However, due to a lack of financial resources, poor women are less likely to receive services from doulas. Thus, it is especially difficult to remedy black maternal mortality without considering the additional impacts of poverty.

Black women are disproportionately represented within impoverished communities and face an additional set of challenges during pregnancy and birth because of the prejudice and discrimination they face in response to their unique identity [30]. Though 21 percent of black women are living in poverty, their additional set of challenges are not taken into consideration for most doula professionals and their practice [31]. Thus, black maternal mortality rates are exacerbated for the most vulnerable poor women of color. The doula consumer market has been “largely driven by and tailored for white women” who can afford their services rather than being inclusive of and focusing on the most vulnerable, which would generate the greatest equity [32].

Continuous access to and support from doula services has been shown to improve outcomes for both black mothers and their babies [33]. Studies show that doula services are associated with lower rates of negative and costly outcomes such as preterm and cesarean births [34]. Thus, doula care is cost-effective as well. A study of 12 states found that the average cost savings from access to doula care among Medicaid beneficiaries would be $58.4 million, and that 3,288 preterm births per year would be prevented [35].

Culturally relevant doulas have similar racial and cultural backgrounds as the mothers they serve, which supports the development of trusting and effective mother–doula relationships. Culturally relevant doulas recognize institutionalized racism in the medical system and help mediate its harmful effects by, for example, “ensuring mothers are asked consent of procedures and are addressed respectfully by medical staff” [36]. They may also help link mothers to needed resources, such as nutrition and housing supports, though this extends beyond their role.

There is a doula care program in Cleveland, Ohio, that could serve as a replicable model for communities across the United States. Birthing Beautiful Communities is an organization that serves Cleveland’s black community with holistic, culturally relevant care and empowerment via a team of black doulas. Inspired to address the black infant and maternal mortality crisis, Christin Farmer established Birthing Beautiful Communities in 2014 to serve the most impacted communities in Cleveland. Farmer had a vision to provide free quality care to black women throughout various stages of motherhood: pregnancy, delivery, and the child’s first year of life [37]. Birthing Beautiful Communities offers: labor support services; life and goal planning; childbirth and parenting education; and healing groups that support mothers with pregnancy stress, anxiety, panic/fear, postpartum depression, and infant loss. Birthing Beautiful Communities strives to create a healing space for women to heal their historical and personal traumas through services like the birthing center and support circles. There is an emphasis on healing, empowerment, and holistic care.

Birthing Beautiful Communities is blazing trails in the health sector. Farmer employs a team of 21 black women to serve Cleveland. She ventures to connect the health, economic development, and business sector via community empowerment centered in equity. Farmer built the organization with community for the community, and describes Birthing Beautiful Communities as hiring “people from the community to work at livable wages, pay a flat fee for every birth they attend, and give them benefits” [38]. Black women lead the organization and are the face of the organization providing perinatal support. Birthing Beautiful Communities is both a health service provider and workforce development program for the black community. Through her organization, Farmer is transforming what the sector looks like in the economics, health, business, and community of Cleveland.

Birthing Beautiful Communities is a model that ought to be replicated throughout America. It employs an equitable business model to empower local communities with economic capital, reflective care, and holistic care that empowers black mothers in their birth journey. Furthermore, it is uniquely positioned to meet the needs of the black community, specifically black women, in culturally responsive care. Black women are valued, empowered, and given quality care. There is potential to replicate this model in other predominantly black communities as well as communities of color across the country.

Site of Delivery and Black Maternal Mortality

The physical location where a black mother gives birth impacts whether she lives or dies. Hospitals may serve predominantly white or non-white populations based on its location and residential hypersegregation. Consequently, the hospitals that serve predominantly white populations have better quality maternal safeguards than a hospital that serves predominantly non-white populations due to our country’s historical lack of investment in and disregard for communities of color [39]. This lesser quality of care experienced by hospitals that serve black and brown families is likely to be explained by organizational deficiencies. It is important to ensure the hospital leadership team is genuinely committed to investing in the rectification of these issues in an actionable manner. Adjusting a hospital’s values to include black maternal health equity, ensuring solid communication between health providers, and utilizing audit and feedback procedures in efforts to reflect on the achievement (or lack thereof) of equitable outcomes addresses these organizational deficiencies [40].

Nonetheless, these differences in organizational outcomes continue to exist when hospitals serve hypersegregated communities. The lack of cultural competency on the part of physicians and the hospital as an institution, the underuse of evidence-based interventions, and a hospital’s status as having organizational deficiencies furthers these disparities [41]. These issues can be addressed through the creation of improvement goals, checklists that mandate use of evidence-based interventions, support from hospital leadership and administration to ensure the implementation of these measures, and the use of audits and feedback to guide hospital standards to support black maternal wellbeing. Black women medical professionals should be consulted in the development of these tools. These efforts mitigate black maternal mortality rates on a class-wide level because they also address the needs of middle- and upper-income black women. Enactment of these initiatives for all black women is imperative because maternal mortality rates remain exceedingly high for black women even when income is held constant.

Policy Recommendations

The United States has a constitutional responsibility to promote the general welfare of all its citizens, especially that of one of its most vulnerable populations: black women. Yet many policies that impact black women are not designed from an intersectional analysis or an understanding that “black women are inherently valuable,” and may therefore be limited in their ability to improve conditions for black women. Policies to reduce black maternal mortality rates should be policies that black women champion because they uniquely address their culturally specific needs. Policies driven by the people most impacted are the most radical and effective because they are rooted in a thorough understanding of the challenges faced by the population of that shared identity [42]. Therefore, to lessen the black maternal mortality rate, the U.S. Department of Health and Human Services should support black women by:

  • Subsidizing quality mental health treatment for black women and communities of color to lessen the high stress levels that they experience. Quality mental health care that is focused on healing trauma and stress management can provide recipients with coping tools and strategies that may help black women navigate a medical system laden with bias against black people, women, and black women. Research demonstrates that quality improvement strategies, including psychotherapy interventions specifically developed for use with low-income people of color, can ameliorate disparities in mental health outcomes.43 Mental health professionals who are black women should be consulted to further develop quality standards and interventions specifically tailored to supporting black women’s mental health.
  • Increasing access to culturally relevant doulas for low-income communities of color by committing resources to expand the development of community-based, health-worker doula services to ensure poor women of color have an advocate and health advisor [44]. The challenges faced by black expectant mothers compound when financial barriers are present. Doula care would benefit low-income mothers because the doula can serve as an advocate and health advisor to a mom who is already preoccupied with demands that come from being black, a woman, and poor. Doula services that are community-based provide the most benefit because a person who is already grounded in the community has a higher likelihood of being culturally responsive and garnering the trust of those in the community.
  • Mandating private insurance coverage of quality doula services. States should pass legislation requiring managed care organizations and other private insurers to include support by doulas as a covered service. This would help increase the likelihood that middle-income black mothers access doula care.
  • Providing free doula services of quality to women who receive either Medicaid, WIC, or CHIP if they already have children and/or cannot afford the cost of a doula on their own [45]. Research demonstrates the effectiveness of doula care for Medicaid recipients: it reduces the rate of cesarean deliveries and preterm births [46]. Receipt of Medicaid, WIC, or CHIP would serve as a useful proxy to measure income since these programs are means-tested. Expanding Medicaid coverage will allow the most vulnerable mothers access to quality doula care. In 2019, New York launched a pilot program to expand Medicaid coverage of doula services in Erie County and Kings County, the counties with the highest maternal and infant mortality rate in the state [47]. Oregon and Minnesota precede New York in allowing for reimbursement for doula services for Medicaid coverage. States can work around the federal mandate for Medicaid reimbursement of licensed professionals by initiating a clinician intermediary billing for doula services as Minnesota does or contract billing for doula services as Oregon has implemented [48].
  • Mandating the use of evidence-based intervention checklists, creating and requiring improvement goals for hospitals, performing audits, requesting and reflecting on feedback to guide hospital standards and interventions, and demanding hospital leadership and administration actively support implementation of these measures to support black maternal health. Black women who are medical professionals should be consulted in the development of checklists and other tools. These institution-based interventions can lessen the harm that mothers, particularly black mothers face during pregnancy and childbirth. Furthermore, given that only five percent of physicians nationwide are black women, expanding opportunities for black women to enter medical professions would help make culturally relevant care more available [49].

Conclusion

Remedying black maternal mortality rates presents an opportunity for the United States to use  intersectional analyses to lessen the black suffering, women’s suffering, and black women’s suffering that has been a pervasive part of our country’s institutions and systems. When we use this framework, we acknowledge the inherent value and humanity of black women. When we create and implement policies targeted at poor black mothers, we also improve outcomes for all mothers. The Department of Health and Human Services can improve outcomes through subsidized mental health treatment, increased access to and provision of community health worker programs, incentivization and regulation of a more inclusive doula industry, subsidized doula costs, free doula services for the most financially insecure women, and improved organizational operations.

Sincere thanks to Terinney Haley, Master of Public Health candidate in Epidemiology & Biostatistics, for her critical review of this paper.

Angélica Marie Pagán, Vanessa Quintana, and Jenine Spotnitz are second-year Master of Public Policy students at the Goldman School of Public Policy

Endnotes

  1. Villarosa, Linda. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times. 2018 April 11. Retrieved from www.nytimes.com/2018/04/11/magazine/Black-mothers-babies-death-maternal-mortality.html.
  2. Gunja, M. Z., Tikkanen, R., Seervai, S.. & Collins, S. “What is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries?.” The Commonwealth Fund. 2018 December 11. Retreived from https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/womens-health-us-compared-ten-other-countries.
  3. Centers for Disease Control and Prevention. “Pregnancy Mortality Surveillance System.” 2019 October 10. Retreived from https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
  4. Ibid. Centers for Disease Control and Prevention.
  5. Centers for Disease Control and Prevention. “Health of Black or African American non-Hispanic Population. 2017 May 3. Retrieved from https://www.cdc.gov/nchs/fastats/Black-health.htm.
  6. Centers for Disease Control and Prevention. “Type of Health Insurance Coverage for Persons Under Age 65.” 2017.  Retrievied from https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2017_SHS_Table_P-11.pdf.
  7. Crenshaw, Kimberlé. “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics.” University of Chicago Legal Forum: Vol. 1989: Iss. 1, Article 8. Retrieved from: http://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8
  8. Ibid. Crenshaw.
  9. Siefert, Kristine, and Louise Doss Martin. “Preventing Black Maternal Mortality: A Challenge for The 90’s.” Journal of Primary Prevention, vol. 9, no. 1–2, 1988.  pp. 57–65. Retrieved from libproxy.berkeley.edu/login?qurl=http%3a%2f%2fsearch.ebscohost.com%2flogin.aspx%3fdirect%3dtrue%26db%3dflh%26AN%3dMRB-FSD0213720%26site%3deds-live.
  10. Ibid. Villarosa.
  11. Ibid. Villarosa.
  12. Jones, Camara P. “Invited Commentary: “Race,” Racism, and the Practice of Epidemiology.” American Journal of  Epidemiology. 2001 August. Retrieved from https://doi.org/10.1093/aje/154.4.299.
  13. Williams, David, et al. “Racism and Health: Evidence and Needed Research.” Annual Review of Public Health. 2019.  Retrieved from https://doi.org/10.1146/annurev-publhealth-040218-043750.
  14. Geronimus, Arline T., et al. “‘Weathering’ and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States.” American Journal of Public Health. 2006 May. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC1470581/.
  15. Ibid. Villarosa.
  16. Lackland, Daniel T. “Racial Differences in Hypertension: Implications for High Blood Pressure Management.” The American Journal of the Medical Sciences. 2014 August. U.S. National Library of Medicine. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC4108512.
  17. Elizabeth Brondolo, et al. “Racism and Hypertension: A Review of the Empirical Evidence and Implications for Clinical Practice.” American Journal of Hypertension. 2011 May. Retrieved from  https://doi.org/10.1038/ajh.2011.9
  18. Carli, Linda L. “Gender and Social Influence.” Journal of Social Issues, vol. 57, no. 4. 2001. Retrieved from http://academics.wellesley.edu/Psychology/Psych/Faculty/Carli/GenderAndSocialInfluence.pdf
  19. Declercq, Eugene, et all. “Report of the Third National U.S. Survey of Women’s Childbearing Experiences.” Childbirth Connection.  2013 May. Retrieved from https://www.nationalpartnership.org/our-work/resources/health-care/maternity/listening-to-mothers-iii-pregnancy-and-birth-2013.pdf
  20. Ibid. Carli
  21. Ibid. Crenshaw.
  22. Ibid. Geronimus.
  23. Goffman, D., Madden, R., Harrison, E., et al. “Predictors of maternal mortality and near-miss maternal morbidity.” Journal of  Perinatology. 2007 August 16. Nature Research.  Retrieved from https://www.nature.com/articles/7211810.
  24. Ibid. Geronimus.
  25. “Stress and Pregnancy.” March of Dimes. Retrieved from www.marchofdimes.org/pregnancy/stress-and-pregnancy.aspx.
  26. Ibid. Villarosa.
  27. Edmondson, Donald and Beth E. Cohen. “Posttraumatic Stress Disorder and Cardiovascular Disease.”
  28. Nagahawatte, N. Tanya and Goldenberg, Robert L.“Poverty, Maternal Health, and Adverse Pregnancy Outcomes.” Annals of the New York Academy of Sciences. Volume 1136, Issue 1. 2008 July .
  29. Tilden, Ellen L. and Caughey, Aaron B. “The Cost-Effectiveness of Professional Doula Care for a Woman’s First Two Births: A Decision Analysis Model.” Journal of Midwifery & Women’s Health. Volume 64, No. 4. 2019 July/August.
  30. “Poverty Rate by Race/Ethnicity.” The Henry J. Kaiser Family Foundation. 2017 May. Retrieved from https://www.kff.org/other/state-indicator/poverty-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D
  31. Current Population Survey: 2016. Census Bureau. 2017 September. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2017/demo/P60-259.pdf
  32. Ibid. Villarosa.
  33. Ibid. Villarosa.
  34. “Doula Care Study.” University of Minnesota. 2016 January 14. Retrieved from https://www.health.umn.edu/news/news-releases/study-doula-care-cost-effective-associated-reduction-preterm-and-cesarean-births
  35. Ibid. “Doula Care Study.”
  36. Wint, Kristina,  Elias, Thistle, Mendez, Gabriella, et al. “Experiences of Community Doulas Working with Low-Income, African American Mothers.” Health Equity. 2019 April 8. Retrieved from http://doi.org/10.1089/heq.2018.0045
  37.   Ibid. Wilder.
  38. Ibid. Wilder.
  39. Howell, Elizabeth A., and Jennifer Zeitlin. “Improving Hospital Quality to Reduce Disparities in Severe Maternal Morbidity and Mortality.” Seminars in Perinatology, vol. 41. 2017 August. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0146000517300435?via%3Dihub.
  40. Ibid. Howell and Zeitlin.
  41. Ibid. Howell and Zeitlin.
  42. Combahee River Collective. “Black Feminist Statement.” 1977.
  43. McGuire, Thomas and Jeanne Miranda. “New evidence regarding racial and ethnic disparities in mental health: policy implications.” Health affairs (Project Hope) vol. 27, Issue 2. 2008 March. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928067/
  44. Gay, Elizabeth Dawes. “New York Governor Cuomo Should Not Play Politics With Black Maternal Health.” Rewire.News. 17 October 2018. Retrieved from rewire.news/article/2018/10/17/new-york-governor-cuomo-should-not-play-politics-with-Black-maternal-health/.
  45. Ibid. Gay.
  46. Kozhimannil, Katy B., Hardeman, Rachel R., Attanasio, Laura B., Blauer‐Peterson, Cori, O’Brien Michelle. “Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health, volume 103, issue  4: e113‐ e121. 2013 April.
  47. New York Department of Health. “New York State Doula Pilot Program.” Retrieved from https://www.health.ny.gov/health_care/medicaid/redesign/doulapilot/index.htm.
  48. Center for Health Innovation & Policy Science. 2019. “The Doula Option.” University of Washington. Retrieved from https://depts.washington.edu/uwchips/docs/brief-doula-option.pdf.
  49.   “Diversity in Medicine: Facts and Figures 2019.” Association ofAmerican Medical Colleges. 2019, July 1. Retrieved from www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018