It’s been all over the news for months: Black women in the United States are dying from complications during their pregnancies or in childbirth at alarming rates, and those deaths are preventable.
Less well explored is how systemic racism and historical trauma have been at the core of what’s driven up these rates over several decades. A March 20 conference entitled The Impact of ACEs on Black Maternal Health took an in-depth look into why Black maternal mortality and complications during childbirth have ratcheted up to crisis proportions.
“Black mothers experience the highest rates of dying and disease of any ethnic group in the United States,” said Rhonda Smith of the California Black Health Network, one of the sponsors of the conference. Others included ACEs Aware, the organization leading California’s ACEs initiative, and the Aurrera Health Group, a firm committed to strengthening the health care delivery system.
Speakers included Dr. Melissa Clarke, clinical transformation physician consultant for 3M Health Information Systems, and Dr. Tanisha Silas-Young, Kaiser Vacaville women’s health chief and Napa and Solano Kaiser women’s health ACEs physician champion. They covered the impact of racism on health, as well what intergenerational trauma and toxic stress mean for pregnant black women. They also discussed how toxic stress and trauma affect the mental and physical health of Black women during pregnancy and predict long-term health outcomes, as well as what solutions are needed to help reverse this trend.
Racism is to blame
The reasons are clear to Dr. Melissa Clarke, who puts the blame squarely on systemic racism, which has led to disparities in income and opportunity. Black women, for example, earn 63% of what white men earn and 20% less than what white women earn, according to Clarke.
“Even though there’s a gender gap, there’s an even greater racial gap,” says Clarke.
Racism also is associated with a greater propensity of chronic health conditions that can lead to complications in pregnancy. Blacks, for example, are 60% more likely than whites to be diagnosed with diabetes, a condition that can cause complications in pregnancy, explained Clarke. (research using data from the Black Women’s Health Study found that Black women who said they were exposed to significant racism on a daily basis were 31% more likely to be diagnosed with diabetes than Black women who reported the lowest quartile of exposure to racism daily.)
Black women have higher rates than white women of complications during pregnancy and labor, according to Clarke. Black women, for example, are 60% more likely than white women to experience preeclampsia, a potentially life-threatening complication of pregnancy associated with high blood pressure. Clarke added that pregnant Black women also experience higher rates of hemorrhaging during pregnancy than white women.
Despite the increased risks pregnant Black women face, they also experience substantial barriers to accessing health care. Black people are less likely to have medical insurance than white people, said Clarke. Nearly a quarter of the Black population is uninsured, according to the Kaiser Family Foundation, compared to 14% of the white population.
There are also far fewer high-quality hospitals and doctors in communities of color, according to Clarke. When Black people do get care, she said, numerous studies have documented the disparities in treatment between Blacks and whites. Among other things, she said, “Black people in general are undertreated for pain and get fewer referrals to life-saving treatments like heart catheterizations, or renal replacement therapy.”
A legacy of mistrust
The current realities, she said, further compound a centuries-long legacy of mistrust. She cites the 40-year-long Tuskegee experiments, a U.S. public health-run syphilis study, in which researchers lied to participants and their families about the purpose and goals of the research, which were to study the trajectory of the disease in untreated Black people without offering them treatment. Clarke also talked about the forced sterilization of Black women around the country from the 1920 to the 1950s, particularly in North Carolina, and the earlier experiments done on enslaved Black women.
“Black women's bodies were used during slavery to experiment on to just learn female anatomy and numerous surgeries were done without anesthesia, without consent, only for that purpose. And so, because of this disparate treatment, we see Black people and Black women lacking a sense of agency when it comes to health care; feeling disempowered.”
While economic disparities might play a giant role in why Black women are much more likely to have complications in childbirth or during pregnancy, income was perhaps less of a factor than racism, according to Clarke. She cites a New York City Health Department study showing that college-educated Black women were three times more likely to experience severe maternal complications than white women without a high school education.
She traces the root of the current crisis in Black maternal mortality to the beginning of redlining. “This was started in the 1940s, when the Federal Housing Authority refused to back housing loans made in predominantly African American neighborhoods, which led to increasing segregation and lack of opportunity available in those neighborhoods, poor quality schools, less jobs available, less reliable transportation going to those neighborhoods. We know from numerous studies that where you live is a huge determinant of how healthy you are. And we see that 80% of health care outcomes can be traced to your ZIP code.”
Redlining and the consequences of it – poverty, lack of opportunity, social mobility, discrimination, and violence -- intensify the impact of adverse childhood experiences (ACEs) and poor health outcomes in adulthood, Clarke said. (The term “ACEs” was first used in the landmark 1998 CDC/Kaiser Permanente Study that tied 10 types of severe childhood trauma to chronic health problems in adulthood, such as hypertension and diabetes). Unremitting toxic stress without the support of a positive adult can have long-term effects, she added.
“That prolonged toxic stress can disrupt the developing brain architecture and increase the risk for stress-related disease, premature aging and addiction well into the adult years,” said Clarke.
The impact is hereditary
To explain how toxic stress can affect the health of future generations, Clarke discussed several studies, including one that found a variation in a gene in the children of Holocaust survivors, which put them at greater risk for post-traumatic-stress-syndrome, high blood pressure and obesity.
Toxic stress that continues in the lives of subsequent generations without any buffers ultimately affects the process of aging and mortality. Clarke talked about studies on telomeres, the caps at the end of DNA strands, whose length is associated with biological aging. One study of Black and white women between the ages of 49 to 55 found that based on telomere length, Black women were on average 7½ years older biologically than white women.
In a study of telomere lengths among low- and moderate-income Blacks, whites and Latinx people in Detroit, researchers found that telomere length was longer in higher-income whites than lower-income whites. But telomere length was shorter among Blacks regardless of their income level. “And the interpretation of that was how others in your environment treat you based on race is not necessarily something that financial security can change.”
Clarke summarized the takeaways from her talk:
- Birth outcomes worsen among Blacks as they age, not just because of economics but also because of racism and trauma.
- Health care providers must recognize the role of toxic stress on maternal health.
- Black women need to have greater access to culturally competent mental health care providers to work on internalized racism and toxic stress.
- Black women need access to culturally competent perinatal care workers with awareness of ACEs and toxic stress and their connection to health outcomes.
Positive experiences can make a difference
Dr. Tanisha Silas-Young reviewed the ACE Study. The more ACEs an individual has, the greater their risk for many coping behaviors and health problems, she noted. “An ACE score of 4 or more unfortunately shows a 4- to 12-times increase in suicidality, depression, substance abuse, tobacco smoking, STDs, obesity, heart disease, cancer liver and lung disease.”
Silas-Young noted that there haven’t been many studies looking at ACEs and maternal health in Black women. But she said you can extrapolate from existing studies showing that if you have a high ACE score but also have high resiliency and social supports, you won’t have an increase in adverse health outcomes in pregnancy and childbirth. Supportive, nurturing relationships are one example of how resiliency can offset adversity.
Other examples include how much an adult felt as a child that they could talk to family members about feelings; felt supported by family members during difficult times; enjoyed participating in community traditions; felt a sense of belonging in high school; felt supported by peers; had at least two adults in their lives, outside of parents, who took a clear interest in them; and felt safe and protected by an adult at home, according to a study in JAMA Pediatrics.
Other examples of resiliency in action include:
- Expressing gratitude
- Activating the senses
- Connecting with nature
- Fostering positive relationships
- Acts of kindness
Silas-Young has worked at Parkland Memorial Hospital in Dallas, which has had more deliveries in its obstetrics and gynecology department than any other hospital in the country. She suggested these strategies for preventing deaths in Black women in labor:
- To prevent hemorrhaging, providers should quantify blood loss during delivery, rather than estimating it.
- For pre-eclampsia, develop protocols for how frequently blood pressure is taken and when anti-hypertensive medications should be administered.
And if there aren’t enough people providing support and caring for Black mms, Silas-Young offers the following strategies:
- Increase the frequency of prenatal office visits.
- Introduce a mindfulness activity during the visit (it can take just a minute or two).
- Offer prenatal support groups for Black moms.
- Set up home visits.
- Encourage the use of labor coaches/certified doulas and health advocates.
- Link patients up with classes on nutrition, sleep hygiene, understanding anxiety and ways to cope with stress
But in order for systemic change to happen in health care, Silas-Young said, health care staff must be required to take training in unconscious bias. In California, this was passed into law in October 2019 as part of the California Dignity in Pregnancy and Childbirth Act. Federal legislation that was reintroduced earlier this year the Black Maternal Health MOMNIBUS Act, will provide funding for community organizations that promote equity.
“I do think that it’s important that all care teams that care for Black mothers get unconscious bias training. But I don’t think that that’s where it stops. There needs to be an ongoing curriculum and constant equity evaluations with feedback,” said Silas-Young. “Equity needs to be embedded in the culture. It needs to be considered when enacting health care protocols, work flows, clinical practices, and be at the forefront in hiring, recruitment and retention practices.”
You can watch the entire conference and learn more here.