In the lead up to her son’s birth, Jacqueline made plans to call 911 for an ambulance to pick her up from her North Florida home and transport her to a hospital about an hour away.

The second-time mom and Guatemalan immigrant, who has lived in the country for a decade, would have relied on her husband to drive her to the hospital. But a few months ago he was deported, leaving Jacqueline and her daughter without the family’s primary source of income, transportation and support.

One morning in March, Jacqueline said, her partner was pulled over on his way to work when law enforcement officials discovered he didn’t have a valid driver’s license. Jacqueline’s pregnancy was in its early stages. Her husband fought his case from detention for three months before U.S. Immigration and Customs Enforcement (ICE) removed him to Guatemala.

“He was deported and I was left behind, thinking, ‘What am I going to do?’” said Jacqueline, who requested that her last name not be published because she lacks permanent legal status. The couple shares an 8-year-old daughter who was born in, and is a citizen of, the United States.

This summer, as she entered the later stages of this pregnancy amid the Trump administration’s turbocharged immigration enforcement, Jacqueline found herself so fearful of being detained that she avoided leaving her home. Her husband’s car sits in the driveway, but there are no signs of him in the small room Jacqueline shares with her daughter. His belongings — tools, clothes, even personal photos — are with him in Guatemala. The only family pictures Jacqueline has are on her phone.

Her partner was the family’s main provider, rotating between picking strawberries or watermelon and packing pine needles for mulch, depending on the season.

Jacqueline struggled to get the most basic items to welcome a baby: Someone gifted her a used carseat and crib, which sit in the packed room along with onesies and other clothing items she’s collected inside a large plastic bag. She’s hoping that a federal assistance program will cover the cost of formula. A baby tub is still on her list.

Medical care in her rural area has been possible only because a small nonprofit organization nearby that provides prenatal care services offered to pay for Ubers so she could continue regular check-ups. Even if she wasn’t behind the wheel, Jacqueline says that just the act of leaving her home feels risky since her husband’s deportation.

“Things got really complicated. He paid our rent — he paid for everything,” she said. “Now, I’m always worried.”

Medical care and support essential to a healthy pregnancy have become harder for people like Jacqueline to obtain following President Donald Trump’s inauguration. Many patients — nervous about encountering immigration officials if they leave their homes, drive on public roads or visit a medical clinic — are skipping virtually all of their pregnancy-related health care. Some are opting to give birth at home with the help of midwives because of the possible presence of ICE at hospitals.

Across the country, medical providers who serve immigrant communities said fewer patients are coming in for prenatal or other pregnancy-related care. As a result, patients are experiencing dangerous complications, advocates and health care providers told The 19th.

“Fear of ICE is pushing my patients and their families away from the very systems meant to protect their health and their pregnancies,” said Dr. Josie Urbina, an OB-GYN in San Francisco.

In January, Trump rescinded a federal policy that protected designated areas including hospitals, health clinics and doctors’ offices from immigration raids. ICE has recently targeted patients in and on their way home from .

A majority of Americans believe ICE should not be carrying out immigration enforcement at health centers. A new poll from The 19th and SurveyMonkey conducted in mid-September found that most Americans don’t think ICE should be allowed to detain immigrants at hospitals, their workplace, domestic violence shelters, schools or churches.

Women are more likely to oppose enforcement in these spaces than men. More than two-thirds of women said ICE shouldn’t be allowed to detain immigrants in hospital settings.

Enforcement is only expected to grow as the administration works to meet its ambitious deportation goals. The federal government is pouring more than $170 billion over the next four years into expanding immigration enforcement, the result of Trump’s signature tax-and-spending bill. About $45 billion has been directed to expanding detention facilities; $29.9 billion is to increase ICE activity.

That expansion could put even more births at risk. Approximately to immigrants without permanent legal status. Already, research has shown these immigrants, who have higher uninsured rates, are less likely to seek prenatal care and are at risk of worse birth outcomes.

Major medical groups, including the American College of Obstetrics and Gynecologists, World Health Organization and the Centers for Disease Control and Prevention (CDC) recommend regular prenatal and postpartum care as a key tool to combat pregnancy-related death and infant mortality.

According to the federal, infants born to parents who received no prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to parents who received regular care.

A published last year found infant mortality rates went up the later families began prenatal care: 4.54 deaths per 100,000 live births for families whose prenatal care began in the first trimester, compared with 10.75 in families whose prenatal care began in the third trimester or who did not receive any at all.

“A lot of patients aren’t going to get help,” said Yenny James, the founder and CEO of Paradigm Doulas in the Dallas-Fort Worth metro.

James said she’s seeing an increasing number of emergency cesarean sections�� because of untreated gestational diabetes, or — a deadly pregnancy complication — that went unnoticed because of lacking prenatal care.

In Denver, OB-GYN Dr. Rebecca Cohen has delivered multiple babies this year for women who have told her that, because they fear endangering themselves or their families, they have received no prenatal care. Several have given birth to babies with fatal fetal anomalies that were never diagnosed because the women did not receive prenatal ultrasounds.

“They were willing to forgo care — their own health care — but to find out that something was devastatingly wrong with their child is when they feel like maybe they should have risked it,” Cohen said. “There’s a sound of a mother’s wail that anybody who has worked labor and delivery has known, and it will haunt you for the rest of your life. To hear that when it could have been prevented, it is just absolutely devastating.”

Early in her pregnancy, Jacqueline received free care at a local clinic. Shortly after her husband’s detention, she called the office to let them know she likely wouldn’t make her next appointment.

“I told them that I probably wouldn’t be able to make my appointments anymore, well, because I’m really afraid given what happened to my husband. And they offered to help,” she said.

Jacqueline and the nonprofit clinic worked out an arrangement: The day of her appointments, someone at the clinic called an Uber to her home, paid for by the clinic, and let her know when it would arrive so she could be ready.

Many people in her small town have come to rely on a single person who does have a valid driver’s license for transportation. That driver recently brought Jacqueline to an appointment with the local office that manages the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which she is relying on for baby formula and food. There were no guarantees that this driver would be available to take her in whenever she goes into labor.

The Biden administration not to detain, arrest or take into custody pregnant, postpartum or breastfeeding people simply for breaking immigration laws, except under “exceptional circumstances.” The Trump administration has not formally reversed that policy. But despite the directive, reports from across the country confirm that ICE has detained numerous pregnant immigrants since Trump took office.

James said that until the Biden guidance is formally rescinded, she will continue to encourage pregnant immigrants to print it out and carry it with them.

“I told my doulas — have them print out this ICE directive, have them keep it with them, so that they know and these agents know that we know our rights, our clients know their rights,” James said.

It’s unclear exactly how many pregnant immigrants are being detained by ICE, or have been arrested by the agency. from the office of Democratic Sen. Dick Durbin found 14 pregnant women in a single Louisiana detention facility at the time of staff’s visit.

Another out of the office of Democratic Sen. Jon Ossoff published in late July found 14 credible reports of mistreatment of pregnant women in immigrant detention. The report cited an anonymous agency official who said they saw pregnant women sleeping on floors in overcrowded intake cells. The partner of a pregnant woman in federal custody said that she bled for days before she was taken to a hospital, where she miscarried alone. A pregnant detainee who spoke to Ossoff’s office said she repeatedly asked for medical attention and was told to “just drink water.” The office received several reports of clients waiting weeks to see a doctor, and that sometimes scheduled appointments were canceled. ICE has the report.

“Pregnant women receive regular prenatal visits, mental health services, nutritional support, and accommodations aligned with community standards of care. Detention of pregnant women is rare and has elevated oversight and review. No pregnant woman has been forced to sleep on the floor,” ICE said in a statement posted on their website.

ICE did not respond to a request for comment.

Fear of being detained is a major contributor of stress for pregnant immigrants. Research shows that even when pregnant patients do receive medical care, prenatal stress puts many at greater risk of complicated births and poor outcomes, including premature birth and low infant birth weight. Babies born are at a 24 percent higher risk of low birth weight, according to one study.

Monica, 38, is expecting her fourth child in November. The Tucson resident, who requested that her last name not be published out of fear of being detained, has lived in the United States for two decades but has no legal immigration status.

This pregnancy has been unlike the others, she said: While Monica has continued with her prenatal care appointments, her anxiety levels about her immigration situation have colored her experience. Her other children, who are in their teens, are U.S. citizens but grappling with the stress of their parents’ situation. Her husband also doesn’t have authorization to live in the country.

“We try to be out and about much less, and to take precautions,” she said. “Whenever we do leave the house, we have it in the back of our minds.”

Monica said she has seen reports of ICE being allowed inside hospitals, and she is worried about facing immigration officers while or following her birth. Her plan is to have her partner and a group of friends at the hospital to make sure she’s never alone.

“My biggest fear is going to the hospital,” she said.

Stress like Monica’s makes pregnancy more dangerous.

“In our hospital, every doctor I’ve talked to — and these are doctors that have been there 20 years — all are saying these past six months they’ve seen worse obstetrics outcomes than ever in their career,” Dr. Parker Duncan Diaz, a family physician in Santa Rosa, California, whose clinic mostly cares for Latinx patients. That’s included more preterm labor and more pregnant patients with severe hypertension.

“I don’t know what’s causing it, but my bias is that it is the impact of this horribly toxic stress environment,” he added, specifically noting the stress caused by the threat of immigration enforcement.

In recent months, Dr. Caitlin Bernard, an Indiana-based OB-GYN, has seen a number of pregnant patients seeking emergency attention who have not received any prenatal health care. One was 31 weeks, approaching the end of her pregnancy. Another was more than 20 weeks pregnant when she came to Bernard’s office, having developed complications from a molar pregnancy —��a rare condition that means a healthy birth is impossible and that without early treatment can result in vaginal bleeding, thyroid problems and even cancer.

“Anytime you’re not able to access that early prenatal care, we do see complications with that,” she said. “And many of these things can absolutely be life-threatening for both the moms and the babies.”

Dr. Daisy Leon-Martinez, a maternal-fetal medicine specialist in San Francisco, said she now regularly cares for patients in her labor and delivery ward who have been transferred to her hospital because of newly developed pregnancy complications. These are often their first doctors’ visits since becoming pregnant. Many of those patients have told her that they did not want to seek prenatal care for fear of encountering immigration officials.

During regular visits, she added, she has advised people with pregnancy complications that they would be best served by a hospital stay — only to be told that her patients no longer feel safe going to the hospital.

The current enforcement environment is challenging immigrant advocates, who are continuing to encourage immigrants to seek appropriate medical care while acknowledging that doing so is increasingly risky.

Lupe Rodríguez, the executive director of the National Latina Institute for Reproductive Justice, said her organization is urging pregnant immigrants to seek the health care that they need, and to be proactive about making plans for themselves and their families in the event that they are detained.

“We can’t know for certain about any given [health care center] whether or not it’s going to be safe. One of the things that we’ve been seeing is leadership at some of these health centers — big hospitals and clinics — have said that they will provide the kind of protection that folks need, that they don’t want folks to be afraid of care,” Rodriguez said.

While those statements signal the intentions of a hospital’s leadership, Rodriguez said, “we still know that there are individuals within some of those care centers that are part of the reporting mechanism or are intimidating people.”

Jacqueline approached the last days of her pregnancy hopeful that the place she had chosen — a large university hospital that workers at her local clinic recommended — would be a safe place for her to give birth.

One night at the end of September, when labor pains grew too intense, she called for an ambulance and made it to the hospital. When she got there, she asked her providers if there were any ICE agents near the building. She had heard of a man at a local hospital being detained after having surgery. They told her there were none they were aware of.

She went on to deliver her baby under general anesthesia after a long, difficult labor. “I didn’t even hear him cry when they pulled him out,” she said. Her only relative left in the area was taking care of her daughter, so she recovered alone at the hospital for five days before heading home in an Uber that a social worker procured for her and her son.

“If my husband was here, he would have been there with me at the hospital,” Jacqueline said while recovering at home. “He would be here taking care of me, of us. I wouldn’t be worried about the things I still want to get for the baby.”

was originally reported by Mel Leonor Barclay and Shefali Luthra of . Meet and and read more of their reporting on gender, politics and policy.

When I delivered my first child, I was diagnosed with thrombocytopenia, a condition that caused excessive bleeding and made an epidural too dangerous. After delivery, stress triggered both preeclampsia and shingles. My daughter spent her first week in the NICU while my family prayed over us both, and I remained on bed rest.

This time, I had a health care team that was prepared to support me through my pregnancy. But too many women don’t have access to that level of care or planning. And a healthy delivery is just the beginning. For many families, the challenges can mount up quickly: a lack of paid leave, unaffordable child care and limited postpartum support. These aren’t personal failings — they’re systemic gaps. And they’re among the reasons .

Recently, I’ve heard a lot of ideas about how to encourage people to have more children, including suggestions from the , such as motherhood medals or one-time baby bonuses. I’ve seen these issues from every angle as a mother, an advocate and as the executive director of the (NAFCC). The answer is clear to me. To build a country where families want to — and are able to — raise children, we must start with three core policies: improving maternal health care, expanding paid family leave and making child care more accessible and affordable.

Improve Maternal Health

The for maternal mortality among wealthy countries. The numbers are even more devastating for , who are nearly three times more likely to die from pregnancy-related causes than white women, regardless of education or income.

As a Black woman with a college education, I face a pregnancy-related mortality rate that is than that of my white counterparts. This time around, I’m fortunate to have a Black OB-GYN who understands these disparities, but many women don’t have access to culturally competent care or even basic prenatal services. Over 2.2 million women live in “,” with another 4.8 million in areas with limited access to maternity care.

Solutions exist. Expanding , especially in rural communities, and ensuring pregnant women have access are meaningful steps toward safer outcomes for all mothers. Additionally, bills like the, introduced in 2019 and 2021, seek to make sure investments are targeted where they are needed most. But there’s significantly more work to be done.

Increase Access to Paid Leave

After my newborn and I made it home in good health, I, like most other parents of young children, had to contend with the tradeoff between staying at home or maintaining employment. Unlike most other developed countries, the U.S. policy. My husband and I are fortunate enough to have paid parental leave plans from our employers, but nearly , according to the U.S. Bureau of Labor Statistics. This forces many parents to return to work before they’re ready or to leave their jobs entirely.

As of 2024, thirteen states and Washington, D.C., have . It’s time to scale these solutions nationally. No parent should have to choose between a paycheck and bonding with their newborn.

Expand Access to Affordable, High-Quality Child Care

To add to the challenge of welcoming a new baby into the family, once parents do return to work, they face yet . For many families, child care payments are and . And yet, the median wage for early educators nationally is $13.07 per hour, according to the published by the Center for the Study of Child Care Employment. 

The math doesn’t work. The cost of sustaining a quality child care system exceeds what families can pay, but still leaves educators underpaid. The solution is publicly funded, universally available child care — something states like are modeling well.

As I take this special time to bond with my new baby and adjust to being a mother of two, my greatest wish is for better family-friendly policies for all American families. Specifically, policies that improve maternal health care and increase access to paid leave and affordable, high-quality child care. If we truly want to encourage and support families in raising children, we must stop asking them to do it alone. These babies will grow up to be our leaders, caregivers and changemakers. The least we can do is ensure they, and their parents, have the support they need to thrive.

In mid-April, nurses in Wichita, Kansas, ratified their first-ever union contracts with two Ascension health system hospitals. The victory followed a similar win in March in Austin, Texas, when nurses at Ascension Seton Medical Center voted to ratify their first union contract with Ascension. Neither success came easily or quickly, say members of (NNU), the country’s largest union and professional association of registered nurses.

“I don’t think [Ascension] calculated on our determination and resolve to get the results we wanted, and our patients needed,” says Marvin Ruckle, NNU member and a veteran nurse who has worked at Ascension St. Joseph in Wichita since 1989, with 24 of those years in the Neonatal Intensive Care Unit. “Our community has been so supportive, coming out to our strikes, bringing us food and water. Workers from all the other unions around the Wichita area — steel workers, UPS, Spirit (airplane factory) — joined us. Most of these people have either been a patient or had family in one of our facilities and they know there needs to be change.

“This (contract) is an incredible step forward for nurses, so we can work with the hospital to make patient care better for our community,” Ruckle says. “But it shouldn’t have taken this long. We were determined, we kept pushing, and all Ascension did was drag out the process.”

One of the nurses’ most significant wins was safe staffing ratios enforceable through a nurse-led Professional Practice Committee. In Austin, hundreds of nurses spent more than a year in contract negotiations and organizing efforts, participating in two strikes to focus attention on their demands including guaranteed lower nurse-to-patient staffing ratios. At all three facilities, Ascension management responded to the nearly 2,000 nurses’ historic one-day joint strike on June 27 with a three-day lockout.

Mission-Driven Ascension

Based in St. Louis, Missouri, Ascension is one of the largest health systems in the U.S., boasting 140 hospitals and 40 senior living facilities in 18 states and the District of Columbia. Becker’s Hospital Review listed Ascension as No. 2 in its 2019 list of 100 of the largest hospitals and health systems in the U.S. and the largest nonprofit health system by hospital count. The nonprofit Catholic health system’s stated mission is to deliver “compassionate, personalized care to all, with special attention to persons living in poverty, and those most vulnerable.”

A deeply researched analysis from the National Nurses Organizing Committee and NNU, “,” questions how closely Ascension hews to that mission, particularly in communities with high poverty rates and a disproportionate number of Black and Latino residents. Ascension, the report states, is one of the nation’s worst offenders in closing obstetrics units and obstetrics services. Over the past decade, Ascension has eliminated obstetrics services at 16 hospitals and slashed more than a quarter of the labor and delivery departments that it had been providing in 2012, a rate three times higher than the national average of 6 percent.

Since 2022 alone, Ascension has closed five maternity wards, all health care markets where Ascension maintains a monopoly or near-monopoly on health services. Half of the hospitals where Ascension closed labor and delivery units are in counties with a higher proportion of low-income residents and people of color, and higher rates of infant mortality than the national average (also known as “persons living in poverty, and those most vulnerable” — see Mission Statement above).

Profits over Patients?

By now, the statistics are familiar to anyone paying attention: the U.S. has the highest rate of death among pregnant women and infants of any wealthy country; maternal mortality is more than 10 times and infant mortality almost double the average among comparably wealthy nations. It is no longer even a nasty secret that Black women are nearly three times as likely to die in childbirth as white women.

As “Dangerous Descent” points out, for the first time in two decades, infant mortality has risen in the U.S., largely due to pregnancy-related complications, which experts attribute to limited access to specialists who deal with complicated pregnancies. According to the Centers for Disease Control and Prevention, more than of pregnancy-related deaths in the U.S. are preventable — and healthcare leaders have a major role to play in improving these outcomes. Tragically, many systems focus their eye most keenly on the fiscal bottom line rather than the fundamental health of their patients.

Hospital consolidation has been on the march over the last two decades, with more than 67 percent of U.S. hospitals now belonging to a larger system, compared to 45 percent in 2000. NNU’s report cites numerous studies that have shown that such highly consolidated markets can lead to price increases and diminished patient outcomes. Hospital corporations say such consolidation creates “efficiencies” that enable them to cut costs. What they don’t say as loudly is that steps such as eliminating and obstetrics services — both major casualties of hospital cost-cutting — also improves their profits. In practice, consolidating labor and delivery limits access to care for many patients in low-income areas who may not have vehicles or good access to public transportation. Increased distance to medical care can result in missed prenatal appointments or an inability of patients to get to the hospital in time to deliver their babies safely.

According to the , more than 400 maternity services closed in the U.S. between 2006 and 2020. Between March and June 2022, 11 health systems announced they were closing their obstetrics services. When birthing units close, obstetricians and nurse-midwives are more likely to go elsewhere, exacerbating the epidemic of maternity care deserts in the world’s largest and most robust economy.

“What was really striking to us,” says Elana Kessler, author of NNU’s “Dangerous Descent” report, “is that this is a mission-driven hospital system under the Catholic church that is to care for the poor and to create a more just society. Their actions are not in line with that mission statement. By closing labor and delivery units in Medicaid-heavy areas with higher proportions of Black and Latino patients, they’re hiding behind their mission while they’re increasing their profits.”

Health reporting news site stated in a 2021 investigation that Ascension, “a wealthy, religious, tax-exempt health system,” had migrated toward behaving like a Wall Street firm, using its wealth to create a sophisticated investment strategy that includes a partnership with the private equity firm, TowerBrook Capital Partners. Ascension stands out from other nonprofit hospitals that have dabbled in private equity investing in the sophistication and expansiveness of its $1 billion partnership with TowerBrook, the STAT investigation found.

On its 2021 federal tax return, Ascension reported that CEO Joseph R. Impicciche received a salary of $13 million. In 2022, the reported that Ascension had spent years reducing its staffing levels to improve profitability even though the chain is a nonprofit organization with nearly $18 billion in cash reserves. At that time, its charity care accounted for 1.9 percent of operating expenses (against a national average of 2.6 percent).

Even with the additional revenue from its investments, Ascension pursued cuts to safety-net hospitals in Washington, D.C., and Milwaukee, Wisconsin, abruptly closing its Labor and Delivery unit in December 2022, leaving Milwaukee’s south side, home to a large immigrant community, completely without a hospital to deliver babies. The move prompted a scorching letter from Wisconsin Sen. Tammy Baldwin, who demanded answers from Ascension on its questionable priorities that funnel cash to its investment funds and executives, putting providers and patients at risk. In her letter, Sen. Baldwin called on Ascension to reinvest its cash reserves in hospitals that serve vulnerable communities and to increase pay and improve working conditions for its “burned out and overextended health care workforce.”

In an April 19 email response to Early Learning Nation magazine, Sen. Baldwin stated that Ascension had replied to her letter. ��“While I’m encouraged that Ascension appears to be taking the communities’ concerns seriously and working to rebuild relationships,” she wrote, “I remain concerned that their business practices appear more like a private equity firm than a nonprofit hospital whose stated mission is to serve the public.”

Understaffed NICUs and Obstetrics Units

“It’s been like working in a MASH unit,” Ruckle said, describing his experience in Ascension St. Joseph’s NICU. Mobile army surgical hospitals (MASH) units, which were phased out in the early 2000s, were known for their primitive conditions, grueling work schedules and frustrating lack of resources. As reported in “Dangerous Descent,” nurses at multiple Ascension hospitals have noted the perpetual crisis caused by staffing cuts and equipment shortages.

“It’s heart-wrenching to go home and wonder if you were able to help that critically ill baby as best you could and worry that they aren’t going to have the best outcome,” he said.

The result for nurses can be not only stress and frustration but, according to Zenei Triunfo-Cortez, one of NNU’s presidents, moral harm.

“As nurses, we have an obligation to advocate for our patients, to do what’s best for our patients,” she says. “But the situation we’re being put in, especially Ascension nurses, is that we know we have to do the right thing and are being prevented from doing so because of the situation in our hospitals. Then we suffer from moral injury. Our hearts are breaking because we want to do what’s best, but our employers are not providing what we need to do so.

“We start asking, ‘Is this really worth my health?’” says Triunfo-Cortez, who has been a registered nurse for 44 years. “The majority of our nurses will be out there fighting for our patients and fighting for what’s right, but it does make us question.”

Recommendations from NNU

Pointing out that Ascension enjoys hundreds of millions of dollars in tax breaks thanks to its nonprofit status yet continues its abandonment of low-income mothers, parents and newborns, NNU and the National Nurses Organizing Committee recommend systemic changes that would align Ascension with its mission:

• Come to the table and listen to nurses; staff every unit to ensure the best care for patients.
• Commit to reopening closed labor and delivery wards.
• Provide obstetric services at all new hospitals Ascension opens or acquires.

Ascension has the opportunity and resources to become an industry leader, says Kessler, the report’s author. “As nurses advocating not only for nurses but for the patients they serve, we know that safe staffing and readily accessible care are completely entwined in the work nurses do — they’re one and the same.

“Ascension will say, ‘Consolidation is part of our business strategy. It’s better for the patient,’ but at the end of the day,” she says, “it doesn’t happen that way. It creates barriers for patients to face — transportation, child care — and when there is not ready access to obstetrics services, pregnant patients are less likely to get prenatal care, which then has a cascade of harmful effects.”

��������Բ����Dz�’s 1 in 50 Report

In late April, Ascension released a in which it reported that one in 50 U.S. babies is now born at an Ascension hospital, no doubt in part to what The Wall Street Journal (WSJ) cited as the corporation’s role as the “most active dealmaker” in its hospitals’ expanding into wealthy areas while shunning poorer ones. Nonprofit hospitals now account for half the $1 trillion U.S. hospital sector. Across the sector, the �³���’s investigation found, though they receive local, state and federal tax breaks in exchange for providing charity and benefiting communities, nonprofits are less generous in providing aid than their nonprofit rivals.

Though the Ascension report states that its commitment is “rooted in the loving ministry of Jesus as healer” and the 32-page report details positive health outcomes throughout the system, NNU’s Kessler says the report doesn’t tell the full story of how those numbers arrived.

“Outcomes for patients no longer served by Ascension wouldn’t be included in the hospital’s data, so the report is incomplete,” she says, “failing to consider the impact on communities where Ascension has shuttered obstetrics services under the corporate strategy of ‘consolidation.’

“Ascension asserts that one in 50 babies are born in their care, which only underscores the importance of Ascension keeping obstetrics services open for the thousands of expectant mothers they serve each year.��Furthermore, a snapshot of data from one year, in one health system, doesn’t tell the whole story of the impact of ��������Բ����Dz�’s decision to close services. It should also be noted t��could weigh the data in favor of showing better than average outcomes.”

“There’s a good amount of research looking at associations between the neighborhood environment and various health outcomes,” says Julia G. Carter, lead author on the study, , published in JAMA Obstetrics and Gynecology. “When I was reviewing the literature, I saw a lack of research on the mother’s subjective experience, which is what our study looks at.”

Because individuals who live in the same community can encounter the same environment in radically different ways, Carter says the research team from Northwestern University’s Feinberg School of Medicine wanted to go beyond the data about exposure to crime and other adverse conditions to look at how the mother’s view of her personal safety affected her and her infant’s well-being.

The researchers took their data from the (PRAMS), a project of the Centers for Disease Control and Prevention (CDC) which, along with state, territorial and local health departments, collects targeted, population-based attitudes on maternal attitudes and experiences surrounding pregnancy. The survey asked set questions of respondents in the participating 46 U.S. states, territories, District of Columbia and New York City, which creates data on 81 percent of all live births in the U.S. Individual states have the option of selecting additional questions to deepen their understanding of their own populations.

For their study, the Northwestern researchers analyzed responses PRAMS had gathered from 2016 to 2020 from the states that had asked respondents how they perceived their neighborhood safety.

Eight states — Illinois, Louisiana, Minnesota, Missouri, Pennsylvania, Rhode Island, Virginia and Wisconsin�� — asked respondents, “During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?” Answers were then categorized as always or often unsafe, sometimes unsafe, rarely unsafe and never unsafe. To assess interpersonal physical and emotional abuse, one item asked whether respondents had been pushed, hit, slapped or physically hurt by another individual in the 12 months before they got pregnant. After 1829 exclusions, 29 987 respondents were included in the Northwestern study. Most of the respondents (78 percent) reported that they never felt unsafe. At the other end of the scale, 3 percent said they always or often felt unsafe.

The researchers then analyzed respondents’ birth outcomes including low birth weight, self-reported depression during pregnancy or postpartum, attending more than eight prenatal care visits, attending a postpartum visit, and breastfeeding for at least eight weeks.

After controlling for maternal age, race and ethnicity, and other sociodemographic factors to test the independent significance of perceived neighborhood safety, the researchers found that, compared with respondents who never felt unsafe in their neighborhoods, those reporting that they always or often felt unsafe had nearly 25 percent higher odds of having a low birthweight baby and 100 percent higher odds of perinatal depressive symptoms. The group that felt unsafe had 10 percent lower odds of attending more than eight prenatal care visits.

Although the Northwestern researchers’ cross-sectional study didn’t assess the factors that could determine why a pregnant person might choose not to seek prenatal care, their study cited an in-depth Canadian published in the BMC Journal of Pregnancy and Childbirth that analyzed the motivators associated with inadequate prenatal care among eight inner-city Winnipeg, Manitoba, neighborhoods. Researchers from the University of Manitoba found that, although the women in their study lived in the same group of disadvantaged neighborhoods, psychosocial, attitudinal, economic and structural barriers and a variety of motivators, separated those women who received adequate prenatal care from those who did not. The study highlights the diversity among inner-city women with respect to their experiences with prenatal care and their perceptions of factors that help or hinder them in accessing this care.

Psychosocial issues that increased the mothers’ likelihood of not receiving adequate care included feeling stressed, having family problems, being depressed and worrying that child welfare officials might take the baby. Being abused by their husband or boyfriend also prevented several of the women from obtaining adequate prenatal care. Structural barriers included not knowing where to get prenatal care or having a long wait to get an appointment. Problems with transportation or child care were mentioned by nearly half the women who didn’t receive adequate prenatal care.

The good news, Carter says, is that these factors have policy implications, which means they can be addressed. Solutions are more likely to be found in such initiatives as providing access to social workers who can help with scheduling and follow up, providing mental health resources, or addressing systemic issues such as the lack of bus stops near clinics.

A reverse image of the neighborhood perception study can be found in the paper, “,” published in the International Journal of Environmental Research and Public Health, which looks at the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes.

Researchers from the University of Albany looked at nearly 300 mother-infant pairs in small cities, suburban regions and rural areas in upstate New York. The neighborhoods were analyzed according to the (COI), a multidimensional indicator of a neighborhood’s favorable social, environmental and educational community attributes. The study, the first to analyze the COI in association with pregnancy health and birth size, demonstrated that positive neighborhood attributes cumulatively contributed to healthy pregnancies and favorable birth outcomes.

While the idea that better neighborhoods make for better health may seem like a foregone conclusion, the contrast among the studies underscores an important point. The factors that give one neighborhood a high COI score and make other neighborhoods a source of fear and concern for mother and child, are all malleable and subject to change.

In their neighborhood perception paper, the Northwestern researchers point out that social and economic interventions that combat neighborhood and domestic violence may be more beneficial in reducing adverse pregnancy outcomes than biomedical interventions. Reducing expensive, often counterproductive police crime-prevention initiatives and mass incarceration in favor of resources that strengthen low-income communities may go further to create a sense of safety not only for pregnant people, but for the entire community.

“The main question,” Carter says, “is what are we going to do about it? That is outside the scope of our study, but assessing the situation is the first step in having this conversation. There are still a lot of steps to make improvements and develop solutions.

“With these social determinants of maternal health, the truth is, there’s no quick fix. But to have the data and the commitment to collectively do something about it makes a big difference.”

Further Reading

��Children from neighborhoods perceived as unsafe by parents engaged in one less day per week in physical activity. Children from neighborhoods perceived as unsafe were less likely to use recreational facilities compared with children from neighborhoods perceived as safe, and children from less affluent families across rural and urban areas had half the odds of using recreational facilities compared with children from the wealthiest families living in urban areas.

Neighborhoods can be a potential source of psychosocial stressors associated with childhood asthma. Parents who perceive their neighborhoods as sometimes or never safe reported asthma at higher rates than those living in neighborhoods parents perceived to be always safe.

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn’t. Rather, it’s a reflection of the program’s limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

“Medicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it’s beneficial, it isn’t as good as private insurance,” says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. “Babies don’t get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn’t suffer because of their parents’ socioeconomic status.”

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, “,” was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality — almost half the rate of mothers with Medicaid — as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study’s first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

“From a biological standpoint for the fetus, that first trimester is when organogenesis occurs,” Johnson says. “The other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs — all the organs — are formed. It’s also a time for recognizing the mother’s baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.”

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don’t allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy — at a time when the clock is ticking for both mother and fetus.

“One of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they’re delayed in their prenatal care, or they haven’t received adequate care in those first months. They’re already behind,” she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

“Here in Alabama, a lot of our population is very rural,” she says. “Some must travel great distances to receive healthcare. When you’re trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

“A lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.”

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, “,” in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes’ 2022 report, “,” finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care — a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain — though not entirely — why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don’t receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and — a serious neonatal illness most common in premature babies, especially NICU babies who don’t get human milk.

Lifesaving Alternatives

These negative outcomes don’t have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers’ access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child’s first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person’s doctor and local providers to care for mother and child throughout pregnancy and the child’s first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

“Race is largely a social construct,” Travers says. “Increasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.”

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother’s socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients —a subject for future study, the researchers say.

The results reflected in these studies don’t point to Medicaid’s failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

“The draw of pediatrics for us as doctors is that when we’re working with children, we can lay the foundation for them to have healthy and successful lives,” Johnson says. “But if you don’t lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. ��“We’ve now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.”

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Here are our top five takeaways:

1. Maternal health care is vanishing. The March of Dimes maternity care deserts as “any county in the United States without a hospital or birth center offering obstetric care and without any obstetric providers.” Its showed that 36% of U.S. counties fit this definition, a 2% increase from the 2020 report.

Areas with low or no access affect up to 6.9 million women and almost 500,000 births nationwide. Of those maternity care deserts, 61% were rural counties.

2. Rural communities are particularly vulnerable. About 2 million rural women of childbearing age live in maternity care deserts at least 25 miles away from a labor and delivery unit, a USA TODAY found. About 1 in 9 rural Native women and 1 in 16 rural Latina women are 40 miles or farther from the nearest maternity ward.

“Half of the nation’s rural hospitals have no obstetric or ob-gyn practitioner,” said Nada Hassanein, health care reporter for . “Research has also found rural, Black communities are more likely to lose their obstetric units.”

Hassanein described the , of a mother who had to drive about 70 miles round trip every other week for her prenatal appointments and to deliver her baby. A long drive or ambulance ride in the face of a life-threatening complication can prove fatal or lead to complications that traumatically change the course of a young life.

3. There are geographic and systemic problems at play. “Rural communities with larger proportions of people of color, such as Jasper, have been found to be farther away from obstetrics than rural white communities,” Hassanein said, adding, “It’s not just a geographical problem, but also a systemic one.”

Our health care system is decentralized and favors volume. For hospitals in these poorer, rural communities, these two factors don’t often offer sustainable support, since they see lower birth volumes and primarily rely on the low rates of Medicaid reimbursements for service.

4. Policies underpin some of today’s ongoing disparities. In Georgia, nearly half of the state’s predominantly Black counties are now considered maternity care deserts.

In researching the state’s health care system, Margo Snipe, national health reporter at , discovered regulations uniquely restrictive in Georgia. “The system makes it super hard to open care, but to shut down a facility, all that’s required is a 30-day notice to the state,” Snipe said.

And existing hospitals or health care systems can fight against the appeal. A woman’s efforts to open a birth center in a Black part of Augusta County are blocked. “She had hundreds of letters of support,” Snipe said, “She still hasn’t been able to open it, because hospitals have fought against it.”

5. Many communities are taking matters into their own hands, like the folks behind the Augusta birth center, and tribal women, who have to travel some of the farthest distances in the nation to receive care.

Hassanein mentioned some who plan on learning to drive an ambulance and others who volunteer as emergency medical technicians. “A hospital closure has a really wide effect on a community, and that has implications for maternal health, but also just general health in an emergency,” Snipe said.

It depends.

• Can incarcerated people be shackled during labor? It depends.
• Can women breastfeed or pump after delivery? Will anyone see to it that their infant receives this milk? It depends.
• Are pregnant people in custody with opiate addiction given medical assistance to detox, or are they left to go cold turkey on their own? It depends.
• Can an incarcerated woman have access to an abortion? It depends.
• Are pregnant, birthing and postpartum people treated with dignity and humanity while behind bars? It depends.
• Do we even know how many pregnant, birthing or postpartum people are behind bars in the U.S.? Actually, that answer is a straightforward No.

Whether incarcerated pregnant people have adequate nutrition, access to obstetric care or even such necessities as maternity clothing depends on what state they’re in, whether they’re in a prison or jail (more on that distinction later), and sometimes simply on the whims of jail staff or local sheriffs and deputies.

According to the , the capriciousness of reproductive care for pregnant, birthing and postpartum pregnant people in custody comes to us via a patchwork of decentralized and overlapping criminal legal systems throughout the U.S. comprising thousands of federal, state, local and tribal systems that together incarcerate more than 2 million people. Around 173,000 of that number are women or girls, primarily people of color, mostly young, and most arrested for non-violent offenses. The U.S. has the highest number of incarcerated people in the world and is second only to Thailand in the number of women behind bars.

Until recently, the pregnancy status of these incarcerated women had not been updated for decades, making it impossible to say with any certainty how many pregnant people were behind bars, how they were being cared for and the outcomes of their pregnancies. The federal First Step Act of 2018 now requires the U.S. Bureau of Justice Statistics to collect data on pregnancy outcomes from federal prisons, but no such requirement is in place for state prisons and jails. Any data at all on the thousands of women in local jails is spotty to nonexistent.

In 2019, Dr. Carolyn Sufrin, a national expert and advocate for reproductive care for incarcerated women, and her multi-sector research team at Johns Hopkins University School of Medicine and School of Public Health published , a significant study that collected data from 2016 to 2017 from 22 state prison systems, the Federal Bureau of Prisons, six jails and three juvenile justice systems, representing 57 percent of females in prison and 5 percent of those in jail. The study found that at any given time, 3 to 4 percent of females were pregnant when they entered U.S. jails and prisons.

An obstetrician-gynecologist with a doctorate in medical anthropology, Sufrin ran a women’s health clinic for six years as an OB-GYN at the San Francisco County Jail before going to Johns Hopkins. She found that the hard data she needed to study maternal health, including pregnancies, miscarriages and abortions behind bars, didn’t exist. She launched the initiative that became the PIPS study, the first-ever systematic study of pregnancy outcomes for women behind bars in the U.S.

“Part of why we know so little is that, as a society, we’ve just ignored these women,” Sufrin says. “We either pretend they don’t exist, or else people believe it’s such a small number of women, ‘Who cares?’ But how do we know it’s a small number unless we study it?

“There’s a saying, ‘Whoever isn’t counted doesn’t count,’ so the lack of data signifies how little we care about pregnant people, especially those at the margins of society.”

As the PIPS project concluded, Sufrin founded the (ARRWIP), which continues to conduct research on reproductive health care issues among incarcerated women. She says she became committed to this specialty as a first-year OB-GYN resident in Pennsylvania when she delivered the baby of a woman from the local jail who was shackled to the hospital bed throughout labor and delivery. Until that moment, she writes in her excellent book, “Jailcare: Finding the Safety Net for Women behind Bars,” like most Americans, she had given little thought to the idea that there were pregnant people behind bars, nor the complicated reality of that fact.

Shackles and Health Care

If the idea of shackling a pregnant woman in active labor seems medieval — or cruel and unusual punishment at the very least — welcome to large swaths of the U.S. Despite well-established medical risks, as of July 2023, only 40 states, the District of Columbia and the federal government have banned restraints in labor and delivery; some have banned the practice at other points in the pregnancy and postpartum period. In Maternal and Child Health Journal, November 2022), authors Camille Kramer et al. report that pregnancy policies and services in prisons and jails vary widely, with little consistency in compliance with anti-shackling legislation even in states where it’s banned. Most facilities station an officer inside the hospital room during labor and delivery, and nearly a third don’t even require that it be a female-identifying officer.

Though state prison systems hold twice as many individuals as jails, the PIPS study reports that more women are held in jails than in state prisons, a statistic that carries profound consequences for these women and their families. The distinction between prison and jail is that prisons are long-term confinement facilities the federal or state government monitors, often by an entity the government contracts. People in prison typically have been convicted of a felony and sentenced to one or more years. Jails are short-term facilities managed by a local or county government. More than 60 percent of women held in local jails have not been convicted of a crime and are awaiting trial, often because they can’t afford bail. A whopping 80 percent of women incarcerated in the U.S. are mothers, and most are their children’s primary caretakers.

The 1976 Supreme Court ruling in Estelle v. Gamble established health care as a constitutionally protected right for incarcerated people, but it didn’t prescribe mandatory services, standardization or oversight, creating the present system of health care roulette for those behind bars. Providing care for incarcerated women presents multiple unique challenges for any institution; caring for pregnant women in custody significantly raises the stakes. Pregnancies are often unplanned and complicated by a lack of prenatal care, a woman’s neglected health before incarceration, maternal trauma, poor nutrition, substance abuse, mental illness, limited social support and low socioeconomic status — all in a correctional system designed for men.

Post-Dobbs Pregnancy Behind Bars

Before the Supreme Court’s ruling in Dobbs V. Jackson Women’s Health, access to abortion already varied widely from state to state and among prisons. After the Court removed the constitutional right to abortion, the choices for pregnant incarcerated women have become even more precarious. Sufrin’s research found that even in states where abortion was legal, some prisons and jails had either official or unofficial policies that prevented incarcerated women from accessing abortion.

Under Roe v. Wade protections, incarcerated pregnant individuals at least had a constitutional right to abortion just like everyone else in the U.S. Despite this guarantee, abortion was not accessible to many in custody. Post-Dobbs, things are likely to get worse for those who are pregnant behind bars.

“We don’t know yet the full impact of the Dobbs decision because it’s hard to study this population,” Sufrin says. “But abortion access for incarcerated individuals was already constrained. How much this is going to impact abortion access in restrictive states is still to be determined.

“What I’m more concerned about is the ripple effect this is going to have on other aspects of pregnancy care in custody. We’ve already seen in abortion-restrictive states like Texas that non-incarcerated people brought to the hospital for obstetric emergencies like bleeding from a miscarriage or their water breaking early are being turned away from care where an abortion procedure would save their lives. They’re turned away because of how the law is written or because physicians fear what might happen if they misinterpret it. Women are basically being told to come back when they’re at death’s door.

“I’m concerned about the impact on incarcerated pregnant people with complications because they will be sent back to prison, which is ill-equipped to handle obstetrical emergencies. We’re likely going to see more pregnant individuals overall in the United States who are going to be sicker, and that may also be true in custody.

“None of this has been studied, so these are just hypotheses.”

When Jail Means Safety

Though it may not be intuitive, Sufrin says the “thorny reality” is that jail can improve outcomes for incarcerated pregnant people and their infants and can increase their chances for successful reintegration into the community. Jail is the new safety net, she writes in “Jailcare.” Women in jail represent one of the most marginalized and vulnerable groups in society. Indigent, addicted mothers too often can only access prenatal care behind bars. Though not all jails provide an environment that supports these women, those that do offer medical and prenatal care, treatment programs, improved nutrition and the relative stability that they’ve lacked can provide a safer, healthier alternative to the lives these women experienced on the outside.

Make no mistake, Sufrin says. Jail is still a place of punishment. The fact that it’s better behind bars for some people than being in the community isn’t so much an endorsement of jail as it is an indictment of our abandoned and ineffective social systems that have broken down and utterly failed these people relegated to society’s sidelines.

“That the system of incarceration has become an integral part of the country’s social and medical safety net is peculiar to the U.S.,” she writes, “and represents one of its greatest tragedies, the whittling away of public services for the poor coupled with an escalation in the number of jails and prisons with custody of that same population.”

“It’s still jail,” she says.

Here are our top 10 takeaways from the conversations:

1. We can look to nature for inspiration. When elephants birth in the wild, the whole herd circles around the laboring elephant. They stay for the entire labor, providing connection, support, protection and defense. “That’s what we think humans need in the perinatal period as well,” Indra Lusero, founder of Elephant Circle, said on Aug. 30. Elephant Circle brings an intersectional, feminist, reproductive justice and design-thinking approach to birth justice to make true transformation possible.

2. The current system is failing families. According to recent data from the Centers for Disease Prevention and Control, 1205 women ” in 2021, and .

The maternal mortality rate in the U.S. rose between 2018 and 2020, showcasing the impact of the COVID pandemic on the pregnant population and resulting in nationwide health care system disruptions. “Things aren’t fair, things aren’t set up justly and we’ve got to start tackling those big issues,” Lusero said.

3. Black women experience an immense burden. During the Sept. 13 talk, Stephanie Aristide of BMMA explained that gaps in the pregnancy mortality rate between racial groups have widened over the past 15 years. In 2020, Black women were disproportionately affected by maternal death, with a mortality rate of 55.3 deaths per 100,000 live births — a significant increase from 2019.

The work of the BMMA is deeply rooted in reproductive justice, birth justice and the human rights frameworks to ensure that all Black mamas have the rights, respect and resources to thrive before, during and after pregnancy.

4. History offers essential context. “When presented with the appalling statistics surrounding Black maternal health in the U.S., we must always take a deeper dive into the root causes of these issues,” explained Aristide. “The regulation of Black women’s reproductive decisions has been a central aspect of racial oppression in America.”

She provided a number of examples: “Enslaved pregnant Black women were forced to work in plantation fields until their labor, rarely given a chance to rest and bond with their babies and were required to return to the fields with their babies strapped on their backs.”

Aristide continued, “The institution of slavery in the U.S. opened the door for all types of unjust medical experimentation on Black women’s bodies, from experimental vaginal surgeries without anesthesia, to stealing cervical cancer cells, all in the name of advancing science.”

These and other atrocities set the stage for persistent harm to Black bodies. Throughout time, Black institutions such as the Tuskegee Institute, churches, community organizations and Black women’s clubs addressed these issues through health education and preventative service initiatives like the National Negro Health Week in the early 1900s.

5. Equitable health care is a human right. “Human rights is a critical dimension,” Lusero said. “When talking to people about issues facing them in the perinatal period, a sense of justice… is really important. People don’t just want clinical solutions or solutions that are familiar. People want things that get at fundamental, core issues of inequities.”

While equity is top of mind for those navigating the system today, the idea remains elusive.��“There’s a lot of interest in health equity, but how health equity can be achieved is not understood,” Aristide explained. “Maternal health is still deeply entrenched in the patriarchal narrative that only cares for women’s bodies in relation to being able to have a healthy baby. And interventions to address adverse maternal health outcomes focus heavily on individual behavior change.”

George Davis, a community advocate with Elephant Circle, mused, “A lot of times, the answers to the problems that we’re looking for have not been thought up yet. We’ve only felt the pain from dealing with this thing.”

6. Solutions exist beyond the status quo. “Policies that only look at services within the traditional medical context are extremely limiting and do not address the core problems of health inequities. They often further aggravate the problem,” Aristide said in the Sept. 13 talk.

Lusero echoed the sentiment on Aug. 30: “If we’re going to change the status quo, we have to innovate. We need new feedback loops. We need accountability.”

Davis pointed out that we must start at the root to inspire meaningful solutions, “So often, things are looked at to be changed on the branches, or the leaves, by pruning, when the problem is so deep in the root. Birth equity and reproductive justice are starting at the root to create change.”

7. Birth work is a powerful pathway. Strong evidence shows that birth work improves outcomes. “Of course, we have to look really largely at the systemic issues behind maternal mortality and morbidity, but birth work is a really important piece of that puzzle,” Lauren Smith of Elephant Circle said during the August talk.

Historically, Black midwives were vital maternity caregivers for communities, especially in the South. Aristide explained, “Over time, discriminatory public policies restricted Black midwives, depleting the maternal care workforce.” BMMA aims to address this gap with its workforce development policy and programming initiatives like the Black Maternal Health Institute and Incubator Hub.

“The goal is to work toward equitable maternal and birth outcomes for Black birthing people through systemic change at the community and state levels.” Milan Spencer of BMMA said. “In very tangible ways, we are building the capacity of our workforce through training and education.”

In addition to this learning space, they annually assemble Black women, clinicians, professionals, advocates and other stakeholders working to improve maternal health at the . They host Black Maternal Health Week every April to build awareness and amplify voices.

8. We must listen to learn and learn to listen. “When listening, you’re engaging in a mindset. It requires you to be generous and generative,” Indra said when explaining the power of listening to other people’s stories.

Pia Long of Elephant Circle said, “It’s important that people tell their story, and it’s even more important that we come up with solutions so that we don’t have to keep telling these stories, so that folks don’t continue to have this pain and trauma that happens when they go to give birth in the United States.”

9. Policy efforts should require community input. “Ultimately, all conversations regarding maternal deaths, policy solutions and improvements needed to the systems contributing to maternal mortality should start and end with the community,” said Stephanie Aristide of BMMA.

To inform a set of bills in Colorado collectively called the , Elephant Circle toured 1200 miles, with stops around the state to engage those who normally don’t have a seat at the table. “By ensuring that community voices and directly impacted people were in every conversation, every stakeholder meeting, it changed the power dynamic at that stage, which helped change the power dynamics reflected in the policies, which helped us pass these bills,” Lusero said.

The essence of the bill package is beyond what’s written into statute. “It’s how we did it and the spirit we brought to it. That’s the spirit we need in the perinatal period, that feeling of being circled around, being part of the herd. Knowing that we have to take care of each other.”

10. Everyone has a part to play in improving outcomes. “You don’t need to be a lobbyist to be an advocate,” Lauren Smith said.

Similarly, you don’t need to identify as a woman to get involved in birth justice work. “As a male, at first, I was like, this isn’t for me. I don’t know what we’re doing. Then I began to listen, ask questions, and study on my own and find out this is exactly where I’m supposed to be,” George Davis said of his experience at Elephant Circle. “In fact, more fathers, men, everyone needs to know about this because this is something that we’re all in together. Reproductive justice, birth equity, we are all born. So it’s a wonderful place to start.”

For those looking to get involved, Milan Spencer from BMMA said, “Our recommendation is to seek out those community-based, grassroots organizations that are leading initiatives locally and get involved in their efforts. Express your passion. Ask what their needs are and what support looks like to them.”

Now, reading Jennifer Banks’ “Natality: Toward a Philosophy of Birth,” I have some insight into why. It wasn’t just about avoiding unpleasantness, mentally putting our hands over our ears to shut out the world (though, judging by the number of wine glasses seen in our Zooms, there was plenty of that as well); it was that we needed some creation in our lives. Amid all that death, we needed birth.

Birth is humanity’s greatest unexplored subject, Jennifer Banks writes in her excellent “Natality: Toward a Philosophy of Birth.” Banks, a senior executive editor at Yale University Press, begins to explore the subject by looking back at humanity’s earliest writings, where, in 2300 BCE, the first identified author sang hymns to the goddess of childbirth, linking birth to creativity, divine powers and her hope for change in the world. In Banks’s introduction — which, for my money, by itself is worth the price of admission — the author writes that birth, for all its recurring presence in the written record, has played second chair to death as humanity’s defining experience. Mortal creatures who wrestle with our own mortality, we are born and then pffft let birth recede into memory, “to that forgotten realm where uteruses, blood, sex, pain, pleasure and infancy constellate.”

In flipping the script, Banks writes that birth is immense, that birth has existential, moral and theological significance at least as great as death. “What does it mean that the greatest power humans have had—the power to create another human being — has been relegated in nearly all periods and all places to a secondary status, turned into a task to be performed by an underclass of people assigned that task on account of their gender?”

The book isn’t a paean to some sentimental or idealized image of motherhood — which, as Banks writes, can be “superficially championed but deeply undermined by mothers’ cultures” when it comes time to pay the bill for the maternity ward, offer maternity leave, feed the mothers’ children or come up with child care. The book is instead an investigation of birth itself — not just childbirth, but birth as creation and creative renewal; an embrace of life and the recognition that each of our births indelibly shape not just our own lives but human life itself. In a provocation that is both wide-ranging and deep, she asks for a set of principles different from the “death-drive that runs deep in Western societies,” imagining a culture less reconciled to its own extinction, “rooted in gestation, intimacy, vulnerability, growth, creativity, reciprocity, change and otherness.”

Banks explores the idea of birth through the works of seven prominent Western thinkers: Hannah Arendt, Friedrich Nietzsche, Mary Wollstonecraft, Mary Shelley, Sojourner Truth, Adrienne Rich and Toni Morrison—who have wrestled with the idea of birth in their own eras and shaped our understanding of our own humanity. She offers their thinking as a powerful antidote to the nihilism with its fatalism, paralysis, cynicism and despair that are the “prevailing features of 21^st century life.”

Hannah Arendt knew a thing or two about nihilism and despair. Born in 1906 in Germany to a family of left-leaning, prosperous Jews, a circumstance that ultimately would see her stripped of citizenship and belonging, with her simple right to exist taken away. During her childhood years while she was running outdoors, reading books and “blithely singing off key,” she and her family were being turned into the “scum of the earth — an undesirable” by anti-Semitic propaganda.

Arendt had been interested in birth before the war, writing that birth and “the miracle of our creative beginnings” are what shape humans and give us our capacity to act creatively in the world. After the war, despite surviving years of unimaginable loss and betrayal, she continued to engage with the idea of birth, now as less of an existential concept than a political one: creative renewal as an act of resistance. She wrote of the connections between birth and freedom and found one English word to encompass that thinking: “natality,” the “miracle that saves the world,” one that decades later gave Banks the central theme for her challenging book.

Arendt’s writings after the war are her attempts to process that cataclysm — how the people she had grown up among and loved had turned against her and her people. Banks’s rich chapter on Arendt could easily be overlaid onto much of our contemporary world. Alienation from one another, dehumanization, racism, cynicism the “fateful repudiation of Earth the Mother” — all fertilize the totalitarian impulse that thrives when people come unmoored from each other. Humanity’s capacity for action, for new beginnings and an embrace of the world repudiate that impulse for tyranny.

Banks gives each of the seven thinkers their due, spending time with each one as she explores their views on birth and their demonstration that each person “in simply being born, creates an opportunity for history to begin again.” She writes of Nietzsche calling for the end of what he saw as the Protestant enchantment with the afterlife toward the earthly, embodied life that comes after birth and imagining a new spiritual tradition embracing birth, life, creativity, sexuality and procreation. Wollstonecraft, with her “soul most alive to tenderness,” recognizes the contradiction of birth’s importance to society and how little value is placed on it. Shelley, with her “Frankenstein: Or, The Modern Prometheus,” created the hideous monster “a motherless human life engineered by ambitious male inventors.”

Banks describes how often Sojourner Truth repeated the phrase “care for one another” in her narrations, and her view that a woman giving birth is a “cosmically significant” event, with women as actors capable of changing their worlds. American poet Adrienne Rich saw birth as a source of human power, sacredness and mystery, but critiqued the institutional motherhood that grew up alongside capitalism and its beneficiaries — a legacy some might say explains why we can’t move the needle on getting child care today. Birth was an integral part of Toni Morrison’s artistic vision, from her first novel to her last, and Banks writes that her era, which saw the confluence of the women’s movement, the fight for racial justice and the postwar years produced one of the “richest periods in the history of writing about birth.”

Life is under threat in the 21^st century, Banks writes, but birth is constantly with us as well. Like Arendt, who had born witness to the Holocaust of neighbor slaughtering neighbor, still never lost “a shocked wonder at the miracle of Being.”

“Natality: Toward a Philosophy of Birth” is not an easy read. It takes some willingness and effort, especially for those of us not familiar with the thinkers whose work Banks shares. But in that it provokes us to think of natality — of birth, creation, nurture, belonging and care — as the antidote to dehumanization, nihilism and despair, it’s an important and beautifully written read.

“That moment is something you always remember,” says Nicole Lynn Lewis, founder of , a Washington, D.C. nonprofit that supports teen parents in getting a college degree. Lewis got pregnant in high school and clearly remembers the moment those little pink lines on the pregnancy test hit her life like a lightning bolt.

“Particularly for teen parents,” she says, “you remember where you were, the circumstances and how you felt knowing you would be forever in a different category from what you had imagined for your life.”

Not every teen facing those circumstances uses that experience to create a national organization to address the needs of young people in the same situation. Lewis did.

“In that moment, if someone were to have told me I was going to be CEO and a founder of a nonprofit organization, I never would have believed them. As a high school student staring at a positive pregnancy test, I was overwhelmed even by what I might achieve in the near term.

“Would I be able to provide basic needs for this child? Was I going to be able to go to college myself? In the moment, I had no concept of what the future could hold for me.”

Going through college as a young mother, she found every day a 24-hour struggle to stay on top of her studies while paying the rent, putting food on the table and being the best mom she could be.

“When I got to the (William & Mary) graduation stage four years later, it was clear to me that I had made it for a reason,” she says. “I knew that my story was rare, but I didn’t know how rare. It wasn’t until I graduated from college and started looking into the statistics around how many teen moms actually get a college degree that I understood. And I knew that I had been through everything for a reason, that my story could benefit other people.”

Those statistics were daunting in the early 2000s when Lewis graduated, and they remain so now. Fewer than 2 percent of teen mothers earn a college degree before age 30, and more than half of all parenting college students leave school without a degree — but often with mountains of debt they incurred in their attempt to improve their lives.

Lewis began to realize that she might be the right person to launch an organization to turn her story into action. But first, she had some work to do.

“I didn’t have a playbook for starting a nonprofit organization, so I immersed myself in as much information as I could about the nuts and bolts of a nonprofit startup,” she says. “By this time, I had worked for several nonprofits so without doing so consciously, I had given myself a training ground on nonprofit work. I picked the brains of every founder I had met in my professional network, asking them what they wished they had known when they first got started, what lessons they had learned and what advice they had for me as I embarked on this adventure.”

Growing an Organization with Equity at Its Heart

Brick by brick, Lewis built Generation Hope, which works directly with young parents in college, surrounding these scholars with what Lewis knows is needed, based on her own experience. The organization provides mentoring, tuition assistance, a peer community and other wraparound services, as well as an early childhood program, Next Generation Academy, that provides literacy, academic and social-emotional supports that enable the scholars’ children to enter kindergarten ready to thrive.

Beyond providing support to individual families, however, Generation Hope works with higher education professionals, policymakers and practitioners to drive systemic change for the one in five college students today who are parents. Of those, 40 percent feel isolated on campus, which has a direct effect on their college completion rates. Many higher education institutions are not designed for students who are parents and many have an out-of-touch idea of the realities these students face.

“I talk to people every day who work in higher education,” Lewis says. “I share the statistic that one in five undergraduate students are parenting — almost a quarter of all undergraduate students are caring for dependents while going to school every day — and for many of these educators, it’s the first time they’ve heard this. It’s a significant population of our students, but an invisible one that has fallen under the radar of most people working in higher education.”

She adds, “When you think of the average college student, you’re not thinking about them having a little one that they’re caring for every day.”

Recognizing the need for data to help colleges and universities understand that parenting students are a substantial part of their student body, Generation Hope works with the institutions to establish methodologies for collecting the data on their students’ parenting status. Without this information, Lewis says, schools are flying blind to the lived experience and needs of their students.

“What we know is that data leads to investments, it leads to supports, it leads to services, it leads to policy. If we don’t measure this data, it’s easy to say, ‘Well, we don’t need that child care solution. We don’t need to ensure that we have lactation spaces that students and faculty can access. We don’t need policies that ensure that professors are supportive and inclusive of parenting students. So, one of the first things we have to do is make this population visible, and that happens with data.”

Generation Hope’s website offers for educators and advocates to support parenting students and eliminate barriers to opportunity for this population that is often so invisible in higher education.

Racial equity is at the heart of Generation Hope’s work as it champions antiracist strategies and policies aimed at the racial disparities that exist at all levels of American society. One arena where this disparity is particularly glaring is in the uneven representation of Black parents in the student loan debt crisis. Black parents hold more student debt than parents or nonparents in any other racial or ethnic group, Lewis says, borrowing an average of $18,100 for college compared with the $13,500 among all students. More than a third of Black college students are parents, and nearly half of all Black female undergraduates are mothers.

“We know that student parents as a group have higher amounts of debt than other student groups,” she says. “The cost of going to college is higher for this population, factoring in the cost of child care, the cost of living for not just the parent but a family. Many student parents can’t live on campus, so they pay for transportation that on-campus students don’t have to pay for.” A Generation Hope found that 82 percent of its student parents reported annual household incomes below $30,000.

Generation Hope provides each of its scholars with up to $2,400 in tuition assistance for up to six years, with an additional $1,000 available each year for emergencies such as car repair or groceries. It provides students with coaches who can help them understand and take advantage of financial aid and has developed relationships with the financial aid offices at more than 20 higher-education institutions in the Washington, DC, area that enable staff to advocate for Generation Hope’s scholars when the need arises. The organization also assists with child care costs, and covers fees and books for students as needed.

Community Support

Another remarkable way Generation Hope supports its students is by surrounding them with a readymade community that connects them with needed resources, and helps with basic needs such as diapers, school supplies, and gas cards. These Resource Families, which can be actual families or families created by a group of friends, coworkers, or colleagues — meet their scholar families throughout the year with group dinners (childcare provided) to break bread together, talk about parenting challenges, and provide a network of support for whatever the scholars are dealing with.

Now in its 13^th year, Generation Hope has demonstrated the practicality of its philosophy that student parents can make it—and alter both their own and their families’ futures—if they’re given what they need for success. The statistics speak volumes: 61 percent of Generation Hope Scholars earn a degree within 6 years, on par with all U.S. college students; 89 percent are employed full time and/or enrolled in a graduate studies program within six months of graduating; 100 percent of Next Generation Academy children scored “on track” on measures for social-emotional development after two years in the academy. Since its founding, Generation Hope has provided over $1 million in tuition assistance. Its six-year graduation rate for Black students is 52 percent — 8 percent higher than the national average.

The organization has now expanded to New Orleans, the next step in its strategic plan on its way to creating a world in which young parents, student parents and their children have every opportunity to succeed. Lewis said her vision is to create transformation across higher education but also to educate people to see this population differently and to create a mindset change regarding the issues they face.

Lewis points out that despite the barriers and challenges, student parents are highly motivated to earn college degrees and broaden the economic possibilities for their families. Her work has shown that they can do that if they have advocates and champions giving them the emotional and material support they need. Her life, as well as the organization she created, are living proof that it can be done. Her memoir, “,” tells the story. She now holds a bachelor’s, a master’s and an honorary doctorate, and sits on the board of trustees of Trinity Washington University. She is married, and together she and her husband are raising their five children.

It’s a life that could inspire big dreams for other young people staring at those two pink stripes—and a call to action for the rest of us to help them achieve those dreams.

The service is growing in popularity because it has been shown to make a dramatic difference in the birth experience for mothers, babies and families. A U.S. Department of Health and Human Services report published in December found that doula services drastically improved maternal health outcomes.�� “Doula-assisted mothers were four times less likely to give birth to a baby with low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding,” the report states. According to the , the one-on-one emotional support provided by doulas has been shown to reduce cesarean births, help shorten the duration of labor and improve the rate of spontaneous vaginal birth.

American mothers need all the help they can get. Though rates of maternal deaths have been declining in most countries, the U.S. has the of any industrialized country in the world, and the Centers for Disease Control and Prevention reports that “stark and unacceptable” racial and ethnic disparities persist in this maternity crisis. A large body of research suggests that doula support is a promising strategy to mitigate these disparities.

Medicaid each year — roughly 1.5 million births — and among the CDC’s policy recommendations to address America’s maternity crisis is to extend Medicaid coverage to make sure that no one in this country dies because of pregnancy. Because states have some discretion in how to use their Medicaid funding, some have begun following the evidence and offering doula services as a benefit to their enrollees.

Michigan has now become the latest state to reimburse doula services for individuals covered by or eligible for Medicaid insurance, joining 15 other states that have done so or are in the process of providing this benefit. In taking this step, the Great Lake State has made it possible for the approximately 45,000 Michigan Medicaid enrollees who give birth each year to access the gift of childbirth assistance that for years has been a luxury enjoyed by those who could pay for the service out of pocket or had great insurance.

Though Michigan has made strides recently in improving maternal and infant health, it still suffers from one of the nation’s highest infant mortality rates, with infant deaths among its Black and Native American communities more than double those among white infants. Black women in Michigan are three times more likely to die from pregnancy-related causes than white women — in keeping with similar national disparities.

To address these inequities, Gov. Gretchen Whitmer launched her initiative, allocating millions of dollars to improve birth outcomes and support birth equity. As part of this initiative, Michigan expanded Medicaid coverage for a full 12-month postpartum period, providing access to critical physical and behavioral health services, dental care, treatment for substance abuse, and more throughout the first year after pregnancy.

In January 2023, Gov. Whitmer announced that announced that Michigan would begin supporting expecting mothers by covering doula services for Medicaid enrollees. In making the announcement, Gov. Whitmer stated that a whopping 63 percent of maternal deaths in Michigan are preventable. (Michigan is by no means an outlier in these numbers: The in 2020 that more than 80 percent of pregnancy-related deaths from 2017 to 2019 in the U.S. were preventable.) To powerfully impact that situation, the state has put together a comprehensive program, a sort of one-stop shop that will spread the word about doula services, build the workforce, and provide ongoing resources and support for Michigan’s doulas.

A Solid Platform for Success

Doulas practiced in Michigan before the launch of the initiative, says Dawn Shanafelt, director of the Michigan Department of Health and Human Services Division of Maternal & Infant Health, who is leading the . “But with the program, Michigan will have a central location where families that have Medicaid insurance can find doulas available in their communities.”

The initiative also provides a registry for doulas that offers webinars, training and continuing education, as well as for enrolling as a Medicaid provider and guidance on billing for doula services through Medicaid. To become a provider, individuals must have completed Michigan Department of Health and Human Services-approved (MDHHS) training, and they can find these approved programs on the website. The initiative provides scholarships for those who want to take the training and become professional doulas — a strategy that both builds the workforce and offers economic opportunity within local communities.

A key component of the program is the Doula Advisory Council comprising 29 individuals, all doulas from across the state who represent the diversity of Michigan’s communities, Shanafelt says. The council will work to promote advancement of doula services statewide and advise the MDHHS on policies, applications and resources, as well as providing advice on content for continuing education and reviewing training programs to ensure they meet Medicaid requirements.

The health department is hiring two doula specialists to work with Shanafelt’s division to serve different geographic areas of the state. She says one of these specialists has been hired — a doula with 22 years’ experience — and a second is on the way.

Medicaid policy includes a maximum of six doula visits during the prenatal and postpartum period, plus one visit for labor and delivery in a hospital setting. The flat reimbursement rate is $75 for each of the six visits, plus $700 for attendance through labor and delivery.

A stumbling block for states accessing Medicaid funding for doula services has been the requirement by the federal Centers for Medicare and Medicaid Services that doula services must be recommended by a licensed healthcare provider. To address this, Michigan’s chief medical executive Dr. Natasha Bagdasarian has issued a standing recommendation that doula services are medically necessary and should be offered to families covered by Medicaid insurance.��In her recommendation, Bagdasarian wrote that doula services should be offered “immediately and on an ongoing basis to Medicaid recipients until such time as determined no longer necessary.”

Results Speak Volumes

Since professional doula services were first offered in 1970s, friction has existed with the medical community, with some doctors and nurses viewing doulas as encroaching on their territory, or just one more body to get in the way of their efficiency during labor and delivery.

“The way to change the mindset regarding who’s a part of the care team is by seeing excellent outcomes,” Shanafelt says. “By seeing that the patient or birthing person’s well-being improved by having a doula as part of their care team, attitudes change.

“Having the American College of Obstetrics and Gynecology recommend having an emotional support person such as a doula present because it is associated with better outcomes for women in labor makes a difference,” she says. “Doulas have been serving birthing persons for decades, even hundreds of years, so this isn’t a new concept. The difference is the recognition of the value and importance of the doula profession.

“The shift is partly a result of the research that’s been published (about the benefit of doulas), but most importantly, it’s come from listening to families. Families tell us what works best for them. They’re the experts. So, if you listen to the experts, you’re going to hear time and time again that doulas make the difference.”

RESOURCES

• , a nonprofit organization connecting Black families to certified Black doulas throughout the U.S. The maternal mortality rate among Black women��, according to the Centers for Disease Control and Prevention (CDC).
• Survey of medical literature demonstrating significant benefit for birthing parents and their infants, notably for Black patients

FACT CHECK

• (Journal of Law, Medicine & Ethics)

Here are 5 top takeaways:

1. Racism is at the root of health disparities. Not all U.S. mothers and babies go through the same experiences in the same way. The infant mortality rate among Black newborns is more than twice that of white babies during the first year. Mothers of color die during childbirth more than three times as often as their white peers. “Racism is the root of where racial disparities begin,” said Sanchez Lloyd — whose work is an initiative of First Steps Kent.

Contrary to the hypothesis that economic circumstances can explain the gap, a conducted by the National Bureau of Economic Research shows that household income plays no role in determining maternal and infant health outcomes. Increasingly, these disparities are recognized as a problem with implicit biases within health care and other systems.

2. Educating physicians and clinical care workers is paramount. Required lessons and tools to investigate personal biases, power and privilege improve the quality of care. Recommended measures include using proper pronouns, pronouncing names correctly and appropriately addressing questions to fathers and other caregivers in the room.

Sanchez Lloyd explained that clinical workers need to “add more humanity and see the entire patient, beyond what is written on their chart.” These efforts make mothers feel they have a voice to advocate for themselves effectively. In addition to educating clinical partners, it is important to engage family and community support systems.

3. Fathers should be in the fold. “We want to break this narrative that Black fathers don’t exist or that they are not present.” Sanchez Lloyd said, “Continuing to approach this from a maternal child health standpoint, we’re leaving out a key ingredient: fathers.”

Outcomes improve when fathers are involved because mothers feel more supported. “You don’t have to be in a romantic relationship with the mother of your child to be a great dad,” she said. Strong Beginnings’ , covers unconventional topics historically left out of fatherhood and recently went virtual. The lessons range from family planning, and prenatal to 18 months after delivery. They ensure fathers feel supported by offering access to mental health therapists and other community resources.

4. Nonclinical, community support is essential. “Community-based prevention strategies help avoid hospitalization and long-term chronic illness,” Spencer explained. “We need to ensure that people have access to the resources they need,” such as housing and a living wage.

Community health workers and doulas are also part of the systemic response. “Community doulas provide physical, emotional and educational support to pregnant and postpartum people up to the first year of birth,” Spencer explained. “They are a reflection of the community. When people are assisting others in the community that they belong to, we tend to have better outcomes.”

5. Some states are making strides. States play an influential role in the implementation of effective, high-value maternity services, particularly through insurance regulations. Medicaid is the health insurer of over 40% of births in the United States and 66% of all births to Black mothers.

Virginia recently became the fourth state to reimburse doulas under their Medicaid program. As of Jan. 1, the Michigan Department of Health and Human Services recognized doula initiatives as being reimbursable. Several other states are in various stages of consideration, planning or implementation of Medicaid doula reimbursements. “There are some gaps, and doulas have shown that they can be present in those gaps, which leads to successful deliveries,” Sanchez Lloyd said.

In early November 2020, she attended an outdoor concert with her mother and younger daughter in Dallas, a couple of days after begrudgingly attending a mandatory in-person meeting at work.

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“When I got home I was like, ‘[The cough] is probably because I was around all the plants and being outside. That probably aggravated my sinuses,’” said Lewis, 33, who lives in Dallas. “Didn’t think much of it, just went to bed. But the next morning I woke up and I felt like a train hit me.”

After being told that some co-workers also felt sick, Lewis decided to get tested for COVID-19 and her results came back positive. But her situation was more complex than most people who have contracted the virus because she was three months pregnant at the time.

Nights were the worst, she said, with the difficulty breathing making it feel like “a weight was on your chest.” Even getting up to go to the bathroom was a chore that required help from her husband and, at one point, her daily diet mainly consisted of just chicken broth and Pedialyte.

Although Lewis was never hospitalized with COVID-19 and later recovered, the experience still sticks with her, and when the coronavirus vaccine became available to high-risk Texans at the start of the year, Lewis jumped at the chance to get vaccinated. On April 23, she delivered a baby boy, Langston, with no major complications.

Not all pregnant women are as eager as Lewis about getting vaccinated, however.

Pregnant women have one of the lowest vaccination rates in the United States: As of Sept. 4, about 25% of pregnant women ages 18 to 49 have received at least one vaccine dose nationally, according to the Centers for Disease Control and Prevention. That’s significantly less than the most recent national average for that age group, which is about 61%.

The Texas Department of State Health Services currently does not collect vaccination data on pregnant women, said Lara Anton, an agency spokesperson, and also does not track cases, hospitalizations or deaths among this group.

Doctors said there’s no single reason for the low vaccination numbers, although vaccine hesitancy and misinformation have played a role.

Recently, pregnant patients with COVID-19 have come in to Texas hospitals at levels not seen earlier in the pandemic, according to some doctors, illustrating the severity and contagiousness of the delta variant amid the state’s most recent COVID-19 surge.

“We’re just seeing a lot more of them progress [to serious illness] very quickly,” said Dr. Manisha Gandhi, chief of maternal-fetal medicine at Texas Children’s Pavilion for Women and Baylor College of Medicine in Houston.

Last August, more than 15 pregnant women were hospitalized with COVID-19 at Texas Children’s Pavilion for Women. This August, the number nearly doubled, according to Texas Children’s.

“This variant is much more aggressive, [and] pregnant women are getting sicker much faster,” Gandhi said.

Combating misinformation

The that pregnant people get the vaccine has given medical professionals hope that more will do so. But they know it will still be a battle to overcome some of the hesitancy that has set in since the start of the pandemic.

“Women want to make the best decision for them and their unborn child, and it’s a really difficult position when they don’t include pregnant or lactating women in the [vaccine clinical] trial,” said Dr. Teresa Baker, professor and regional chair of the department of obstetrics and gynecology at the Texas Tech Health Sciences Center in Amarillo.

Pregnant and lactating women have long been excluded from initial clinical trials due to the possibility of putting an unborn fetus at risk, Baker said, so it wasn’t a surprise that the same thing happened during the development of COVID-19 vaccines. But with the lack of initial information about how COVID-19 affects pregnant people and mixed guidance by CDC and leading medical organizations, many pregnant people felt left in the dark about the best way to protect themselves.

“We just were working with a lot of unknowns for a long time and that made it uncomfortable for everyone, but I think we’re catching up slowly,” Baker said.

A recent study in the found that the vaccines offer similar protection for both pregnant and nonpregnant women.

Dr. Jerald Goldstein, founder and medical director of the Fertility Specialists of Texas, said false claims circulating on social media that women will become infertile or sterile from being vaccinated have contributed to some of the hesitancy.

The online misinformation has “definitely created a lot of work for doctors in terms of talking to patients who really, really believe that,” Goldstein said.

According to a recent study in the journal, F&S Reports, “neither previous illness with COVID-19 nor antibodies produced from vaccination to COVID-19 will cause sterility.”

Studies have also shown that receiving the vaccine does not lead to an or .

Gandhi, the maternal-fetal specialist at Texas Children’s, said the most important part of her day now is making sure patients realize the benefits of getting vaccinated and how much it reduces the risk of getting sick with COVID-19 and having to be intubated or enduring a premature delivery.

She has also urged people who are pregnant to not wait until they deliver their baby to get vaccinated.

“The highest risk time is while they’re pregnant,” Gandhi said. “… Getting vaccines [generate] antibodies that can cross the placenta and potentially protect the baby so there’s actually a bonus: You’re also adding to the protection of your baby who may get exposed after delivery.”

Making the choice

Austin resident Brittany Clay has never really seen herself as an early adopter to much in life. However, things changed once she learned she was pregnant in October 2020.

By then, she had already lost a family member to the virus. In July, her uncle, who had colon cancer, died from complications of COVID-19. Then, in October, her grandfather also died from complications of the virus and her parents landed in the hospital with pneumonia after contracting COVID-19.

“We said our goodbyes to my uncle over the phone, we said our goodbyes to my grandfather over the phone, and when I knew things were not going well for my parents was when they stopped answering their phones,” said Clay, 33. “They couldn’t speak on the phone anymore. It was too difficult for them with breathing. And it was like, ‘Wow, we’re literally saying goodbye to our loved ones, we’re telling them it’s OK to go over the phone — on speakerphone. It was the most horrible thing.

“It was such a scary time for our family, and when you go through circumstances like that, it’s just not that difficult of a decision to get the vaccine,” Clay said.

But the vaccine wasn’t available to high-risk people until December, and Clay still wanted to do her homework first. In January, about six months before the CDC recommended pregnant people get the coronavirus vaccine, Clay and her husband started collecting reports and studies about pregnant women and COVID-19.

Clay said she also gravitated to reading about experiences shared on social media by doctors who were pregnant themselves and got the vaccine.

“Being pregnant in a pandemic has so many added stressors and so many additional layers of fear and unpredictability, so much of it can be out of your control,” Clay said. “So then to add this additional unknown of this vaccine that, you know, has been around for nine months is a really scary decision, and I just try to honor and respect the fact that this is a decision that people have to make on their own.”

During her research, she also reconnected with Lewis, an old classmate from Texas Christian University, through social media. Clay was curious to hear about Lewis’ experience with COVID-19 during pregnancy.

Since reconnecting, they have bonded over motherhood and the shared experience of getting vaccinated while pregnant. Clay was fully vaccinated by February and delivered a baby girl named Navy on June 22.

“I later went back to [Lauren] after I had Navy, and I was like, ‘You might have saved my life. Thank you so much for sharing your COVID experience with me,’” Clay said.

For both women, the importance of getting vaccinated was underscored by the news that one of their TCU classmates who was unvaccinated had died from complications of the virus after delivering her baby.

“That has felt so haunting and so sad,” Clay said. “She was just so young and her family is now really trying to get the word out about the vaccines, and I recognize the severity of the cases are just getting more and more severe for pregnant women.”

Lewis has made it a personal mission to encourage pregnant women to get vaccinated and posted videos of herself being vaccinated on social media.

“If you have any questions, please reach out to me,” Lewis said on video in February after receiving her second dose. “I’m very pregnant, so I have a different perspective because I’ve had COVID.”

Lewis said she hopes other expectant mothers will heed her advice.

“I mean, [COVID-19] really sucked the life out of me,” Lewis said. “… Honestly, I’m waiting to go get my third shot. I want to get it because I don’t ever want to feel the way I felt with COVID, and I don’t want anybody to ever feel that way when they don’t have to.”

Allyson Waller is a reporter , the only member-supported, digital-first, nonpartisan media organization that informs Texans about public policy, politics, government and statewide issues. 

Disclosure: Texas Christian University has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete .

focused on solutions for the perinatal phase, which goes from pregnancy through the first year postpartum. Nine innovators presented, then a roundtable zeroed in on Colorado’s recently passed package of birth equity bills, which highlighted how social entrepreneurship can drive policy innovation.

Promise Venture’s Vance Lewis, senior program manager and Awara Mendy Adeagbo, head of strategic initiatives) moderated the virtual event. Adeagbo referred to her personal health journey on the way to giving birth to her baby son last year, saying, “Having a positive birth outcome should not be a matter of luck. The maternal and infant health crisis… is unconscionable and it’s preventable. We can turn this tide by centering the perspectives, experiences and needs of BIPOC communities in a strength-based, holistic way.”

Here are our takeaways from :

1. The history is shameful. , Black moms are dying at 3 to 4 times the rate of their White counterparts. The statistic is the product of a long history, from slavery and Jim Crow through the disinvestment and policy choices of today. In recent decades, politicians and the media have, in essence, blamed the victim through a narrative that questions mothers’ decisions.

According to Kiley Mayfield of the , this focus on individual behavior has distracted us from systems of oppression that have been in place throughout the nation’s history. Marqi Taylor, founder of Philadelphia’s called out “centuries of racial malpractice” that have led us to the point where people of color often don’t trust the medical institutions where they live, which is why activists have formed alternative communities.

2. Birth centers and doulas listen to women and birthing people. ’s mission is to develop “abundant community birth infrastructure.” Safe, culturally relevant midwifery, explained Leseliey Welch, improves maternal health outcomes and reduces the number of caesarean deliveries. Char’ly Snow of said birth centers not only save lives, they reduce insurance costs by $2,000 per birth.

The solution isn’t expensive technology but rather caring, trusting relationships. Twylla Dillion of and Tia Murray of made similar arguments for birth doulas who help women navigate the experience, advocate for them and make them feel supported.

3. Data counts—but what kind? Echoing Lewis, who cited the human right to “maintain personal bodily autonomy,” Kimberly Seals Allers, of (that is, the word Birth minus the B for Bias) declared, “Bias-free care should be a human right.” Describing the Yelp-like app for pregnancy and new motherhood, Allers asserted, “Community-driven feedback loops lead to more respectful and equitable maternal and infant care.” Tracy Warren of made the case for better data informing decisions in government and by institutions.

4. Let communities lead. On July 6, the State of Colorado signed a groundbreaking establishing basic human rights standards in perinatal care for all people (including those who are incarcerated), aligning perinatal care data and systems for equity and continuing the Direct-Entry Midwifery program. (According to the , a Direct-Entry Midwife is “an independent practitioner educated in the discipline of midwifery through apprenticeship, self-study, a midwifery school, or a college/university-based program distinct from the discipline of nursing.”)

Show+Tell celebrated the work of , which championed the package. Founder and director Indra Lusero stressed the importance of listening to community members and letting their priorities dictate strategy.

5. Stay tuned for further progress. Activists and advocates continue to push for local and national solutions. Joy Spencer of talked about building dignity through income supports where paid parental leave is missing. Led by Alma Adams (D-NC) and Lauren Underwood (D-IL), the U.S. House of Representative’s Black Maternal Health Caucus recently unveiled the . The legislation aims reverse the tragic history of BIPOC perinatal health through targeted public investment.

If Dr. Catherine Monk and her research team have their way, these visits soon will routinely include high-quality psychological interventions as well, based on researchers’ growing awareness of the effect mental and emotional stress during pregnancy can have on the mother’s health and the baby’s brain development.

Monk, professor of medical psychology in the Departments of OB/Gyn and Psychiatry at Columbia University Irving Medical Center, directs the department’s research laboratory, where a team of researchers focuses on the earliest influences on children’s development by connecting perinatal psychiatry, developmental psychobiology and neuroscience to study child development in utero.

Their research increasingly underscores the direct links between a mother’s psychological and emotional wellbeing, and changes taking place in her developing child’s brain.

As one strategy to help women and prevent mental health risks for their future children, Monk leads a new integrated care program, Women’s Mental Health @Ob/Gyn, that embeds mental health care practitioners within obstetrics and gynecology, and employs all the tools at their disposal to help reduce stress levels in their pregnant patients.

Adult psychiatric illness and mental health issues such as depression are known to be profoundly affected by the genes a person inherits and by the quality of care they receive as a child. Researchers now know a pregnant woman’s stress, anxiety and depression can create a “third pathway” for mental health concerns, Monk says.

The precise mechanism of the damage to the child’s neural development isn’t fully known, but numerous animal models and epidemiological samples indicate that distress-based changes in pregnant women’s biology are associated with negative cardiovascular, metabolic and psychological effects in their children. The release of cortisol, adrenaline and other stress hormones creates a chemical stew that can alter the brain chemistry of the fetus: Reduce the mother’s stress and lessen the harm to the developing child.

Though the womb is a baby’s first home and as influential as any they will ever have, researchers are just getting started probing its mysteries. “About 20% of pregnancies end in miscarriage, which is usually in the first trimester. Is that because of such a big stress effect that the baby doesn’t make it?” Monk says.

“The second trimester is a time of phenomenal brain development, but the synaptogenesis (the development of neural circuits) really peaks in the third trimester. In the third trimester, we start seeing early births, and stress possibly plays a role in those. We are in our infancy in terms of parsing out which trimester is particularly relevant to what exposure.”

One dramatic effect that is known about stress — and that illustrates its profound influence in utero — is that fewer male babies are born to women who are physically and psychologically stressed. On average, about 105 males are born for every 100 female births, but one study Monk and her colleagues conducted measured 27 different indicators of psychosocial, physical and lifestyle stress, and found that about a third of the women were experiencing “clinically meaningful” high levels of mental stress and sub-clinical levels of physical stress. Among these women, the male-to-female birth ratios were dramatically altered, 40/60 and 30/70, respectively.

After social upheavals such as the 9/11 terrorist attacks, the relative number of male births decreased, Monk says. Studies have shown that males fetuses are more vulnerable to adverse environmental conditions. This suggests that highly stressed women are less likely to have male babies because they lose the pregnancy, often without even knowing that they were pregnant.

“Many researchers want to study women who are pregnant during our current, very stressful period,” she says. From the COVID pandemic itself to job losses, loss of health insurance, concerns about family members, changes in hospital labor and delivery policies, a woman’s inability to have her caregivers with her for the birth or with her at home afterward, the Year 2020 wins the stress sweepstakes for just about all of us, and especially so for pregnant women. What this will mean for babies born during this time will bear close watching — and interventions whenever and wherever they can be made.

Despite the fact that 10 to 15% of women in the U.S. experience depression in pregnancy or postpartum — and up to 30% when substance abuse and anxiety are factored in — most pregnant women encounter barriers to accessing mental health services. Most insurance companies don’t cover behavioral health care or do so adequately, so women have to go outside their network for it — if they are able to get it at all. The consequences are not only devastating for the depressed woman and her developing child, they are costly for society.

Important Interventions

Monk emphasizes that, though prenatal stress has these effects on the developing child, it isn’t in itself a life sentence for the baby. Important interventions such as regular obstetric visits that keep a close eye on the mother’s blood pressure, weight and other health indicators can make a big difference, as can making sure the woman receives adequate nutrition and supplemental vitamins, particularly iron and zinc.

The care and warm interaction both a mother and baby receive during the postpartum period can also go a long way toward mitigating prenatal harms. As it turns out, social interaction is good medicine for both mother and child. ������

The good news is that none of the prenatal and postpartum interventions Monk and her team recommend are massive, intrusive or burdensome. Their Women’s Mental Health service deploys two psychologists, two social workers and two psychiatric nurse practitioners — one of whom is a doula — to meet their pregnant patients’ emotional and mental health needs.

Another intervention is called (Practical Resources for Effective Postpartum Parenting), which Monk describes as “very light-touch” — six sessions in which a coach prepares women for the postpartum period with mindfulness tools so they can find groundedness and calm when they need it. We provide education about what to expect with their baby coming, and provide a lot of tools for them to feel confident in being able to take care of the baby.

“The mother’s calm can then help the baby be its calmest self, too.”

Monk says the pandemic has required that these PREPP sessions now be conducted via telemedicine, but that has created a silver lining in showing that even prenatal visits can be successfully conducted through smartphones. This is especially important for women who are economically, socially or geographically disadvantaged — which all too often means women of color.

As with other effects of intergenerational stress and poverty, Black women and other women of color are disproportionately affected by both physical and psychological stress, which makes interrupting the pattern particularly important. Even families that don’t have computers at home usually have a smartphone, so the ability to reach these women through telemedicine opens up a whole new arena of accessibility for populations without access to the internet.

Though social distancing is one of the primary keys to controlling the spread of coronavirus, following distancing orders during these times can be especially difficult for pregnant women. Family and friends should never underestimate their ability to stay connected and make a dramatic difference simply by calling, Zooming, FaceTiming and using technology in whatever ways they can to provide the social support that is so essential for a woman during her pregnancy and in the postpartum period.

Monk says her intention is that the Women’s Mental Health @Ob/Gyn project will serve as a model for embedding mental health care into America’s obstetric practice nationwide and eventually pave the way for including behavioral health services in primary care settings more generally. When families are able to access counseling and psychotherapy as easily as they can get a strep test or cholesterol screening, that will be one giant step for a healthy — and mentally well — human future.

Sabra Bell remembers what it was like to be pregnant and low on funds. “Extra cash would have been useful,” she says. “I would have paid off my debts and bought a nice stroller, crib, breast pump, baby clothes and more.”

Today, Bell and other mothers are drawing on their personal experience in their work as researchers on the Abundant Birth Project, an ambitious pilot seeking to reduce the incidence of premature birth in San Francisco.

Starting in 2021, the program will distribute a monthly income supplement of $1,000-$1,500 per month to 100 low-income black and Pacific Islander pregnant women. Payments will continue for the duration of a woman’s pregnancy and then for the first two months of the baby’s life.

Kara Dukakis, an early childhood development senior program officer at , which is one of the pilot’s funders, champions the Abundant Birth Project for the way it explicitly acknowledges racism as a factor in these women’s lives. “An incredibly important part of the pilot is that women of color are hired to be the researchers,” she says. “Because they have lived the experience, they can truly empathize with the women the project supports.”

Maile Chand, another researcher who has “been there” herself, adds, “Not only will this financial opportunity help San Francisco black and Pacific Islander families better provide for their children, but it will also transform the emotional and physical state mothers are in going into their birth.”

The Science Behind the Project

The Abundant Birth Project is grounded in both science and respect for moms. Thanks to advances in medical science, premature babies have a far greater chance to survive and thrive than ever before, but it’s still ideal for a pregnancy to last 40 weeks, or close to it. Cognitive deficits and physical disabilities frequently accompany preterm births, and black women give birth prematurely, as white women.

“The strain of ongoing financial insecurity,” says Dr. Zea Malawa, director of Expecting Justice, “contributes to chronic stress and is associated with premature birth. Although San Francisco has programs to address poverty, they are not enough to close the gaps. The high rates of preterm birth experienced by the black and Pacific Islander community require a more urgent and upstream intervention.”

The Abundant Birth Project builds on of Jackson, Mississippi, which distributed $1,000 monthly for 12 months to 20 women. , was found to help women to improve their nutrition, prepare for baby and engage in self-care to moderate the effect of stressful life events. Reduced incidence of low-birth-weight infants and pre-term birth also resulted.

Free Money? What’s the Catch?

There is no catch.

Unlike conditional cash transfer programs, which distribute money only when subjects adhere to certain behaviors (for example, attending school or visiting the doctor), the program commits to awarding stipends without stipulation.

“Most public assistance programs have complicated eligibility requirements,” says Deborah Karasek, a researcher with the at the University of California, San Francisco, which is partnering with on the Abundant Birth Project. “However well intentioned, these requirements often prevent black and Pacific Islander pregnant women from obtaining the resources they need—and they tend to exacerbate mistrust in the system.”

The Abundant Birth Project, in contrast, provides direct, unconditional cash aid—returning to women the power to make their own decisions.

Pregnancy can simultaneously bring great joy and acute stress. Even for mothers with a steady partner, financial resources and robust social networks, this time can be overwhelming, even traumatic. Pregnant women without these assets are susceptible to mental and physical health threats—and this is before a new person suddenly enters the picture, demanding food, attention and medical care.

The Abundant Birth Project won’t make everything right for the moms and babies it touches—but it’s a start.

Among African American mothers and babies, the crisis is even more acute. Across the income spectrum, from all walks of life and all levels of education, Black women die from preventable pregnancy-related complications at three to four times the rate of non-Hispanic white women. The death rate for Black babies is twice that of infants born to non-Hispanic white mothers.

The (CAP) reports that African American mothers are twice as likely to have an infant who dies by the baby’s first birthday, and are twice as likely to experience life-threatening pregnancy-related complications known as severe maternal morbidity (SMM), compared with non-Hispanic white women. Although other women of color — notably American Indian, Alaska Native and some Latina communities — also experience an appalling increased risk of poor outcomes, data show that racial disparities between Black women and non-Hispanic white women are the most glaring.

In the U.S., a pregnant woman’s health, her baby’s ability to thrive, survive and even her own chance at life, depend to large degree on her race and geography, says , senior policy analyst for early childhood policy at CAP. An CAP released late last year analyzed vast racial disparities state-by-state in infant health outcomes throughout the nation in both infant mortality and low weight birth.

“As more research has come out over the years, one thing becoming increasingly evident is that these disparities in maternal and infant mortality are mostly rooted in racism,” says Novoa, who authored the issue brief for the report. “The reason we can say this is that, even when you control for social-economic status, education or access to resources, all those factors, we still see that Black women and infants have worse health outcomes on average.” Racism — not race itself — and the systemic barriers fueled by both explicit and implicit bias are the drivers of these outcomes, she says. Structural racism compromises health.

In CAP’s state-by-state analysis, geographic disparities are stark; racial disparities are starker. For example, white babies born in New Jersey die at a rate of 3.4 deaths per 1,000 births, which is comparable to Germany’s infant mortality rate. But Black babies born in Wisconsin are dying at nearly five times this rate: 15 deaths per 1,000 births — a rate higher than that of Syria. With , users can explore the infant mortality rate and the percentage of babies born at low birth rate by race, ethnicity and state to see where and for whom the infant health crisis is most severe. Available data show estimates for five demographic groups: white, Black or African American, Hispanic, Asian or Pacific Islander, and American Indian or Alaska Native, and users can compare two groups to see how outcomes differ by race and ethnicity across states, except in some states where the sample sizes were too small to yield precise estimates.

What Birth Weight Really Measures

A baby’s weight at birth is a major determinant of their chance at surviving and thriving in life. Low birthweight is defined as when a baby is born weighing less than 5 pounds 8 ounces; babies are considered premature if they are born before 37 weeks’ gestation. Though some low birthweight babies are healthy, and some are born small because their parents are, many others have serious short-term health problems that need treatment, such as trouble eating, gaining weight, staying warm enough and fighting off infections. Low birthweight babies can have breathing difficulties and later development difficulties. Again, in the U.S., race has a distinct impact on an infant’s birth weight, with nearly twice as many Black infants being born at a low birth weight as non-Hispanic white babies.

, a pediatrician and senior fellow for the , stresses that low birth weight in itself is neither a death knell nor destiny. With plenty of medical, family, nutritional and other supports, underweight and premature babies can recover and thrive, particularly given the almost miraculous developments in recent years in neonatal care. But when that preventive care and those needed interventions don’t come into play, he says, the result can be a dangerous vulnerability that affects brain development, brain function and a variety of physical issues for the child’s lifetime.

“Unfortunately,” he says, “when a small, premature baby is born into an environment of stress and poverty, we have ‘double jeopardy.’” If you have low birth weight and, simultaneously, a context of, poverty, family stress, discrimination, insecurity and insufficient nurture, then unfortunately, that double jeopardy grows exponentially — 1 + 1 = many more than 2 — meaning it’s additive into future vulnerabilities. The majority of time, if the environment is strong, supportive, simulating, safe and secure, there’s a lot of natural recovery, resilience and healing capacity for a low birthweight baby. But that’s not the usual story.

“And then, unfortunately as this vulnerable child does not experience a strong and supportive environment of relationships, their development falls off its trajectory and is increasingly more difficult to bring back on track,” Willis says.�� “In our current culture, once a child falls start falling off track, there are too many forces, attitudes and belief structures that make it very hard to recover — not the least of which is often insufficient treatment services. If you have a 4-year-old child who is struggling, has trouble paying attention because his environment is stressed and there’s not been enough attention to nurturance and building essential capacities, the stressed and unsupported child may start ‘acting out’ in pre-school and get kicked out. And that begins a spiral toward greater and ongoing difficulties. From the family standpoint, they’re worried about his/her future. From the child’s standpoint, he is developing his behavioral and social habits and patterns of being. And from the teacher and environment, the child is a problem — and now you’re off to the races. The bad-kid track.”

The Costs of Low Birth Weight and Prematurity

The societal costs of premature birth are substantial, but those dry numbers can’t capture the devastation low birth weight and prematurity bring to babies, mothers and families. For every baby who fails to thrive, there is a mother who experiences the stress of dealing with a child in precarious circumstances or a father and extended family that have to deal with getting time off to care for the mother and child and the multiple layers of worry, stress and economic hardship that can involve.

“These young infants may have to spend significant amounts of time in the neonatal intensive care unit (NICU), and that’s costly,” Novoa says. “It’s financially costly for the healthcare system. It’s also costly on a micro level for individual families. Parents with newborns in the NICU often want to be with their baby at the hospital, but many parents have to go back to work right away because they don’t have paid time off of work. Even parents with paid leave often burn through it and have to take unpaid leave or go back to work sooner than they’d like. In either case, financial and job-related stress can compound the emotional stress—including sadness, guilt, fear—that parents experience when they have a preterm or low-weight baby.”

Again, the load of stress weighs especially heavily on Black women and women of color, according to the CAP report. The stress isn’t garden-variety worry, Novoa says. It’s a physiological burden of emotional and mental anguish, decades of bracing for fight-or-flight from the tigers of economic hardship and psychosocial adversity that create a form of premature aging called “weathering” that increases Black mothers’ susceptibility to numerous negative health outcomes. Being devalued on a daily basis quite literally wears a person out.

Addressing the Disparities

But just because this is the current state of affairs throughout the U.S., Novoa says, doesn’t mean it has to be. The interactive report shows the steps various states have taken to improve infant health on three interrelated domains: healthy families, economic and work supports and infant health outcomes. Addressing the infant-maternal health crisis in the U.S. is an all-hands-on-deck moment, she says, and will take a variety of approaches. But the improvements observable in states that have made policy changes show that implementing evidence-based policies and investing in family support programs can go far in ensuring that all infants have the opportunity to thrive.

“We know addressing these disparities is something that will require changes to our current healthcare policy,” Novoa says. “We also have to think expansively about what we are doing to support families and parents better beyond healthcare. We want to talk about the opportunities the states have to do things better, not just about what’s wrong. Each state has room for improvement and most states are doing something well. Louisiana, for example, has expanded Medicaid, and it has a modest, refundable to help low income families. So even though a state may not have great health outcomes yet, there is a glimmer of hope that some state policymakers have taken appropriate, right action on this.”

Avoiding the Good-Bad Paradigm

A pitfall in looking at how dire the situation is would be to fall into a right-wrong, good-guys/bad-guys view of the situation, both experts say. The CAP created the interactive report as a tool to help citizens and political leaders see the gaps and where improved policies can have an effect.

“Solving this will take an any-and-all-in approach,” Novoa says. “We’re encouraged to see how this information is gaining momentum at both the federal and state level. I’ve been working on this issue for a few years and it’s heartening to see the attention that policymakers are paying to these issues since I’ve started.”

Just the fact that we are having the conversation now is encouraging news, Willis says. “We’re talking out loud at many, many levels about the realities of structural racism that have been the foundation of this country and are still disruptive to child flourishing.

“There are some policymakers and the public who appear not to care about the challenges of so many families. This segment of society believe that people create their own destinies and believe that national and state polices best support self-determination. But knowledge from the research is building about the impact of poverty on health and wellbeing and the effect of racism on health outcomes — and this means impacts on the economic and workforce of the future for our country. The youth in this county seem to have a stronger sense of equity and the importance of supporting the wellbeing of all.�� They see that building the capacity of our next generations for our nation’s economic vitality is essential and I’m hopeful we’ll see major shifts soon in social policy.

“The situation we’re facing is tragic,” he says, “but it is also full of hope and opportunity. We know the forces that drive both vulnerability and resiliency. But we also know how to assure the wellbeing of all young children. Now we have to do it at a scale that meets the challenge. I find that thrilling for the future.”

For other mothers, though, the feelings of sadness, exhaustion and anxiety run much deeper and can overtake the woman’s ability to care for herself or her family. This deep level of stress has a medical diagnosis — postpartum depression (PPD) — and it is treatable: Medical guidelines recommend counseling and possibly antidepressants for all women experiencing it. Untreated, PPD can have serious consequences for both mother and child and can even spiral into psychosis where the mother may be a danger to herself or her baby.

Medical treatment recommendations don’t matter if women suffering PPD never receive that diagnosis, are not able to access care or are constrained from seeking help by culture and family standards — as is particularly the case for African American and low-income mothers.

About one in seven women in the U.S. develops postpartum depression, or about 15% of American women. For Black women, the risk is much greater, says Dr. Joia Crear-Perry, an OB/GYN who is the founder and president of the , dedicated to eliminating racial disparities in birth outcomes and a co-founder of .

“For Black women, the risk is almost twice that — and that’s just the people we know about,” Crear-Perry says.

For Black women dealing with PPD, seeking help can be particularly fraught with cultural and familial expectations, she says. The Strong Black Woman ethos has served African American women for many generations, describing and affirming the fortitude they’ve needed to prevail in the face of countless challenges. When it comes to childbirth, however, that same strength-based identity can isolate a woman just at the moment she needs the most support, authenticity and connection.

Postpartum depression is not caused by something the mother is doing or failing to do. Though the causes are not entirely clear, the mood disorder likely results from a combination of physical and emotional factors. Chemical changes take place in a woman’s brain after childbirth as hormone levels drop drastically. This chemical seesaw creates mood swings that can set everything in the mother’s life off balance. Fragmented sleep is a major contributor to postpartum depression — from getting up every two hours to feed the baby to chemical changes in the mother that keep her brain so revved up sleep becomes impossible. The result can be an unrelenting exhaustion that feeds on itself and creates a dangerous downward spiral.

“There is a lot of shaming and stigma around mental health,” Crear-Perry says, “and a great deal of stigma about being seen as weak for having to ask for help. We’re supposed to be able to take care of our families, to keep it together and keep marching, right?”

Overcoming that internal and external judgment can feel out of reach to depressed mothers, and even their best intentions can be thwarted by knowing implicitly if not explicitly that as a woman of color, the cards are stacked against her. According to the , women in the U.S. are more likely to die from childbirth or other pregnancy-related complications compared to women in other developed countries. The data show that Black women are three to four times more likely to die from pregnancy-related death than their non-Hispanic white counterparts, and research shows that half of these deaths — primarily from hemorrhage and hypertension — are preventable. Pregnant Black women are to be murdered by their intimate partners than white women. And according to the National Institutes of Health, Black mothers are several times more likely to suffer from PPD but less likely to receive treatment and follow-up.

“To be clear,” says Crear-Perry, “those statistics aren’t because of physiological differences. Being Black isn’t a risk factor for illness, death and depression — being exposed to racial bias is the risk factor.”

According to the , this bias disproportionately affects the quality of care mothers receive during childbirth; research has shown that doctors spend less time with Black patients and the care Black mothers receive is less effective. Providers are less likely to believe Black women’s self-reporting of pain and support their breastfeeding, and more likely to ignore their symptoms and dismiss their complaints. Education, socioeconomic status and even fame offer no protection from the bias Black women encounter, demonstrated by high-profile stories such as tennis superstar health catastrophe and the death of Shalon Irving, an epidemiologist at the Center for Disease Control and Prevention.

The reports that Black women were less likely than white women to initiate mental health care after delivery and more likely to put off seeking treatment longer after the child’s birth. Early detection and treatment can reduce the negative impacts of the illness, but even in that regard, Black women who started treatment were less likely to receive follow-up or continued care compared with white women who initiated treatment. The study reported that Black women generally preferred psychotherapy over taking antidepressants, but for many, getting psychological services can be nearly impossible because states are not required to offer those benefits in their Medicaid plans.

Some African American women suffer in silence because they are afraid of being reported to child protective services if they admit that they are having trouble caring for their children. There’s reason for worry: Numerous studies have shown that child welfare workers are more likely to deem Black mothers unfit to care for their own children and to recommend that the children be removed from their home. According to Child Welfare, two Texas studies found that while Black families on average tended to be assessed with lower risk scores, they were 20% more likely to have their case opened for services, and 77% more likely to have their children removed instead of being provided with family-based safety services.

“So, if you’re worried about someone taking your baby from you and about not being listened to by your doctors and all these other concerns, that makes you even more depressed, right?” says Crear-Perry. “Especially if you’re substance abusing and need help, you worry about trying to get treatment because they’ll take your baby.” Small wonder that fewer than 15% of African American woman with PPD seek professional care.

Altering this complex situation will take nothing less than a transformation of multiple systems in U.S. society — medical, social and political — and a number of non-profits and professional groups are working toward those ends. In the meantime, Crear-Perry says two of the most effective solutions are deeply rooted both in culture and in history: midwives and .

“Childbirth is not a medical phenomenon,” she says. “It has been medicalized, but prior to it becoming white men anesthetizing you and pulling the baby out with forceps, it was indigenous. Even if the role wasn’t called a ‘doula,’ there was someone to care for the mother and support her throughout her pregnancy and birth.

“When I first heard ‘doula,’ it was from a wealthy friend who was pregnant, and I saw it as a thing for rich people. But when you understand what a doula actually provides, doesn’t everybody deserve that support, that person to watch out for them?”

According to , some research shows that one of the greatest triggers for depression is a significant deviation between what a woman expects or plans and what actually happens — whether an unplanned C-section, complications at delivery, a baby with medical issues or difficulties with breastfeeding—particularly with those mothers who do not have support. Supporting the mother through the anticipated and the unforeseen is the work of the doula; caring for mother in a highly individualized way has always been the work of the midwife. Helping the mother get set up for successful breastfeeding is the work of both.

“For Black mothers,” Crear-Perry says, “midwives and doulas aren’t a luxury, they’re the fix.”

I spoke to Dr. Joia Adele Crear-Perry, founder of not one but two efforts that confront these issues — and —about the scope of the crisis and what can be done.�� Crear-Perry, a mother of three children, formerly served as director of clinical services for the City of New Orleans Health Department. In 2016, she addressed the United Nations Office of the High Commissioner for Human Rights to urge a human rights framework to improve maternal mortality.

“It’s in my nature to ask ‘why,’” Crear-Perry explains. For example, upon discovering that the State of Missouri would expand Medicaid access to moms addicted to opioids, her immediate question was: Why just opioids? Is there a medical reason to include just this one type of addiction that happens to be associated with poor white people? At the forum where she brought up this concern, the author of the provision said he never thought if it that way.

“We should have fixed this during the crack epidemic,” Crear-Perry insists, recalling indignantly that when a mother, a pharmacist, went to the emergency room as a patient, the staff treated her like she was there for the free drugs.

The matter of who is and is not eligible for Medicaid coverage has life-and-death consequences. of the Center on Budget and Policy Priorities, “Medicaid coverage improves families’ financial security by protecting them from medical debt and helping them stay healthy for work. Medicaid coverage also has long-term health, educational and financial benefits for children.”

It follows, therefore, that if the program is implemented in ways that discriminate against one group, there will be adverse health consequences—suffering and, let’s face it, death—for people in that group, especially if they are already vulnerable due to other social and economic factors. Crear-Perry points to Medicaid expansion in Michigan, which has work requirements, but only in Detroit and Flint, ostensibly because these two urban areas have low unemployment rates.

These problems don’t just affect Black people, though. When Crear-Perry lived in Louisiana, she could see how the racial narrative around public benefits affected all low-income families. “When poor whites start to think, ‘These are for poor people,’ they mean poor black people, and it makes them less likely to avail themselves of supports,” she notes.

Crear Perry does believe there are reasons to be optimistic about the overall health and race picture in the United States. “Students and residents are more receptive,” she says, noting that are pushing medical schools to address racism in their curricula.

Take one extremely revealing index: the perception among medical professionals that black skin doesn’t “feel pain” as much as white skin. The bias is less prevalent among younger doctors. “You can’t end racism,” she admits, “but you can fundamentally change the acceptability of it.”

For Crear-Perry, one of the most promising—and underappreciated—avenues for systemic change in the field of health care in general and reproductive justice specifically has to do with how Medicare (and private insurance companies) calculates the dollar value of a medical intervention. Initiated in 1989, the Relative Value Unit (RVU) system establishes the value of 7,000 distinct nonsurgical and physician services. (The late economist Uwe Reinhardt wrote two wonkish but relatively clear-sighted blogs about RVUs for The New York Times in 2010; see and .)

“The inherent devaluation of women’s health is embedded in our RVU system,” Crear-Perry says. “Hospital CEOs often call Labor and Delivery Units a loss leader. They know that it is underfunded, but they have data that shows women make the household decisions on health care. So they are willing to lose money on the care for a woman because she will bring her husband to that hospital for a knee surgery that they do make money off of, or cardiac catheterization for their fathers.”

Making health care professionals more aware of systemic biases may be an uphill battle, but advocates like Crear-Perry are making vital progress.