An Open Letter to the 2020 Democratic Candidates:

Senator Cory Booker and Representative Ayanna Pressley released a plan last week to the House and Senate to address the maternal mortality issue that is plaguing the nation.  The MOMMIES Act seeks to change Medicaid in six different ways to improve outcomes.  The plan is one of many recently, highlighting this important issue.  Physicians are taking notice and eager to hear how far politicians will go to make this a priority.  Physicians have been wrestling with the fact that not only is healthcare not accessible to many in this country, its inequitable distribution is hurting women, specifically Black women.  

There are groups of organized physicians who share commonalities through the specialty of obstetrics, progressive values, interest in driving policy change, and a focus on dismantling systemic racism.  In the intersection of those groups, the information has been looming for years. Groups have formed specifically to address this crisis.  As daily witnesses, we know that our Black patients are having worse outcomes and receiving poorer care.  The exact reasons seem large and untouchable, but they weigh on our minds. It is clear that physicians and healthcare teams need to lead the way on this.  What is not clear, is if the politicians know how much physicians have to offer.  

The MOMMIES Act is an excellent start to address the complicated issue.  It is supported by Senators Gillibrand, Harris, and Warren. They have all released plans of their own to address maternal mortality and racial disparities.  Booker and Pressley’s plan seems to go the furthest, focusing on extending Medicaid.  With this plan, coverage would not abruptly stop 60 days after birth but cover the first year after birth, an important time for a woman’s emotional and physical health.  It extends the coverage to more than just obstetric care, because specialty services and dental care affect maternal outcomes too.  It will also include supportive services like doulas and telemedicine.  All these measures would improve obstetric outcomes, but they still focus too much on only obstetric and postpartum care and do not recognize that Black women, live a lifetime of risks before even getting pregnant.

Unfortunately, none of the policy proposals go far enough.  Physicians caring for women often wonder, who are the physicians working on these bills?  Most advocates for Black maternal morbidity can rattle off solutions that would improve outcomes off the top of their heads and yet even when we see an exciting plan that seems to be on the right track, it still seems to leave out critical aspects. Of course, as we have seen in the last week, experts are often not consulted in important discussions around maternal care.  In Georgia, Ohio, Alabama, and Missouri, legislators have proposed and passed bills to *extensively* restrict women’s access to abortion and contraception.  It is clear that physicians have not been involved because two of these bills include “a procedure for an ectopic pregnancy, that is intended to reimplant the fertilized ovum into the pregnant woman’s uterus.” This procedure does not exist and any Physician could have explained that easily to the legislators.  Of course, this is part of the strategy employed by the GOP in passing strong abortion laws. Democrats, however, would be well served to consult experts if they want to really tackle the issue.  

The reason Black women are suffering is not just a symptom of racism in medicine, its because Black women live in a country that lacks respect for women and undervalues and disrespects Black Americans.  It is no wonder that Black women are two to three times more likely to die in childbirth than white women. Maternal outcomes for Black women are tied to a lifetime of exposure to racism, stress, and experience with social or economic marginalization (a concept known as “weathering”).  Unfortunately, when a woman experiences a bad outcome, it is usually impossible to sort out the confounders that contributed to that outcome.  If we could point to a racist healthcare member or biased hospital policy, it would be an easy fix. The truth is that addressing maternal morbidity for Black women means addressing racism in medicine but also the systemic failures of our government both at the state and federal levels.  

Fortunately, women's advocates like us, who work within healthcare, have been working hard to come up with solutions to this problem and address what we can. First and foremost, healthcare must be a universal right. Access to care is paramount. Maternal health cannot exist without access to birth control and safe abortions. Likewise, healthcare throughout a woman's life will directly improve maternal and fetal outcomes.  A study last month in JAMA shows that in states that expanded Medicaid, Black babies had a significant reduction in outcome disparities.  So too would paid maternity leave. It would relieve the strain on women (disproportionally Black women) who have to return to work immediately after birth because they cannot financially take advantage of federal disability and FMLA laws.  Twenty-five states have laws protecting puppies from being adopted before 7-8 weeks of life but many women are forced to return to work by 6 weeks because they can’t afford more time away from work. Not only would this baby bonding time be advantageous for babies, but women would have less risk of postpartum depression, would be able to return to healthy weight easier, and their infants would benefit from more time during a developmentally critical stage.    

Education and advocacy should be considered as well.  Women should have access to free birthing/pregnancies classes developed especially for Black women.  Classes can be aimed at how to navigate the system, resources available, and common risks that Black women face in pregnancy. North Carolina assigned case managers to pregnant high-risk Medicaid recipients and nearly eliminated the disparity gap between Black and white moms.  In California, the California Birth Equity Collaborative is partnering with hospitals, advisory groups, and Black women to research and develop quality improvement measures.  This might include mandatory staff training on implicit bias, mandating data collection and reporting for each hospital, and offering birthing/pregnancy classes directed towards Black women.  Partnering with doulas to provide support to women before and during delivery is another exciting idea starting to gain traction.  The answer is multifactorial and we are trying to tackle as many aspects as we can.

Another important factor left out of all of these plans is to consider that representation matters. Black women need access to doctors, midwives and nurses who have shared experiences and perspectives. There is a long history of medicine taking advantage of African Americans and Black women in particular.  The distrust that developed from this relationship is deep and is often reinforced when women do not feel heard by their physicians. Having a Black physician allows women to start at a higher level of comfort. But Black physicians are underrepresented in medicine, making up less than 6% of physicians.  Improving this statistic would go a long way in providing women with physicians who represent them and understand their unique needs.  This can be done by developing mentorship programs, recruiting black students, medical residents, and providing funding for the training that they need to go into obstetrics.  

Another issue is an overall shortage in Obstetricians. Access to board certified Obstetricians or Family Practice doctors trained in obstetrics is decreasing every year and the shortage will only exacerbate the problem. Physicians need to be encouraged to enter the field of obstetrics and to remain, especially in areas that are most at risk.  Improving reimbursement rates so that they reflect how other surgical specialties are reimbursed would easily address this. Obstetricians are being priced out of caring for the most vulnerable women as they are unable to afford malpractice insurance given the poor reimbursement rates. They are having to give up obstetrics, leaving women less access.  If these measures are not a part of the solution, the specialty that is already underserved will continue to deteriorate and have fewer resources for the communities that need it most.
 
We look forward to hearing more about the ideas that the 2020 candidates have, and hope that maternal outcomes and racial disparities among them will be an ongoing topic of discussion.  But, we ask that you consider and consult with experts when formulating your plans.  There are many brilliant Black women physicians, uniquely qualified, who can lead you with their personal and professional experiences.  


National Birth Equity Collaborative http://birthequity.org/about/about-the-founder-and-pres/

Black Mamas Matter https://blackmamasmatter.org/

National Medical Association, nmanet.org

Association of Black Women Physicians www.blackwomenphysicians.org


The undersigned,
Carmen Baxter,MD,
Parul Gupta, MD,
Emi Ponce de Souza, MD