Pregnancy can be an exhilarating time of one’s life as parents look forward to welcoming a new member into their family and navigating the wonderful journey of parenthood. Exciting questions abound: What color will we paint the nursery? Is it a boy or a girl? However, for many black mothers in the United States, a much more pressing question lingers: Will my child live? For women of color, ensuring that their child survives is often their sole priority.

The United States currently has one of the highest infant mortality rates of all developed countries in the world. Infant mortality is defined as death that occurs within the first year from birth, and according to recent governmental data, black infants in America are now more than twice as likely to die as white infants. This tragedy is compounded by the fact that the United States also has one of the highest maternal mortality rates. In fact, the United States is currently one of thirteen countries that has a higher maternal mortality rate today than it did 25 years ago, with black mothers dying at a rate nearly four times larger than their white counterparts. As black mothers and infants die at an unprecedented rate, researchers are searching to find a solution. What is causing this enormous and frightening disparity, and what can be done to address it?

Though infant mortality rates have significantly declined in the early part of the 20th century, the crisis of infant mortality has become increasingly exacerbated over recent decades. While infant mortality rates have risen overall in the United States, black infants fare far worse than other races. In 2014, data released by the United States Office of Minority Health showed that black infants in America experience a mortality rate of 11.4%, compared to non-Hispanic white infants’ rate of 4.9%. They are also more likely to die of sudden infant death syndrome (SIDS) and low birthweight than white infants, which are both preventable causes of death.

Black mothers often also die of preventable causes within the year after pregnancy due to seemingly minor issues such as blood clots and hypertension. CDC data has reported that the rate of preventable post-pregnancy near-deaths in black mothers has risen an astonishing 200% between 1993 and 2014. Historically, researchers have attributed these disparities in health outcomes to poverty and lack of education within the black community. Doctors, often pointing to data that showed black women have higher rates of type II diabetes, teen pregnancy, and drug use, have assumed that because black women were economically disadvantaged, their personal choices contributed to the detrimental health outcomes of both themselves and their children. However, these hypotheses have been proven to be unsupported. Recent CDC studies have found that this racial disparity transcends all levels of American society, as the data revealed that babies born to college-educated black mothers were still more likely to die than children of high school-educated white mothers.

Many researchers have since ascribed this to inadequate access to prenatal care among black mothers, which is partially true. There are several barriers to the access of healthcare that plague black communities — black mothers are more likely to be uninsured before they become pregnant, which can lead to delayed access to prenatal care, predominantly black neighborhoods tend to have fewer hospitals, and the cost of transportation to hospitals and healthcare in other areas can pose a financial burden to many lower-income mothers.

The answer may also lie within gender bias in regards to treatment. Researchers have found that women often feel that they are not being taken seriously by their doctors and have a difficult time having their medical concerns addressed by health professionals, which often translates into poorer quality care for women. As recent surveys have shown, women are prescribed pain medication at a lower rate than men, wait longer than men for care when admitted to the emergency room, and more likely to be told that their pain is caused by emotional distress or is “psychosomatic” — a diagnosis that harkens back to decades of doctors diagnosing any and all female ailments as “hysteria.” It is likely that the experience of black women in a clinical setting is even worse, and this is largely due to cultural insensitivity on the part of physicians and deeply ingrained racial prejudices within the overarching healthcare paradigm.

Rachel Johnson-Farias, the current director of the Center for Reproductive Rights and Justice at Berkeley Law, argues that the quality of care provided to black mothers is a primary factor regarding the alarming disparities in health outcomes. “Lower income women and women from other marginalized communities have less access to healthcare, but when they do get access, the quality of that care isn’t quite what it should be,” Johnson-Farias says. As studies have found, these prejudices can manifest in a variety of ways, such as black women’s experiences being doubted and dismissed by doctors, being condescended to and disrespected, and having their knowledge about their own medical conditions ignored. “A mother knows something is not right with their body and they go tell the doctor that something is wrong and they are told, ‘You’re crazy,’” Johnson-Farias says.

These distressing experiences can lead to increased distrust toward physicians among the black community, which in turn can worsen clinical experiences for patients of color, especially during pregnancy. As Johnson-Farias explains, “Poor health outcomes follow because a problem that could have been addressed and remedied when the woman says it’s a problem has to become a crisis before a doctor will address it as an actual issue.”

To many black women, the root of this issue is crystal clear. “It’s racism — that’s ultimately the main thing at play,” Johnson-Farias says. Though the effects of racism may seem difficult to quantify, this has not stopped researchers from trying. Studies have shown that simply living as a black person in the United States can cause several stress-related conditions, as the constant strain of navigating discrimination and avoiding violence can cause serious harm to several bodily systems. Harboring this constant stress, especially as a pregnant woman, can take a toll on both mother and child, and in this way, enduring racism is now viewed as a causal factor within many health promotion paradigms.

In this time of crisis, many black women have begun to search for care outside of the traditional model. A doula is a trained individual that assists a woman throughout her pregnancy, providing emotional and logistical support as well as empowerment and education. While doulas are not medically trained, they remain by a mother’s side while she is in the hospital and can often help women better advocate for themselves and receive higher quality maternity care. They can do this by promoting a mother’s sense of self-efficacy during her pregnancy by urging her to communicate her needs and facilitating interactions between mothers and their healthcare providers.

Their assistance can often reduce stress and result in a variety of positive health outcomes. In fact, one study found that continuous support from doulas have led to large decreases in the number in cesarean and instrumental vaginal births, reduced need for oxytocin augmentation, and shortened durations of labor. Doula assistance is even more impactful for women from marginalized racial backgrounds. The study also found that doula-assisted mothers were four times less likely to have babies with low birth weights, two times less likely to experience birth complications involving themselves or their baby, and significantly more likely to initiate breastfeeding.

Doula collectives, such as the Bay Area Doula Project, have been springing up across the country as a response to the crisis. These organizations are committed to offering resources and services to women of all backgrounds throughout their reproductive journeys and can provide abortion, birth, and postpartum support. While the Bay Area Doula Project uses a low-fee sliding scale and allows mothers to pay what they can, other doulas can pose significant financial burdens to expecting mothers. To expand doula accessibility for black women, some states have begun providing funding for these programs. In April 2018, New York became the third state, along with Minnesota and Oregon, to expand Medicaid coverage to cover for doula services.

In addition to seeking help from doulas for support, many women are eschewing the hospital altogether by turning to midwives. Midwives are licensed medical professionals who provide a variety of healthcare services such as gynecological examinations, contraceptives counseling, and labor and delivery care. Their services include a variety of options that seek to minimize or eliminate unnecessary medical interventions during the birthing process, as the Midwives Model of Care emphasizes that the pregnancy and birth are normal life processes that should be allowed to take place as naturally as possible. “After so many years of going to a doctor, working with a midwife was the first time I received actual care,” Johnson-Farias says.

Though doulas and midwives can provide numerous benefits — in fact, midwifery was historically prolific throughout the United States, as it allowed mothers to give birth in the privacy and comfort of their own home — the medical community has become increasingly skeptical towards the practice of midwifery as technology and surgical techniques have advanced. Medical professionals argue that the practice is unsafe, especially for high-risk pregnancies. Today, many states are reluctant to support the movement, and some legislators have passed policies that aim to limit the ability of doulas to assist in the birthing process. For example, most home births are not covered by insurance policies. As a result, midwives are far less prevalent in the United States than in comparably affluent countries, assisting in only around 10% of births nationwide, and the extent to which they can lawfully act varies between states.

“Systematically, we have seen a lot of policies that make it difficult to get out-of-hospital care. There’s a lot of emphasis on getting to a hospital, but for a lot of low-income women, they live in rural areas. There’s a real problem of access when it comes to actually getting to the hospital to get the care that one needs,” Johnson-Farias explains.

Despite these restrictive policies, midwifery continues to thrive in many areas of the country, and research shows that the personalized care and support provided by midwives can lead to positive health outcomes. Johnson-Farias is an advocate of integrated midwifery care, a practice where the use of midwives is integrated into the overall regional health system and is embraced by traditional medical professionals rather than shunned.

Johnson-Farias’s research examines how policies could promote access to out of hospital care, and is particularly concerned with these policies impact low-income women. “My research is examining how Medicaid could cover out of hospital births, like we’ve seen in Washington, and if we could implement this model here in California,” she says. Johnson-Farias believes that alternative forms of care could ultimately provide a solution to America’s black maternal and infant mortality crisis, and many recent studies support this.

One study found that states that had integrated midwifery care, where midwives and traditional healthcare providers engage in interprofessional collaboration, were associated with significantly higher rates of physiologic birth, fewer obstetric interventions, and fewer adverse neonatal outcomes. The study analyzed hundreds of laws and regulations in 50 states, such as the settings where midwives are allowed to work and whether they can fully participate in pregnancy- and childbirth-related care, make decisions without a doctor’s approval, give medication prescriptions, be reimbursed by insurance companies, or gain hospital privileges. The authors concluded that the more included midwives were in the prenatal and postpartum process, the better the health outcomes for mothers and their babies. Conversely, states with some of the most restrictive midwife laws and practices perform significantly worse on key indicators of maternal and infant well-being. These states also have high black populations, which perhaps suggest that increasing access to midwife and doula care could address racial disparities in maternity care.

In the future, increasing access to doula and midwife care could be a potential solution to the black maternal and infant mortality crisis. Policymakers should work to make these services more widely available for those who need them.