Black women in the Americas bear a heavier burden of maternal mortality than their peers, but according to a report released Wednesday by the United Nations, the gap between who lives and who dies is especially wide in the world’s richest nation — the United States.
“The risk factor is racism,” said Joia Crear-Perry, an OB/GYN and founder of the National Birth Equity Collaborative, a nonprofit group dedicated to eliminating racial inequities in birth outcomes and one of the report’s co-sponsors. “This report drives this home over and over. When your pain is ignored, when your blood pressure is ignored, you die, and that happens across the Americas.”
There are more than 209 million people of African descent in the Americas, meaning it has the largest population of people who are descended from the African victims of the transatlantic and Mediterranean slave trades. And while the report identifies a shared root cause for the region’s growing maternal mortality crisis, it has different manifestations reflecting each nation’s history and culture.
Between 2016 and 2020, maternal deaths increased 15 percent in Latin America and the Caribbean, and by 17 percent in North America, according to the report from the U.N. Population Fund, which is the United Nations’ sexual and reproductive health agency.
Maria J. Small, an associate professor of obstetrics and gynecology at Duke University School of Medicine who researches global racial and ethnic disparities in maternal health, said examining the way racism drives disparate maternal outcomes in countries with a legacy of slavery is “conceptually one of the most important things about this paper,” which she was not involved with.
“Throughout the Americas, the similar experience of forced migration and many of the fundamental tenets and behaviors left over from those institutions are still driving some of the outcomes in the current times,” she said. “I often think it’s just a matter of historical circumstance that some people may have landed in one country versus another.”
The nature of the data itself, though, is one of the challenges in fully understanding the scope of the problem because of a lack of consistency and uniformity in how countries across the region report health outcomes based on race and gender.
Notably, the report said, only a third of the nations in the hemisphere identify Afro-descendants as a population that experiences barriers to health.
“We’re seeing a failure of states to take the action that’s needed,” said Emilie Filmer-Wilson, a human rights adviser to the U.N. Population Fund. “We want to bring visibility to this issue, and the challenge is the data, which renders the situation invisible.”
Of the countries that examine the data by race, 15- to 49-year-old Black women and teens in Suriname between 2016 and 2017 were 2.5 times more likely than their peers to die during birth or in the period afterward. In Colombia in 2020, they were 1.6 times more likely to die than their peers, the report said. And in 2021 in Brazil, Black women were 1.6 times more likely to die than White women.
One of the goals of the U.N.’s sexual and reproductive health agency is to have “zero preventable maternal deaths” by 2030, but the report highlights the work still to be done on “a crisis in need of an immediate solution.”
“If you look broadly, women of African descent in the Americas still fare very poorly in many of the development indicators you talk about with health,” said Patricia Da Silva, program adviser for the U.N.’s agency on sexual and reproductive health. “We’re talking about access to education, access to water, the pay gap. All of these factors directly affect a woman’s ability to get access to quality of care.”
And still, she said, the stereotypes that Black women face in their day-to-day lives are often present in the rationale given for why they face worse health outcomes: their poor choices or their bad genes.
People say racism is rare in Costa Rica, but Siannie Palmer said if someone calls out to a White woman walking down the street, “they’re going to say ‘señora’ or ‘señorita.’ But if they saw a Black woman walking, they’re going to say ‘negra,’ ” which means Black.
“She may be Black, but she’s still a lady,” said Palmer, who has worked as an OB/GYN nurse, which is similar to a certified nurse midwife, in Límon since 1999. The province sits on Costa Rica’s Atlantic coast and is home to much of the nation’s Black population.
That type of discrimination, be it conscious or not, serves as a barrier to care for many Black people who often delay going to the doctor for fear of being mistreated, she said, even though the law in Costa Rica guarantees pregnant people have access to medical care.
The way providers talk to patients of color matters, including where and how health information is asked. “If you talk to her in a rash way, you lose her,” Palmer said. “She’s not coming back.”
Of the eight countries that report prenatal visits by race, Brazil, Costa Rica and Suriname are three where parity had been reached among Black women and their peers in 2018. And, compared with their peers, a higher percentage of Black women in Cuba attended at least four prenatal visits.
“We often think of the U.S. as being a place where health-care information and resources are transmitted to places that have lower resources, but that is absolutely a paradigm that needs to be disrupted — and can be disrupted,” Small said. Instead, solutions can be found in other nations — and Small offered as an example the report’s mention of maternity homes, which offer a more residential, community-oriented setting for people who are close to giving birth.
The report noted that maternity homes in rural Cuba are used, in part, “as an alternative to the mistreatment” Black women and girls experience in hospitals and clinics. “I never thought of them in that context,” Small said. “That is something I’d like to see explored more.”
Just before the pandemic, Lenita Reason, a community organizer in the Boston area, said she came across several pregnant Brazilian immigrants eager to return home to give birth. They told her that caring for a newborn would be easier in Brazil with their family network to help. Most of them “were light-skinned,” she said, noting that their “experience would be very different than the ones with dark skin.”
Brazil, she said, has gotten better at talking about issues of race, when in years past “everything was about class, but the opportunity was always better for people with lighter skin.” Then, Reason, executive director of the Brazilian Worker Center, a Boston nonprofit dedicated to defending and advancing labor and immigrant rights, shared the story of her niece’s miscarriage as an example.
Last year, the 20-year-old, who was four months pregnant and uninsured, went for a prenatal visit at a community clinic in Belo Horizonte, a city in southeastern Brazil, Reason said. Such clinics are publicly run and treat an assortment of conditions, but the providers aren’t always best-suited for the care that’s needed. The doctor on duty that day, she said, was a dermatologist who was unable to find the baby’s heartbeat and who, as a result, ordered an ultrasound to be done, but at a different location.
It would take a month before Reason’s niece could be seen — two hours away.
“When she was able to see the doctor, the baby was dead,” said Reason, who happened to be in Brazil when her niece was transferred to a maternity hospital nearly six hours away. When she went to visit, Reason said, her niece was talking with two other young women who also delivered stillborn infants. Most of the women at the hospital, she said, were Black.
According to the U.N. report, Black women in Brazil were more likely to be dissatisfied with the quality of their health services than were White woman.
Maternal health is informed by an accumulation of life events that start long before pregnancy and that are centuries in the making. That’s why it is a top predictor of a nation’s health, reproductive health equity and human rights experts said, adding that addressing maternal mortality means understanding the effects imposed on expectant mothers by racism, housing and education policies, pollution and climate change.
“Our objective is not only that women survive, but that they thrive,” Filmer-Wilson said. “That thrive aspect often gets overlooked because we’re only looking at the mortality part.”