Nearly 700 women in the U.S. die from pregnancy-related complications every year.
“I have been present in a hospital when a mom has died,” says Christina Marea, PhD, MA, MSN, RN, CNM. “It impacts everyone working on the unit. It’s a shadow, a weight that hangs on us. It is so devastating and heartbreaking—and so much of it is preventable.”
In 2019, the U.S. recorded 20 maternal deaths for every 100,000 live births—by far the worst rate among comparably wealthy countries. And according to the CDC, about 60 percent of those deaths were, as Marea says, preventable.
“This country has the best knowledge, the best access to technology, the best medicine, and yet our women are so disadvantaged,” says Dr. Cathy Collins-Fulea DNP, CNM, FACNM, president of the American College of Nurse-Midwives. “Why is that?”
Pregnancy here is especially dangerous if you’re a woman of color. The CDC reports that Black women in the U.S. are about three times more likely to die from pregnancy-related causes than white women.
“There’s been decades and decades of research looking at maternal mortality,” says Ebony Marcelle, MS, RN, CNM, FAANM, “and it turns out that all the things we kind of thought that it was—marital status, lifestyle, education—no. It’s racism, and the effects of racism on the institutional level and systematic level.”
Now Marcelle and Marea are among a growing number of nurses who want to make serious change. Drawing on their advanced education and clinical expertise, and with grant funding from the Hillman Foundation, these nurses are developing innovative programs that will ensure better and safer birth experiences for people of color.
For each of these advanced-degree nurses, the spark ignited with firsthand clinical experience that morphed into, depending on whom you ask, outrage, worry, a sense of responsibility, or often all of the above. And while they’re fully aware that there is no single magic-bullet solution, they’re all fully committed to fighting for health equity and saving lives.
“We need to get more providers in the community who look like the community.”
—Karie Stewart, APN, MSN, MPH, CNM
Since starting her job as director of midwifery services at the University of Chicago, Karie Stewart, APN, MSN, MPH, CNM has met many patients who specifically sought her out as their midwife because she, like them, is a woman of color.
“They have heard the numbers and maybe even experienced someone passing away or having issues during pregnancy or after pregnancy,” Stewart says. “They say they feel safer with me and feel like they will have a better chance of ‘not dying’—that’s their words—while having a baby.”
In Chicago, Black women are about six times more likely to die from pregnancy-related conditions than white birthing people, according to data from the Chicago Department of Public Health. That data, combined with what her own patients were telling her, prompted Stewart to create Melanated Maternity Community Care, which received a Hillman Emergent Innovation grant in 2021.
“I wanted to do more than just providing care,” she says, so she developed a program that weaves together several evidenced-based strategies.
MMCC creates cohorts of eight to 10 Black pregnant women who receive group prenatal care from a certified nurse midwife who is also Black. Stewart says research studies back up both the group care and racially concordant approaches as resulting in better health outcomes for people of color.
A Black nurse coordinator rounds out the team, helping connect participants with any community resources they may need, from mental health support to housing assistance.
The program continues serving participants for a full year after they give birth. Postpartum doulas—mostly cross-trained certified nurse assistants, who are also Black—offer parents ongoing, in-home support, while Black nurse midwives provide several office visits in the first eight weeks after birth.
Stewart says the fact that each person in the chain of care identifies as Black is crucial to the model she’s developed. “Patients want a provider that they can relate with and who they feel will understand their life journey,” she says. “When that happens, they’re much more apt to open up,” which in turn means that red flags come to light rather than hiding in the shadows.
“I’m just hoping that institutions can utilize this model to really heighten education and get more providers into the community that look like the community,” Stewart says.
“This began with our shared sense of moral outrage at how our maternity care system looks.”
–Christina Marea, PhD, MA, MSN, RN, CNM
Marea and Marcelle had both been nurse midwives for over a decade before having their own babies—“and we were still a mess,” Marcelle remembers.
They realized that if two experienced clinicians with strong support systems and resource access were struggling this much, their patients from underserved communities in Washington, D.C. must be facing a profoundly rougher postpartum period.
“To have access to the care ourselves that we were not able to give to our patients—the feeling is grief and outrage,” says Marea, who is a post-doctoral fellow at Georgetown University’s Medical Center.
Now she and Marcelle are re-envisioning the standard postpartum care model, which typically includes just one follow-up provider visit six weeks after delivery. In its place, they’re developing a comprehensive 12-month postpartum plan, with funding from a 2021 Hillman Innovations in Care grant.
“We know through tons of decades of research that 50 percent of the [maternal] deaths are occurring after delivery,” says Marcelle.
“And those patients are often people whose death could have been prevented by this high-touch care,” adds Marea.
Their intervention is designed to offer the support and resources that birthing people need “in order to thrive, have strong families, and find joy in that postpartum period—instead of feeling like they’re hanging on by a thread,” Marea says.
They plan to include home visits from a nurse or certified nurse midwife in the first month postpartum, followed by a group care support system and remote access to a resource nurse. Some of the details may shift, though. “An incredibly important part of our intervention is that each component will be fully designed with feedback from both our staff and patients,” Marea says
The program will serve the same Washington, D.C. residents who receive prenatal care from Community of Hope—a nonprofit that supports low-income people and those experiencing homelessness, and where Marcelle is director of midwifery.
“When we thought of designing this intervention, part of it is taking the responsibility for meeting patients where they are,” Marea says, “and the other part is offering racial or cultural congruency, so that patients don’t have to enter this dynamic feeling defensive, feeling mistrustful, feeling worried they’re not going to be believed about what’s going on in their life.”
“We want to transform the system where the focus of healthcare is on the care side,” she adds.
“We’re there not just for the birth experience, but your life experience while you’re pregnant and the first year after.”
—Dr. Kimberlydawn Wisdom, MD, MS
When April joined a group prenatal care program in Detroit, she was expecting her fourth child and had never carried a pregnancy to term before giving birth. Her past pregnancies had also been marked by personal medical risks, including preeclampsia, and brought struggles with anxiety and depression.
Thanks to the groundwork of Dr. Kimberlydawn Wisdom MD, MS and Collins-Fulea, April’s most recent pregnancy was healthy and low-stress, culminating in a full-term delivery at 38 weeks.
Now April’s experience is one of several featured success stories on the website for Wisdom’s Women-Inspired Neighborhood (WIN) Network: Detroit. The program has served more than 300 women since it launched in 2016. And among those hundreds of participants, the vast majority of whom are women of color, Wisdom says there have been no reported maternal deaths.
Though she developed her project to address infant mortality—a focus of Wisdom’s work ever since she became Michigan’s first state surgeon general in 2003—her data reflect how it’s helping to keep moms safer, too.
After learning about the CenteringPregnancy model at a conference, Wisdom decided to follow its group prenatal care approach, but with her own twist. Her WIN Network: Detroit added in community health workers, who visit participants at home between group care sessions to offer extra support and resources.
“We embrace these women and we care for them at a much deeper level,” Widsom says. “We want to know, are you sleeping at night? Do you have a safe house to live in? Did you eat? Are your children eating? Do you have a bassinet at home?
“If you don’t have what you need, we identify ways to get you those resources,” she adds.
Under the WIN model, community health workers continue supporting new moms through their first year postpartum. “We are like your partner in caring,” Wisdom says. “We’re there not just for the birth experience but your life experience while you’re pregnant and the first year after.”
Given the data-backed success of her program, she hopes to expand both its size and scope. With funding from the Hillman Innovations in Care grant, which she received with Collins-Fulea in 2018, Wisdom grew the WIN Network to a second site in Detroit and one in Cleveland. “I want this to be a name that can be replicated all over the world,” she says.
She’d eventually like to add a CenteringParenting program, too, which would extend the group meet-ups into those early newborn days—and maybe even beyond. “I think about it as creating community from the inside out, from cradle to college or career,” she says.
“There’s no level of income that protects Black women from experiencing racism and bad [maternal health] outcomes.”
—Dr. Nastassia Davis, DNP, MSN, RN, IBCLC
Dr. Nastassia Davis, DNP, MSN, RN, IBCLC vividly recalls a viral Facebook post from early 2019, in which a 27-year-old pregnant woman named Lashonda Hazard wrote about visiting the hospital for severe stomach pain and feeling like she was not listened to or taken seriously. She died hours later.
Davis also remembers reading about Beyonce’s preeclampsia and emergency C-section; about Serena Williams describing how she “almost died” shortly after her own emergency C-section; and about Kira Johnson, a successful entrepreneur who spoke five languages, who died from a hemorrhage after the birth of her second son.
There was one thing that all four women had in common: they were Black.
Taken together, Davis says, those stories illustrate that worse outcomes for Black birthing people aren’t only tied to socioeconomics, access to care, or even pre-existing comorbidities. “It really has to do with structural racism and implicit bias,” she says. “It’s about not being humanized, not being listened to, not being heard when complaints are being expressed, and just not being taken seriously.”
That’s why Davis is working on a research project that will serve African-American women from all walks of life—and she’s adapting the Nurse-Family Partnership model to do it.
In the 40-plus years it’s been around, NFP has become a gold standard in maternal and public health care. The program pairs low-income, first-time expecting moms with nurses who visit them at home starting early in pregnancy and continuing until their new baby turns 2.
NFP has served over 340,000 families since 1996, and reports major improvements in maternal health and mortality—including fewer cases of pregnancy-induced hypertension and preterm births compared to a control group.
“The NFP model is really the most well-known nursing model that exists in home visitation,” says Davis, who is an assistant professor of nursing at Montclair State University. “But I also realized there are a significant number of gaps in how this program is structured.”
“In what we know about the Black maternal health crisis, income doesn’t make a difference, and these incidences could happen at any pregnancy, whether it’s your first pregnancy or your last,” she adds.
With funding from a 2020 Hillman Emergent Innovation grant, Davis’s home visitation program will be open to any Black pregnant people. In fact, she will specifically be seeking out women of all socioeconomic statuses.
She’s still in the data collection phase, and “our research will guide the development,” she says, but she hopes to have the program up and running by Summer 2022. She also plans for all of the nurses she hires to be well-versed on implicit bias, anti-racism and reproductive justice, “so we can create more of a safety net around these families.”
Looking beyond her project, Davis says it’s crucial that all healthcare workers receive ongoing training in implicit bias and anti-racism in order to move the needle on maternal mortality. She also believes that the crisis could be vastly improved with one simple action: listening.
“If [the hospital] had listened to Lashonda Hazard, they would have realized that she was really in a bad way,” she says. “They could have intervened and saved her life and her baby. It’s listening that really has a significant role in the prevention of maternal deaths.”
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