Want to make birth more equitable? Adopt a framework for respectful maternity care 

Respectful Maternity Care Framework NBEC Image

An interview with the National Birth Equity Collaborative (NBEC) about Respectful Maternity Care

Our system of birth care is broken. Black women are three-to-four times more likely to die from pregnancy than their white peers1—and most of those deaths are preventable.2 During labor, Black mothers are less likely to receive pain medication, and more likely to report that their providers didn’t address their pain adequately during delivery.3 The crisis impacts infants, too—Black and AIAN (American Indian/Alaskan Native) babies are twice as likely to die during their first year of life compared to white babies.4

Even though the numbers tell a clear story of racial disparity, we haven’t done nearly enough to improve experiences and outcomes for BIPOC (Black, Indigenous, and people of color) mothers and their children. Of course there are well-meaning providers who work hard every day for their patients, but the problem runs deeper. To reach birth equity, we need systemic change.

That’s where the National Birth Equity Collaborative (NBEC) comes in. In collaboration with Johns Hopkins University and Ovia Health, NBEC has developed a comprehensive framework that guides hospitals and health systems toward anti-racist healthcare practices, and provides practical tools to measure and track progress. 

We talked with leaders at NBEC about why racial disparities run so deep in maternal and infant care, their practical on-the-ground work to improve birth equity, and what employers and payers can do to help.

Q: Tell us about the National Birth Equity Collaborative (NBEC). What’s your goal and mission?

NBEC creates transnational solutions that optimize Black maternal, infant, sexual, and reproductive wellbeing. We shift systems and culture through training, research, technical assistance, policy, advocacy, and community-centered collaboration with a vision that all Black mamas, babies, and their villages thrive.

The Research & Strategy Team works with all teams on funded and independent research, builds professional networks for birth equity, and eliminates silos in pursuit of NBEC’s strategic vision. We intentionally incorporate reproductive justice and decolonized methodologies in all of our research. We support NBEC’s programmatic teams and their research opportunities. We manage a large number of relationships and assist other NBEC teams with their activities towards our collective Strategic Plan. We create opportunities to publish original content and disseminate research.

Q: You use the term Respectful Maternity Care. Can you tell us what that means?

Respectful Maternity Care is a global movement. We have learned from partners at White Ribbon Alliance, with branches all over the world, that women and birthing people are asking for specific things and one is to not be disrespected at a time like childbirth. The problem is that the maternal health crisis in the U.S. is worsening, and we need a culture of Respectful Maternity Care to change it.

Maternal health inequities weigh on Black and Indigenous communities globally and every country is different with its cultural, social, and structural systems. The data in the U.S. shows that our inequity is due to structural and interpersonal racism. We need to be honest about how Black women are treated during maternity care. 

Q: Why was it important to take a stand and create this framework?

Despite the prevalence of racist microaggressions and bias fueling disrespect in labor and delivery care in the U.S., there are limited tools that can measure disrespect or that encourage provider behavior change. Our systems acknowledge racism in maternity care and are exploring innovative anti-racist models for quality improvement.  

NBEC has launched the Respectful Maternity Care Initiative, shifting the culture for all mamas! 

Q: What challenges do diverse women face today in their healthcare? 

All childbirth is a complex psychological and physical shift in a person’s life. It is undeniably natural and specifically medicalized, putting birthing people in precarious positions. The medical challenges that Black mamas experience can be due to chronic conditions or some pathologized illness. The challenges that we are trying to measure are specific to the intersectional experience of Black mamas in spaces that also dehumanize all birthing people.

Racial microaggressions are lumped into the familiar experience of disrespect felt by Black mamas. Unmeasured racism can impact Black maternal health, from the quality of prenatal care and the intake process, to being overstepped in consent procedures or pain crises being ignored.

Q: What impact do those challenges have on outcomes?

Institutional racism in health care systems prevents equitable funding, positive community collaborations, and even individual processes like patient complaint reporting. Equitable systems would be delighted to lead community collaborations that would increase the scale and impact of patient experience. The lack of energy towards these system-quality improvements highlights the lack of equity.

Providers have reported being overwhelmed and under-resourced in these inequitable systems. The most well meaning providers cannot appropriately care for birthing people when they do not have adequate time to listen, communicate, treat, and evaluate their patients. Crisis situations, overcrowded hospitals, and provider shortages exacerbate the harm that comes from unresponsive providers in a culture of overmedicalized birth. Provider burnout is apparent and dangerous to patients. Providers can take care of Black women respectfully when they are also fully present and well. 

Every mama is an expert on their own body. If providers believed that, mamas would not have pain crises ignored, signs of hemorrhage questioned, and preventable deaths. Mamas would not have to get into squabbles with nurses about unnecessary restraints or have their requests to walk in labor or drink water denied. Applying this knowledge in labor and delivery is the beginning of shared decision making.

Patients are not trusted by their healthcare providers to be honest, to care for themselves, to follow directions, or to be autonomous over their bodies. The core of this challenge is that the medical system has created an environment of authority, fear, and dehumanization for Black mamas over time. These mamas are exhibiting a natural distancing between the agent of healthcare service, which is a response to not feeling safe. Mamas don’t need to be more trusting of health care systems, health care systems need to be more trustworthy.

Q: What does your Respectful Maternity Care framework look like?  How does it work and who can use it?

The Cycle to Respectful Care is a theoretical framework based on the birth experiences of Black mothers, created to inform the ways hospitals and health systems achieve respectful care. This framework complements existing provider educational tools and promotes anti-racist and birth equity practices. The Respectful Maternity Care initiative bridges community assets to hospital care by centering the cultural, biopsychosocial, and holistic needs of Black mothers in order to reduce disparities in clinical and patient reported experience and measure outcomes for all birthing people.

A culture of respectful care would prioritize sexual and reproductive wellness for all people, whether or not they want to have a baby. Raising the bar for anti-racist care means we should expect our healthcare providers to prioritize tools created for, by, and with Black mamas.

Q: How can patient self-reporting and patient-driven care influence outcomes? 

The data we need can only come from people with lived experience, because clinical data alone is not providing feasible solutions. Hospitals and health systems are aware of their inequitable outcomes. They engage in learning collaboratives, quality improvement initiatives, PDSA cycles, and short cycle solutions for poor health outcomes. Though some systems reap overall clinical benefits, they fail to correct the racial inequity. NBEC is trying something different by creating quality improvement tools that are rooted in the experiences of Black mamas in their own local contexts. 

The most effective health improvement models, to date, are created by health science research scholars and health care providers in the Black Mamas Matter Alliance network. They use research methodologies and implementation science to legitimize community knowledge. Dr. Karen Scott’s SACRED Birth Initiative, Aza Nedhari’s Mamatoto Village, Jennie Joseph’s The JJ Way, and Black Women Birthing Justice are all examples of systems solutions with Black families at the helm.

Q: How can payers and organizations help make systemic change toward birth equity? 

Those aforementioned solutions that lead to respectful maternity care are fighting towards validation and scalability. Quality improvement tools created by, for, and with Black communities are on the long trail to being considered evidence-based, which includes a history of tests, evaluations, and manuscripts. The other path to advancement is the strategic plan of payment systems. Employers and insurance companies hold significant power and can choose to invest. 

The Affordable Care Act of 2010 was an excellent example of a culture shift of payment systems towards quality of care. One of the policy suggestions, in addition to expanding Medicaid, was extending the postpartum health coverage to one year for all birthing people. There are only five states that have made that policy shift, today. Medicaid is the number-one payer of childbirth medical services, covering over 42% of birthing people. This sets an undeniable precedent for what is considered standard, and other payers follow. 

One way to leverage this power is to challenge hospitals and healthcare facilities to change behavior in order to change outcomes. Having them partner on and invest in pilot phases of new anti-racist measures, like NBEC’s Respectful Maternity Care Patient Reported Experience Measure, is a specific action for this goal. 

Have questions about how your organization can improve birth equity? Reach out to NBEC, a team of advocates for change in the Black maternal health and infant mortality crises. And get in touch with Ovia to learn about data-driven solutions for reproductive health, family building, pregnancy, and parenting.

1:  Howell, Elizabeth A. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018 Jun; 61(2): 387–399. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915910/

2: Centers for Disease Control (CDC): https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm?s_cid=mm6818e1_w 

3:  Reuters: https://www.reuters.com/article/us-health-postpartum-pain/black-hispanic-mothers-report-more-pain-after-delivery-but-get-less-pain-medication-idUSKBN1XM2R4

4:  March of Dimes: https://www.marchofdimes.org/materials/March_of_Dimes_2021_Full_Report_Card_11152021_v1.pdf