Racial and Equitable Systems Approach in Maternal Healthcare Design
By Dr Sharon Attipoe-Dorcoo and Dr. Leia Belt
Birthing people racialised as Black in the United States (U.S.) have some of the worst maternal outcomes globally. Therefore, we believe intersectional approaches to healthcare that account for the contextual complexities of the race are necessary for equitable maternal outcomes. January 23, 2024, marked the American College of Obstetricians and Gynecologists (ACOG) National Maternal Health Awareness Day, with this year's theme being 'Access in Crisis.' Healthcare access encompasses the ability of individuals to secure timely, affordable, and appropriate medical services essential for maintaining and improving their health. Access to maternal health care has increasingly become unobtainable for many patients in the United States due to three main factors: structural inequity (including racism, sexism, and classism), increasing poverty, and a lack of healthcare resources, particularly in rural areas.
According to a 2022 March of Dimes report, 5.6 million birthing people—about one-third of the U.S. birthing population—lived in counties identified as maternity care deserts, where access to maternal health services is limited or unavailable. Structural racism, defined as the totality of ways that societies foster racial discrimination through mutually reinforcing systems, reveals this is due to compounding and interrelated inequities in social, structural, commercial, and political determinants of health. Racial inequities in birth are a national issue; however, initiatives that help Black families in urban centers like New York and Los Angeles often miss the mark in addressing the needs of Black families living in overwhelmingly white, rural, and Midwest settings, such as Iowa or the Dakotas. Because of this, we need a systems design approach to maternal health. We must examine how the legacy of structural racism impacts Black birthing families' relationship to the healthcare system, as this understanding will shed light on the barriers we face.
The legacy of racial violence and segregation —including sundown towns, Home Owners' Loan Corporation redlining maps of the 1930s, and racially restrictive covenants in housing deeds—exacerbates contemporary obstacles and continues to shape the lives of all Americans. Health systems researchers and practitioners need to be aware of ways in which the legacy of structural racism aggravates maternal mortality rates and can exacerbate inequities in healthcare access such as rural hospital closures, and maternity care deserts.
Consequently, our current healthcare system is unable to adequately serve growing populations that lack birthing centers, hospitals with obstetric care, midwives, and trained obstetricians/gynecologists and ultimately failing to meet the diverse needs of birthing people, especially those who are not part of dominant groups across various factors (e.g., race, sexuality, language, country of origin, and religious background). In these instances, other perinatal services like doulas, and lactation consultants could help fill the gap. Community-centered recommendations like training more International Board Certified Lactation Consultants (IBCLC) or Doulas racialised as Black are extremely helpful. Still, even these significant efforts must be part of a multi-level, comprehensive strategy.
To be effective, they require individuals to not only master the roles of a doula or IBCLC, but also to develop skills as entrepreneurs, health educators, administrative assistants, and more. If the geographic population lacks education, lives in poverty, or is burdened with long working hours in their primary roles, “training more doulas of IBLCLs” becomes a moot point, because professionals do not have the resources to sustain these interventions, rendering them less- or ineffective. A systems design approach goes beyond focusing on a target population or a single disparity; instead, it systematically examines the interlocking effects of geography, politics, history, and institutional structures that shape and impact the health of communities.
By adopting this framework, we can recognize these intersecting inequalities and determinants of health, ensuring that initiatives not only acknowledge the existence of these communities but also address their distinct needs. This further highlights why only expanding Medicaid, training more doulas of color, providing terminal funding, or introducing sporadic policy shifts is insufficient. A systems design approach, on the other hand, will ensure that our health systems are structurally equipped to directly tackle the nexus of racism and rurality.
Since our inadequate healthcare system fails to meet the unique needs of structurally under-resourced communities, we suggest current tools for health system design, exemplary institutional examples, and policy initiatives as initial resources for fellow health systems researchers and practitioners to explore. Until our health systems are structurally designed to directly tackle the nexus of racism and rurality while recognizing the evolving demographics of our rural areas, we will fall short in meeting the needs of many Americans. To make progress in improving our poor maternal health outcomes, we must address the enduring legacy of racial injustice and center the voices of under-resourced communities across the U.S.