Black Maternal Mortality Rates Remain High: How Employers Can Improve Outcomes Through Benefits Interventions

In September 2017, Serena Williams became not only a symbol of outstanding tennis achievements and exceptional female athleticism, but also, through the experience of giving birth to her daughter Olympia, a symbol of the risks of pregnancy and childbirth in the United States—especially the risks faced by Black people. Williams developed blood clots within hours of giving birth and underwent multiple emergency surgeries. She detailed her story in Elle magazine.

Data from the U.S. Centers for Disease Control and Prevention (CDC) shows that maternal mortality rates are rising across all ethnic groups. In 2021, the most recent year for which data is available, the overall maternal mortality rate was 32.9 deaths per 100,000 live births, nearly double the rate in 2018, three years earlier. For Black women, the rate in 2021 was as high as 69.9 per 100,000.

Economist Emily Oster, writing on her blog "Parent Data," emphasized that this disparity cannot be simply attributed to differences in average income. Citing recent research, she noted: "While for non-Black women, the risk of negative health outcomes decreases with income, this is not the case for Black women. Black women in the top 10% of income have similar rates of severe complications as Black women in the bottom 10%."

Similarly, although higher body mass index (BMI) is associated with adverse pregnancy outcomes, and average body weights differ across racial groups, this is also not a valid explanation. Oster wrote: "Black women have more complications at all weight levels. Notably, underweight Black women have significantly higher rates of severe maternal morbidity than obese White women."

Health, income, or even fame were not protective factors for Serena Williams—she had to argue with hospital staff to get the necessary CT scan. So, what exactly is the problem?

Lack of being heard

"In the healthcare system, women are less likely to be heard," Dr. Neel Shah, Chief Medical Officer at Maven Clinic and Assistant Professor at Harvard Medical School, told HR Dive. "And women of color, especially Black women, are the least likely to be heard."

The theme of "not being heard" recurs in Black women's childbirth experiences—whether they narrowly escape danger or tragically lose their lives.

Williams described her experience of repeatedly requesting blood thinners and a CT scan of her lungs, knowing she had a history of blood clots. Nurses dismissed her requests as "crazy," but Williams insisted, and eventually a nurse contacted her obstetrician, who agreed with Williams's assessment. The scan revealed blood clots in her lungs. "Being heard and appropriately treated was the difference between life and death for me," she wrote.

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"There is a very thin line between what is called clinical intuition and what is actually racism."

Dr. Neel Shah

Chief Medical Officer at Maven Clinic

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The documentary "Aftershock" tells the stories of two Black women who tragically passed away. Shamony Gibson died of a pulmonary embolism just 13 days after giving birth to her son. Amber Rose Isaac was diagnosed with HELLP syndrome and died during an emergency cesarean section. In both cases, the women had complained of symptoms for weeks or months, but were ultimately ignored until it was too late.

Doctors often try to reassure patients, telling them that pregnancy involves some physical changes that may feel strange but are normal. However, sometimes normal symptoms like fatigue and shortness of breath can indicate more serious conditions.

Unconscious bias plays a significant role in these oversights. "There is a very thin line between what is called clinical intuition and what is actually racism," Shah said. "You walk into a room, and if the patient looks pale, you think 'maybe she's anemic.' But of course, if you are a person of color, your 'pallor' manifests differently."

Analyzing data from Maternal Mortality Review Committees, Oster found that pregnancy-related deaths among Black women are more likely to stem from cardiac or blood-related issues, such as embolism, cardiomyopathy, and other heart conditions. "This doesn't explain why, but it's important to know because many of these conditions have better outcomes if effectively treated," Oster wrote.

In other words, the tragedy and injustice of Black maternal mortality lies precisely in the fact that it is largely preventable—if only someone would listen.

Changing the approach

The Midwife Center in Pittsburgh is one of over 400 independent birth centers in the United States. Birth centers aim to help people stay low-risk through "high-touch, client-centered care," Christine Haas, the center's executive director, told HR Dive. The center's midwives also focus on social determinants of health to help people achieve healthy pregnancies.

A 2022 study found that Black individuals are less likely to begin prenatal care early in pregnancy, which may be a contributing factor to adverse outcomes. The reasons for this access barrier are varied, ranging from what Haas calls "maternity care deserts"—areas lacking providers—to difficulties accessing transportation or childcare services.

The Midwife Center employs a full-time community engagement coordinator to ensure its presence in communities across the city and to dispel misconceptions about the types of insurance it accepts. The center also strives to attract a diverse group of providers. Haas cited research showing that Black patients have better outcomes in environments with more Black providers. She also noted that due to a long history of structural racism, some Black individuals harbor distrust of the healthcare system.

A risk-adjusted study found that Black women, as well as White and Hispanic women, experienced fewer adverse outcomes when using birth centers compared to hospitals.

Of course, even with high-quality care, complex pregnancies can still occur; for those cases requiring more intensive care, the center works with patients to transfer care to collaborating physicians or a midwifery team practicing in hospitals, Haas said. Unless a client leaves the city or other issues arise, transfers are always to trusted medical partners with whom the center has close relationships.

Areas where employers can step in

Given the evidence that strong advocacy and early intervention can change the landscape of Black maternity care, some employers are beginning to use benefits to fill these gaps in the healthcare system.

In 2021, Walmart launched a doula benefit in Georgia, expanded it to Louisiana, Indiana, and Illinois a year later, and finally rolled it out nationally (except Hawaii) in 2023. The benefit allows eligible employees to receive doula care during pregnancy, with up to $1,000 reimbursed. Walmart cited Black maternal mortality data when deciding to expand the benefit.

Doulas provide support to pregnant individuals during pregnancy, childbirth, and the postpartum period, helping ensure their preferences and concerns are heard by healthcare providers. Their involvement in the birthing process has been shown to reduce cesarean rates—which are more likely to lead to blood and heart-related complications—and may lead to other positive outcomes, including a more satisfying birth experience.

HR professionals can offer standalone doula benefits like Walmart's, or ensure access to doula care for those who need it through other benefits. Most health insurance plans do not cover doula care, although some plans have begun exploring this option. Rhode Island is an exception, having required private insurers to cover doula care since 2022.

Flexible Spending Accounts (FSAs) can serve as a pathway for doula care coverage, although a letter of medical necessity may be required, which can be a barrier depending on the accessibility of the patient's care provider and their willingness to provide the necessary documentation. However, Qef Johnson, a Brooklyn-based doula and founder of The Magical Birth, told HR Dive that her clients are typically able to use FSAs to pay for her services.

Employers can also partner with virtual fertility and women's health service providers as a bridge between employees and in-person care providers. For example, Maven Clinic (where Johnson provides doula services) allows employees to connect with doulas, mental health experts, and other providers within 30 minutes of submitting a support request.

The platform aims to address ongoing concerns of pregnant individuals and provide more nuanced support. Shah cited gestational diabetes as an example, a condition that requires significant dietary changes and can raise a host of questions, such as how to plan meals according to complex rules and how to manage blood sugar issues. Through Maven Clinic and similar platforms, employees can connect not only with primary care providers but also with nutritionists and other specialists they need.

Ovia Health, which offers similar support, found in a study last year that Black women ranked digital maternal health tools among their top five most important benefits, while White women did not—suggesting that access to such benefits may help fill the gaps in care that Black employees experience before, during, and after pregnancy.

Beyond healthcare, Shah, Haas, and Johnson all emphasized the importance of adequate paid leave during the postpartum period. In addition to offering benefits, some suggest that employers who truly value support should foster a culture that encourages employees to use their leave.

Finding joy

Despite the alarming statistics surrounding Black pregnancy and childbirth, HR professionals can also make room for the joy and excitement that comes with expecting a new life. Connecting pregnant employees with advocates who actively champion their health and interests may help them focus on what truly matters.

The fear of not being heard can itself prevent people from having the birth experience they want, Johnson told HR Dive. Some pregnant individuals make decisions based on fear rather than desire about whether they want a highly medicalized or highly non-medicalized birth. While she will talk about it, Johnson said she doesn't want clients to focus too much on outcome disparities.

The stress of racism can accumulate and create more stress. "It's kind of like a cycle," she said. On the other hand, those who feel confident in the support from providers or advocates can enter the birthing process in an empowered state.

"I had a client who was very nervous about Black maternal health when she was pregnant," Johnson said. "When it came time to give birth, she was completely focused on what she wanted, had that energy to convince everyone to focus on her, follow her instincts, and have the birth the way she wanted, and she ended up having a really great experience."

"Once you feel supported, you feel like you can do what needs to be done," Johnson said.