Contributors:
Central East Addiction Technology Transfer Center
Central East Mental Health Technology Transfer Center
Central East Prevention Technology Transfer Center
The African American Behavioral Health Center of Excellence
The African American Behavioral Health Center of Excellence and the Central East Technology Transfer Centers have forged a collaborative relationship to address and inform providers about the alarming maternal health disparities for Black women. To delve into this complex, yet important topic, the these centers have developed a workgroup to equip providers in better understanding these disparities and best practices to working with their clients. Please see our first article, Urgent Call to Action: Addressing the Crisis of Black Maternal Health Disparities, as an introduction to the alarming facts and to set the tone for this work.
In recent years, research has unveiled alarming trends highlighting the profound disparities faced by Black women in the United States, particularly concerning pregnancy-related complications, birth outcomes and long-term health implications. The disparities are glaring and it is crucial to recognize that they are not arbitrary. Black women face a disproportionate burden of adverse pregnancy outcomes, including preterm birth, low birth weight and maternal mortality8, compared to white women. Black women are also three times more likely to die from a pregnancy-related cause than white women7. To understand the root causes of these disparities, we must unravel the intricate interplay of social, economic and health determinants, with chronic stress emerging as a critical factor. Chronic stressors not only jeopardize the health and well-being of Black mothers but also contribute to intergenerational health inequities.
Chronic stress or long-term stress is an insidious force that permeates our daily lives, affecting individuals on physical, emotional and psychological levels. Chronic stress is a prolonged and persistent state of physiological and psychological tension resulting from exposure to stressors that exceed an individual’s ability to cope, often leading to adverse health effects5.
As public health professionals, our commitment to understanding the multifaceted dynamics of health compels us to explore the intricate relationship between chronic stress and its impact on pregnancy outcomes, particularly among Black women. In this health brief, our exploration into the impact of chronic stress on the body and its correlation with unfavorable pregnancy outcomes among Black women is a call to action. By illuminating the pathways through which chronic stress exerts its influence, we can inform targeted interventions, policies and healthcare strategies that address the unique needs of this population.
Key Findings
The Impact of the Social Determinants of Health
Understanding and addressing the health disparities in Black maternal outcomes requires a comprehensive examination of the social determinants of health (SDOH). Social determinants of health encompass the conditions in which individuals are born, live, work and age15. These determinants, shaped by historical, systemic and structural factors, significantly influence health outcomes and contribute significantly to the heightened levels of chronic stress experienced by Black women during pregnancy and childbirth.
While all social determinants of health intersect and collectively contribute to the challenges faced by Black women, socioeconomic disparities, structural racism and discrimination emerge as the determinants with the most profound impact. The historical legacy of slavery, segregation and ongoing systemic inequities perpetuates an environment where Black women face unique stressors and obstacles throughout their maternal journey. The cumulative effect of racial discrimination contributes significantly to chronic stress, influencing maternal health outcomes2.
Adverse Pregnancy Outcomes (Racism and Weathering)
Chronic stress intricately weaves into the fabric of maternal health, significantly impacting outcomes for expectant mothers. In the context of Black women, the lens must shift from race as a risk factor to the pervasive influence of chronic stress stemming from both systemic and interpersonal racism. The persistent exposure to discriminatory practices, structural inequalities and racial bias contributes to an elevated state of chronic stress throughout the lifespan of African Americans11.
This cycle of intergenerational stress is known as the “weathering” phenomenon, and this concept encapsulates the cumulative toll of chronic stress on the health of African Americans over time. It reflects the premature deterioration of the body and mind resulting from prolonged exposure to social and environmental adversities, leading to accelerated aging and health decline11.
The constant activation of the body’s stress response due to chronic stress contributes to physiological changes, including increased inflammation and dysregulation of hormonal systems. These changes are linked to chronic conditions such as diabetes, hypertension, obesity, cardiovascular disease (CVD), and metabolic disorders11. Simultaneously, chronic stress adversely affects reproductive health outcomes for Black women, contributing to higher rates of preterm birth and low birth weight, which are leading causes of maternal and infant mortality within the African American community13. Chronic stress is also associated with adverse mental health outcomes among African American women, including higher rates of depression, anxiety and psychological distress, and the toll on mental well-being has cascading effects on overall health4. The stigma surrounding mental health within the community, coupled with limited access to culturally responsive mental health services, exacerbates these challenges.
Healthcare Disparities
Black women experience barriers in accessing affordable and quality healthcare and supportive services, including a lack of health insurance, higher medical debt and longer travel times to hospitals, which can further increase the impact of chronic stress on maternal health outcomes13. Implicit bias and racial discrimination within the healthcare system further compound this issue because they represent significant barriers to achieving equitable healthcare for Black women during pregnancy and childbirth.
Implicit biases are unconscious attitudes and stereotypes that affect the understanding, actions and decisions of individuals or groups3. Within the healthcare system, implicit biases often lead to differential treatment and poorer health outcomes for Black women. Studies have shown that healthcare providers may hold implicit biases that result in the underestimation of Black women’s pain, leading to delays in appropriate treatment and management of conditions such as preeclampsia and other pregnancy-related complications. These biases can erode trust between Black patients and healthcare providers, leading to disparities in access to care and adherence to treatment recommendations.
Racial discrimination within the healthcare system exacerbates disparities in maternal health outcomes for Black women. Black women often face systemic barriers such as limited access to quality prenatal care, higher rates of medical interventions during childbirth and increased maternal mortality rates compared to their white counterparts. Discriminatory practices, including racial profiling, unequal access to resources and inadequate communication, contribute to the perpetuation of healthcare disparities among Black women.
Moreover, the intersectionality of race and gender further compounds the effects of discrimination. Discriminatory practices can manifest in various forms, including disrespectful treatment, dismissive attitudes towards Black women’s health concerns and disparities in pain management strategies.
Recommendations
The evidence underscores the critical importance of addressing chronic stress as a determinant of Black maternal health outcomes. Interventions and policies aimed at mitigating stressors, promoting social support networks, addressing structural inequalities, and providing culturally responsive healthcare are essential to reducing disparities and improving Black maternal health outcomes. To mitigate the impact of chronic stress on Black maternal health outcomes, it is imperative to implement targeted interventions at multiple levels and we must prioritize:
Expanding Access to Mental Health Services
Increase access to mental health services specifically tailored to the needs of Black mothers. This includes culturally responsive counseling, support groups and therapy sessions that address the intersectionality of race, gender and socioeconomic status. Integrating mental health screenings into routine prenatal care can help identify and address stressors early in pregnancy, reducing the risk of adverse outcomes. In addition, access to preconception and prenatal services through ACA and expanded Medicaid make pregnancy and birth safer and can reduce the rates of maternal death for Black women14.
Advocating for Policy Changes that Address Structural Inequities
Advocate for policies and initiatives that address the root causes of structural inequities contributing to chronic stress among Black women. This includes policies to address systemic racism, reduce income inequality, improve access to affordable housing, and provide equitable opportunities for education and employment. Collaborate with policymakers, community leaders and advocacy groups to develop and implement strategies aimed at dismantling institutional barriers and promoting health equity.
Enhancing Healthcare Provider Training
Healthcare providers should receive training on cultural humility and culturally responsive care to better understand and address the unique stressors experienced by Black women. Cultural humility and culturally responsive care are essential components of providing effective and equitable healthcare because these approaches recognize the importance of acknowledging that the experiences and challenges faced by Black women are deeply rooted in historical, systemic and cultural factors. To be effective, and to ensure sustained adoption of culturally appropriate practices, training must be provided across systems and at multiple levels in all service provider organizations.
Cultural humility involves a commitment to self-reflection, lifelong learning and humility in engaging with patients from various cultural backgrounds. It requires healthcare providers to recognize their own biases, limitations and assumptions, and to approach each patient with openness, respect and a willingness to learn6. Culturally responsive care involves actively incorporating patients’ cultural beliefs, values and preferences into healthcare decision-making6. In the context of pregnancy care for Black women, culturally responsive care entails listening to their concerns, soliciting their input and co-creating care plans that align with their cultural values and preferences1.
Cultural humility and culturally responsive care help to foster a healthcare environment that respects diversity, promotes trust and tailors care to meet the unique needs of each patient. They also help to enhance patient engagement, improve communication, and ultimately, ensure that Black mothers receive appropriate support and resources throughout pregnancy and childbirth.
Additionally, healthcare institutions should prioritize diversity and inclusion initiatives, promote equitable access to resources and support services, and implement policies that mitigate the effects of racial discrimination within the healthcare system. Collaborative efforts involving healthcare professionals, policymakers, community organizations, and stakeholders are essential to dismantling systemic barriers and advancing health equity for Black maternal health outcomes.
Promoting Holistic Support Systems
Develop community-based programs and support networks that provide holistic support to Black mothers. This may include peer support groups, doula services and community health workers who offer emotional support, practical assistance and advocacy throughout the perinatal period. Engaging with community organizations, religious institutions and grassroots initiatives can help build strong support systems that address the social determinants of health and mitigate chronic stressors.
Investing in Early Childhood Development
Recognize the importance of early childhood development in mitigating the long-term effects of chronic stress on maternal health outcomes. Invest in programs that support early childhood development, including maternal and child health initiatives, early education programs, and access to high-quality childcare services. By addressing the social determinant of health early in life, we can break the cycle of intergenerational stress and improve outcomes for both mothers and children.
In conclusion, addressing chronic stress among Black mothers is not only a moral imperative but also a public health imperative. By prioritizing the unique needs of Black mothers within our health and public health initiatives and collaborating across sectors to implement evidence-based strategies, we can work towards achieving health equity.
References
