Advocacy Project Essay

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Mitigating Maternal Mortality:

Nationwide Implementation of the Black Infant Health Program

Although mothers dying from pregnancy and related causes should be a thing of the past,

maternal mortality rates are actually rising in the United States, and African American women

are disproportionately affected by that increase. Specifically, as shown by Nina Martin from

ProPublica, black women are a whole 243% more likely to die from pregnancy or related causes

than white mothers (Martin and Montagne). Recently, the news has featured stories of black

families from all walks of life that are caring for newborns after they lost a mother to maternal

mortality. After reading the stories of lost African American mothers, it becomes hard to imagine

how we aren’t doing more to protect them from this terrible maternal outcome. Therefore, it’s

critical that the main causes of maternal mortality are clearly identified and mitigated, especially

for the most at risk black mothers. There are a number of factors that increase a woman’s risk of

maternal mortality, and studies show that black mothers are more likely to experience the most

harmful factors than white women.

African American mothers are more likely to have sociodemographic and health risks,

which increase their probability of negative birth outcomes. Black mothers are more likely to be

obese, not have adequate insurance and prenatal care, not have completed high school, and have

unintended pregnancies than their white counterparts, which are all factors associated with

negative birth outcomes such as maternal mortality (Louis et al. 691). In fact, as shown by Greg

Alexander, a professor who helped define the field of perinatal epidemiology, white women were

2.5 times more likely to be considered an extremely low risk pregnancy (didn’t have any possible

medical, lifestyle, or socio-demographic risks) than black women (211). Alexander’s study

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highlights how black women are much more likely to be in disadvantaged situations which end

up negatively impacting their health and birth outcomes. Therefore, in order to reduce the risk of

maternal mortality for black mothers, the other disparities they face will need to me ameliorated

as well.

While sociodemographic factors and health backgrounds play an important role in

maternal mortality for black women, they don’t fully account for the disparity of maternal

mortality rates; even African American mothers who don’t have sociodemographic and health

risks are disproportionately affected by maternal mortality, and stress is likely the cause. Studies

show that low-risk black mothers who would be expected to have healthy pregnancies are still

more at risk than their white counterparts (Alexander et al. 211). This trend is reflected in the

graph below, which shows that even when African American women are college graduates, they

are still more likely to

suffer from severe

maternal morbidity than

white mothers who

didn’t graduate from

high school (“Severe

Maternal Morbidity”).

For the African

American women who are low-risk but still vulnerable to maternal mortality, the unique stressors

they face are shown to account for the remaining disparity. As reported by Lisa Rosenthal, a

psychology professor at Pace University, racism, sexism, histories of abuse and mistrust in the

Courtesy of the New York City Department of Health and Mental Hygiene, these graphs depict the rates of maternal morbidity among New York mothers.

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medical system, and most importantly, the intersectional identities of African American women

are all unique stressors black women face which lead to elevated levels of stress (978). Unique

stressful experiences make even low-risk African American mothers more vulnerable to maternal

mortality because stress and health outcomes are directly linked, with mothers who experience

chronic stress facing a greater susceptibility to disease, poorer overall health, and a reduced

capability to recover (Louis et al. 692). Therefore, it is important to address both

sociodemographic risks and stress which disproportionately affect black mothers, because by

doing so, the major causes of maternal mortality could be combated, and all black mothers would

be included in the solution.

As rates of maternal mortality rise for black mothers across the United States, it becomes

imperative to find a solution that will directly and effectively combat negative birth outcomes for

the most at-risk mothers. Black mothers often need health resources and social support in order

to have healthier pregnancies, and that’s exactly what the Black Infant Health (BIH) program

provides. Established in 1989 by the Maternal, Child, and Adolescent Health Division of the

California Department of Public Health, the BIH program provides group social support

interventions and case management services for African American mothers in California

(“Program Overview and Administration”). Implementing the Black Infant Health program

nationwide would provide African American mothers with the services and support they need to

ensure healthy pregnancies and infants. Additionally, considering that the funding for the BIH

program is already in place on a national level thanks to the Maternal and Child Health Block

Grants from Congress, other states already have the funding to implement the program into their

existing services, so long as they prioritize this pressing public health issue. Overall,

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implementing the Black Infant Health program nationwide would be the best solution to decrease

rates of maternal mortality because the program addresses the causes of negative birth outcomes

for black mothers, has already shown success in California, and could feasibly be funded by

states.

The first part of the BIH program that African American mothers have access to is group

sessions which directly aid in the management of maternal stress and creating positive birth

outcomes, therefore reducing their risk of maternal mortality. As shown by Lisa Rosenthal, a

psychology professor at Pace University, stress has an important influence on maternal health, as

it affects the immunological,

metabolic, cardiovascular, and

neuroendocrine pathways which

therefore lead to negative birth

outcomes (Rosenthal and Lobel

987). However, in a study done

by Agnieszka Skurzak, a

professor at the Medical

University of Lublin, mothers

who received social support had reduced feelings of stress and were better able to cope with

maternal and life stressors (170). Therefore, the negative effects of stress on maternal health are

addressed and ameliorated by the BIH program because they provide 10 prenatal and 10

postpartum group sessions aimed at increasing the social support black mothers receive

(“Program Overview and Administration”). The program is directly addressing one of the causes

Courtesy of Maya Sugarman for KPCC. This photo shows a group session from the Los Angeles Black Infant Health Program, Great Beginnings for Black Babies.

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of maternal mortality through their group sessions because social support reduces maternal stress

and health risks. Additionally, the support groups provide black mothers with supportive peers

who likely face the same stressors as they do. This is critical because as shown by Paula

Braveman, a professor of Family and Community Medicine at the University of California San

Francisco, black mothers who experience stress related to discrimination and racism are about

twice as likely to experience negative birth outcomes than mothers who don’t face those chronic

stressors (10). When BIH programs provide black mothers with peers and group facilitators who

understand their circumstances, are trained to provide support, and can empower each other,

those mothers will not only be more likely to have better health outcomes, but they are also

directly addressing some of the most relevant and damaging stressors for African American

mothers. As shown in the image to the left, in group sessions, black mothers are surrounded by a

group of peers and professionals who they can trust and receive support from, and the women

report feeling empowered, supported, and confident after attending (“Black Infant Health”).

Clearly, social support plays a critical role in maternal health outcomes, and the BIH social

support sessions directly target stressors specific to black women and those lacking social

support, which are causes of many maternal health issues.

The BIH program also provides case management and individualized recommendations

for black mothers, giving them the resources they need to have successful pregnancies equivalent

to their white counterparts. The individual sessions with a case manager address three topics:

health, relationships, and finances (“Program Overview and Administration”). Considering that

black mothers are more likely to have health, social, and demographic risk factors than white

mothers (Louis et al. 691), the case management services provided by BIH programs are able to

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identify and eliminate some of those risks. For example, case managers often provide health

insurance application assistance and financial aid to mothers in need. Both of those factors were

identified as having an impact on maternal health outcomes (Louis et at. 691), and therefore the

BIH program is helping to eliminate some of the root causes of maternal mortality by providing

mothers with resources and recommendations they may otherwise go without. The case

management aspect of the BIH program does wonders for decreasing maternal mortality rates for

black mothers because it links them with the services and resources they need to ensure healthy

pregnancies, something that certainly should be in place nationwide.

The BIH program is strong even in theory, but the fact that their methods have been used

in California for almost 30 years and have shown evident success makes the BIH program an

undeniable resource for other states to adopt. In a report done by Jane Yoo and Kristin Ward from

First 5 LA, there were reduced rates of infant mortality, preterm births, and very low birthweight

for black Los Angeles mothers who went through the BIH program compared to the rest of the

African American population in LA (12). While the report didn’t specifically compare rates of

maternal mortality, birthweight and infant health outcomes are widely used as a measure of

maternal health as well, especially because maternal mortality is often caused by multiple factors

(Burton et al. 142). That being said, the First 5 report also determined that the BIH program

successfully, “increased social support and reduced isolation; increased mastery of health and

parenting knowledge and skills, positive psychological change, and health-promoting behaviors,”

which are all factors that decrease stress and negative birth outcomes (Yoo and Ward 7). A study

by Winnie Willis, a public health professor at San Diego State University, showed similar results,

with individuals who went through the BIH program showing birth outcomes comparable to the

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overall population in the area, even though black mothers and infants are traditionally at an

increased risk without the program (321). Clearly, both the First 5 report and Willis’s study show

the marked effectiveness of the BIH program. In addition to the successfulness of the program,

the individual locations throughout California are reaching a considerable number of families,

with one Los Angeles BIH program aiding more than 1,500 families in 2016, and hoping to

increase their number of clients by 500 families in the coming year (“Programs: Black Infant

Health”). If that success were to be expanded nationwide, the number of black mothers and

families that could receive aid and experience better health outcomes would be staggering. The

BIH program clearly reduces the causes and rates of maternal mortality and negative birth

outcomes in California, which is a difficult task considering the complexity of maternal mortality

disparities.

While the Black Infant Health program addresses the main causes of the maternal

mortality disparities, alternative policies such as the Preventing Maternal Deaths Act of 2017 are

not as successful in truly combatting the issue at hand. HR bill 1318, the Preventing Maternal

Deaths Act, was introduced in March 2017 by Jamie Beutler. The bill calls for a more thorough

review of maternal mortality through review committees and assurance that state health

departments will develop plans to improve maternal health based on the information they obtain

(United States Congress). While this policy would certainly contribute to the understanding of

why maternal mortality rates are increasing for black mothers, it does not include a specific

course of action to combat negative birth outcomes. The failure to establish an action plan for

combatting maternal mortality outweighs the feasibility of implementing this bill; because

although some states already have review boards and the rest could easily develop their own, if

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those states don’t have effective methods of reducing the outcomes they are researching, there

won’t be any change to maternal mortality rates. Without specific programs in place to aid black

women and assure their maternal health, review boards and a clearer understanding of maternal

mortality will be useless. Therefore, although states should be paying attention to who is most

affected by maternal mortality and why that is the case, the Black Infant Health program is

already successfully addressing some of the most prominent causes of maternal mortality, so it

makes most sense to dedicate funds and resources to making real change and helping real

families.

The funds that are used to run the BIH program in California are available nationwide,

meaning that states adopting the program could feasibly fund it as well. The BIH program in

California is funded by Title V Maternal and Child Health Block Grants from Congress, support

from First 5 California, Title XIX of Medicaid funding, and state general funds (“Program

Overview and Administration”). While some of these resources such as First 5 California are

specific to one state, Title V grants are the main source of funding, and those are made available

on a national level. According to the US Health Resources and Services Administration, states

and jurisdictions match Title V money by contributing at least three dollars of state or local

money for every four federal dollars provided. Many states also overmatch the grants, and

therefore, over $5 billion is made available every year at the state and local levels for maternal

and child health programs such as BIH (“Title V” HRSA). These funds are made available to

states to combat issues such as maternal mortality, so it’s a matter of using them effectively and

appropriately, as BIH programs would be able to do. Therefore, in order to implement the BIH

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program nationwide, states would need to redistribute their Title V funds to include this program,

however, the reallocation would be both beneficial and certainly worth the cost.

States should use a portion

of their Title V grants to implement

the BIH program because maternal

mortality is a growing problem in

the US, and the BIH program

efficiently aids the most at risk

mothers. As shown in the graph to

the right, only 4.36% of Title V

funds go toward aiding pregnant

women, while 75.94% are used for children (“Title V” HRSA). While it is certainly important to

ensure positive health outcomes for children and adolescents, the Health Resources and Services

Administration shows that health outcomes for mothers are getting worse while their children

experience improved health outcomes. As shown in the graphs below, maternal morbidity and

Courtesy of the Health Resources and Services Administration. This graph depicts which populations Title V block grants are assisting.

Courtesy of the Health Resources and Services Administration. These graphs portray the National Outcome Measures (NOMs) that are used measure maternal and child health and lead legislation and programs for Title V.

Maternal Mortality Rate Maternal Morbidity Rate

Infant Mortality Rate Child Mortality Rate

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maternal mortality are increasing nationwide, while mortality for infants and children are

decreasing (“Title V” HRSA). These trends are important because even though outcomes are

improving for children, the majority of Title V grants are still being used for programs that focus

on children’s health. While it is critical that state funds continue to support children’s health and

maintain the successes they’ve achieved, some of the funds undeniably need to be reallocated to

programs which will improve maternal health, because maternal outcomes are only getting

worse. The Black Infant Health program would be a good way for states to use their Title V

funds to support mothers because by providing black women with resources and social support

both before and after their pregnancies, the BIH program actually promotes healthier lives for

both mothers and their babies (“Program Overview and Administration”). Therefore,

considering how important it is for states to put more effort into maternal health, especially for

the most at risk black women, the BIH program could feasibly be funded by states because a

reallocation of funds is both necessary and realistic.

Clearly, the BIH program could be funded by states, and considering how successful it

has already been in California, it becomes hard to imagine how the program isn’t already a

national staple. The fact that there are successful and feasible solutions out there that not all

mothers have access to is truly disappointing. Implementing the Black Infant Health program

nationwide could allow so many more black women to become the mothers they planned on

being, as we have already lost far too many to maternal mortality. With all of its potential and

success, the Black Infant Health program absolutely needs to be implemented nationally, because

there are so many at risk black mothers who deserve equal chances of being healthy and

becoming great mothers, and this program is going to help them do that. 


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Works Cited

Alexander, Greg R, et al. “Racial Differences in Birthweight for Gestational Age and Infant

Mortality in Extremely-Low-Risk US Populations.” Paediatric and Perinatal

Epidemiology, vol. 13, no. 2, 1999, pp. 205–217, doi:10.1046/j.1365-3016.1999.00174.x.

“Black Infant Health Program.” California Department of Public Health, 1 Mar. 2018,

www.cdph.ca.gov/Programs/CFH/DMCAH/BIH/Pages/Default.aspx.

Braveman, Paula, et al. "Worry about Racial Discrimination: A Missing Piece of the Puzzle of

Black-White Disparities in Preterm Birth?" Plos ONE, vol. 12, no. 10, 11 Oct. 2017, pp.

1-17, doi:10.1371/journal.pone.0186151.

Louis, Judette M., et al. “Racial and Ethnic Disparities in Maternal Morbidity and

Mortality.” Obstetrics & Gynecology, vol. 125, no. 3, Mar. 2015, pp. 690–694., doi:

10.1097/aog.0000000000000704.

Martin, Nina, and Renee Montagne. “Nothing Protects Black Women From Dying in Pregnancy

and Childbirth.” ProPublica, 7 Dec. 2017, www.propublica.org/article/nothing-protects-

black-women-from-dying-in-pregnancy-and-childbirth.

“Program Overview and Administration.” Black Infant Health (BIH) Program, California

Department of Public Health, 2015.

“Programs: Black Infant Health.” Great Beginnings for Black Babies, www.gbbb-la.org/

programs.

Rosenthal, Lisa, and Marci Lobel. “Explaining Racial Disparities in Adverse Birth Outcomes:

Unique Sources of Stress for Black American Women.” Social Science & Medicine, vol.

72, no. 6, Mar. 2011, pp. 977–983., doi:10.1016/j.socscimed.2011.01.013.

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“Severe Maternal Morbidity in New York City.” New York City Department of Health and

Mental Hygiene, 2016, New York, NY.

Skurzak, Agnieszka, et al. "Social Support for Pregnant Women." Polish Journal of Public

Health, vol. 125, no. 3, Sept. 2015, pp. 169-172. EBSCOhost, doi:10.1515/

pjph-2015-0048.

“Title V Maternal and Child Health Block Grant.” California Department of Public Health,

www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/Title-V-Block-Grant-Program.aspx.

“Title V Maternal and Child Health Services Block Grant Program.” HRSA Maternal & Child

Health, Health Resources and Services Administration, 1 Jan. 2018, mchb.hrsa.gov/

maternal-child-health-initiatives/title-v-maternal-and-child-health-services-block-grant-

program.

United States, Congress, Preventing Maternal Deaths Act of 2017. 2017. www.congress.gov/bill/

115th-congress/house-bill/1318.

Yoo, Jane, and Kristin J Ward. “Black Infant Health Evaluation.” First 5 LA, 2011,

www.first5la.org/files/BIH_FinalReport_11112011_Combined.pdf.