Bias, Before First Breath

How structural racism and implicit bias impact America’s babies, even prior to birth


Becoming a new mother in America is more dangerous for some mothers than it should be. Each year, 700 women die in childbirth or from pregnancy-related causes in the United States, the highest number of any developed nation. 

Health inequities in America mean that overwhelmingly, Black women and their infants are the ones impacted: Black mothers are 243% more likely to die from pregnancy than white ones. These discrepancies are wide ranging: American Indian and Alaska Native women are also 2x more likely to experience an adverse outcome as compared to  their white counterparts. Too many of our mothers are dying of preventable causes. The CDC estimates that 70% of maternal deaths are avoidable – which helps underscore the urgent need to create tangible change. 

Recent forces have helped shine a long overdue spotlight on the Black maternal mortality crisis in America. In April, the Biden Administration released a proclamation during Black Maternal Health Week, and planned legislative changes to address implicit bias in healthcare and apply funding where it is truly needed. Congress is fielding the “Momnibus” bill, which would fund grassroots organizations at the community level, actively establish bias training programs, and fill gaps created by social determinants of health (SDOH). Late last year, the HHS released an action plan to reduce maternal mortality and adverse outcomes by 50% in five years.

It is heartening to see action finally being taken: our mothers deserve more. At the same time, while we champion standardized and equal access to care for all of our mothers, we cannot overlook the newest cry in the room: the infant’s. Even before drawing her first breath, a baby girl’s future will be irrevocably shaped by structural racism and socioeconomic factors way beyond her control. 

That’s why, to address health inequities, we must begin with our babies. Despite great advances in NICU technology and managed healthcare, infant mortality is on the rise – and it disproportionately affects Black babies. Today, black infants are twice as likely to die as their white counterparts

While we need new standards set at a governmental level to help equalize access to care, expand coverage, and provide funding for much-needed programs, it takes all of us to create change. Here are three steps individuals and care teams can begin to put into action today:

Diagnose and treat your implicit bias

Implicit bias is all too common and can be hard to recognize. Two out of three clinicians hold unconscious implicit bias against Black and Latino patients. Doctors were also more likely to recommend more advanced and effective medical treatments for their white patients than for their Black ones. Barriers to care impact both mother and baby, long after the delivery date. 

It’s no longer enough for clinicians to focus on documenting   symptoms, case notes, and diagnoses — they should also have training for recognizing and overcoming bias. A good first step is building inclusive language vocabularies. Words like “minority,” “underserved,” “failed,” “lapsed,” and “non-compliant” are loaded with prejudice and limited in their ability to paint a full picture. By opening our ears, hearts, and minds, we can help eliminate biases that can have a long-term impact on the health of our mothers and their new babies. 

Make room for more voices in the delivery room

All too often, the first time a pregnant woman meets her attending physician is after her water breaks, in the delivery room. Fortunately, midwives and doulas are helping to fill the gap. They act as teachers, friends, and advocates by providing support, resources, information, and education to new moms-to-be. Experienced in delivery and medical jargon, they can help navigate the healthcare system and access benefits that expand coverage.

A recent study showed that states with higher midwife integration scores saw significantly lower rates of preterm birth and low birth weight babies. Many doula and advocacy services are provided pro bono via non-profit groups. True expansion of care at scale calls for state Medicaid agencies to improve reimbursement rates for out-of-hospital birth options, and for midwives and doulas to receive living wage compensation for their very important work. In the hospital setting, care providers can help reduce obstacles by embracing new care team members and listening to all voices in the room.

Becoming a true care team, from preconception to postpartum

From family planning to prenatal visits, through delivery, and postpartum follow-ups, a care team should be in place every step of the way. Experts recommend a minimum of 13 prenatal visits. Infants whose mothers did not receive prenatal care are 3x more likely to have a low birth weight, and 5x more likely to die in infancy.

Unfortunately, recurring doctor’s visits, especially for prenatal care, are all too often skipped. In 2016, 24% of pregnant women received fewer than the recommended number of prenatal visits. 10% of Black women, 12% of American Indian or Alaska Native, and 8% of Hispanic women received late or no prenatal care, as compared to 5% of white women. State-based expansions to Medicaid can help ensure more equitable access to vital care. Lack of workday flexibility, food insecurity, limited access to transportation, and other SDOH can interfere with a mother’s ability to keep appointments. On the provider side, small changes can help account for and overcome these care gaps, including: de-stigmatized screening programs for nutritional or financial needs, community outreach, local partnerships, and offering telemedicine appointments during evenings and weekends. 

Every baby deserves equal access to the necessary health care services to have a healthy first year of life and beyond. By taking small steps today to improve the quality of care for all of our mothers, we can work to lighten the burden on our young ones. We can all play a part in addressing the pervasive framework of implicit bias and structural racism that yield health inequities and care gaps caused by SDOH. Ultimately, we are all working toward a reality where we break the cycle of inherited systemic bias, so that every baby can begin their life with a healthy start.

Ellie Stang, MD is the Founder and CEO of ProgenyHealth.