Twenty-seven-year-old Shakiela Riley had her birth plan ready. In her first trimester, she found an OB-GYN, reached out to a doula for an in-person consultation, and took a handful of pregnancy classes. A Milwaukee native, Riley, who is African American, did not want to leave anything to chance in a state where black mothers die at a significantly higher rate than their white counterparts.
Then came the coronavirus crisis.
By late March, when Wisconsin’s governor announced a statewide lockdown, Riley’s two pregnancy classes moved online. Her doula canceled their in-person meeting. Most of her meticulous plans have been disrupted.
Black and nine months pregnant in a state with one of the worst records on black maternal health nationwide, according to the Wisconsin Department of Health Services, Riley is at the center of not one but two public health crises that have disproportionately impacted black communities.
“I’ve been feeling good so far,” Riley told The Fuller Project. “But, everything is so up in the air, you just don’t know how it’s going to go.”
Pre-pandemic, black mothers in Wisconsin died at five times the rate of white mothers, according to the Wisconsin Department of Health Services. Nationally, black mothers die at 3.2 times the rate of white mothers. In Wisconsin, the poverty rate for black residents is more than 2.5 times greater than the state’s overall poverty rate, and between three to four times the poverty rate for white Wisconsinites, according to the 2018 Wisconsin Poverty Report. Wisconsin health officials and advocates have long raised the alarm about the dire state of black maternal health. Now, they say, the coronavirus crisis has laid bare a ‘perfect storm’ of health inequalities that further risk black women’s lives.
Milwaukee Health Commissioner Jeanette Kowalik has heard anecdotal reports of an uptick in miscarriages and stillbirths, she tells the Fuller Project. Her department is monitoring the situation, and working to mitigate the impact of COVID on its black pregnant population, she says. “Given that the disproportionate amount of residents positive for COVID are black, this puts all of our black mothers at risk,” Kowalik said in an email.
Disparate impact of coronavirus and maternal health on black Americans
Each time Riley takes a twenty-minute roundtrip bus ride from her downtown apartment to her doctor’s office at the Aurora Health Center for her bi-weekly prenatal appointments, she worries she’ll contract coronavirus. While bus drivers now limit the number of passengers onboard to a ten-person maximum, Riley says passengers often skirt the rules and she can’t afford a car or the extra fees to park near her apartment.
“The coronavirus is something that’s always in the back of my head,” she said. “What if someone gets on the bus coughing?”
Roughly 34 percent of black Americans who live in urban areas use public transportation, compared to 14 percent of white Americans, according to the Pew Research Center. Pew also found that black Americans were less likely to own vehicles, despite being more likely to have to travel farther distances for work.
“Health disparities are a direct result of a ‘perfect storm’ of factors including but not limited to low socioeconomic status,” Kowalik said.
Access to transportation, whether or not jobs are considered “essential” (grocery store employees vs. white-collar workers), and access to safe housing impact, people’s ability to keep themselves safe during an outbreak.
Safe access to food for lower to moderate-income Wisconsinites is another area of concern. At the beginning of the pandemic, Riley had her groceries delivered through friends and delivery services. But now, she has to shop in-store to receive food assistance through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition program that provides food and other resources to lower-income pregnant and postpartum women and children under the age of five.
“Racism still impacts their ability to receive quality care.”Kwajelyn Jackson, Feminist Women’s Health Center
Three weeks ago, Riley cautiously made her first trip to the store since the pandemic began. But strict WIC parameters means she can only shop for specific brands in specific stores. The restrictions added roughly 30 minutes to her normal shopping routine.
Even before the pandemic hit Wisconsin, Riley worried about receiving quality and identity-conscious care. When her primary care doctor confirmed her pregnancy, Riley knew she wanted to see a black OB-GYN.
“I wanted to feel that somebody could relate to me and what I was going to go through during my pregnancy,” said Riley.
Many of the same factors that have fueled the disparate impact of the coronavirus on black Americans, such as implicit bias in health care, also impact black maternal health, says Kwajelyn Jackson, Executive Director of the Feminist Women’s Health Center in Atlanta, Georgia.
“Racism still impacts their ability to receive quality care,” says Jackson, who also serves as an advisory committee member of the Black Mamas Matter Alliance, an organization focused on black maternal health. “Economic disparity is a part of why black people are disproportionately dying but it’s not the whole story.”
For that very reason, Riley decided not to use a referral from her primary care provider and instead went searching for a black OB-GYN in her network. Riley says there was only one in her area.
“Just hearing past experiences from friends or my other cousins who delivered,…they’ll bring up an issue or ask a question and just be brushed off,” said Riley, “I would never know how to respond to that situation.”
Black patients see better health outcomes when they see black health providers, suggests a 2019 study conducted by the American Economic Association, which found that pairing a black patient with a black provider narrowed the black-white gap in cardiovascular deaths by 19 percent.
Racial bias plays a factor in whether or not patients receive pain management care, research shows: Black Americans are less likely to be treated for their pain, and they experience longer wait times on average compared to white patients, which can prove fatal.
Many black women at the health center express more comfort working with providers who could relate to their shared experiences as black women, Jackson says.
Even with a black provider, changes amid coronavirus outbreaks intended to promote public safety make an already challenging task of giving birth as a black woman that much more difficult — and dangerous.
Although Riley planned to have her mother, her cousin, and her best friend, who is a labor and delivery tech, in the delivery room with her originally, many hospitals in Wisconsin have instituted a one person per delivery room policy, meaning she can only have her mother there to support her.
“Frequently, physicians and other healthcare providers are making very quick decisions on behalf of the pregnant person,” says Jackson. “Having someone who is at least relatively clear-minded and present, who can advocate on behalf of the person who is giving birth, is critical.”
In addition, Kowalik is concerned hospitals in the area will follow the lead of hospitals in other parts of the country, and recommend inductions and potentially unnecessary C-sections to reduce patients’ time in the hospital. African-American women in the United States are more likely to have cesarean births, according to a paper published in the American Journal of Public Health. Researchers attributed this finding in part to providers being less likely to listen and adhere to African-American patients’ medical preferences.
“As more and more Black birthing people go to hospitals for care, we will anticipate hearing more stories of mistreatment,” said Kowalik, referencing the potential for black patients to be coerced into medical procedures such as C-sections that they don’t want and might not be medically necessary.
Although she suspects that because black patients have already come to expect a level of mistreatment in their medical care, that incidences of maltreatment due to the coronavirus may take longer to reach her office.
“I look at [black maternal] health disparities and health inequities as a result of a series of decisions that were made across generations,” said Dorianne Mason, Director of Health Equity, Reproductive Rights and Health for the National Women’s Law Center, by phone. “And so, the solution is not, unfortunately, going to be one thing, it’s going to have to be a series of decisions that undo those harms from generations of decisions.”
Prenatal and post-delivery plans move online
Kowalik is about to roll out a Doula program for prenatal mothers in Milwaukee, which is home to nearly 70 percent of Wisconsin’s black population,
Milwaukee’s Department of Maternal and Child Health services is limiting in-person contact for as many of their programs as possible. Screenings for potential mood disorders in new parents who participate in one of the MCH’s prenatal and postpartum home visitation programs have become virtual. These screenings will look for potential mood disorders, and refer parents out for assistance. Eligible pregnant persons in the city of Milwaukee can make inquiries about these programs over the phone.
But moving all online and over-the-phone is not always possible. Certain programs, such as newborn health screenings, still require beneficiaries to access services in-person.
Managing the postpartum period without her larger support network concerns Riley, who has struggled with both depression and post-traumatic stress disorder due to witnessing domestic violence during her childhood. Research shows women of color are more likely to suffer from postpartum depression but are much less likely to receive treatment. In recent weeks, Riley has kept in touch with her therapist by video.
“I’ve been doing this all by myself,” said Riley. It’s been a month since she’s seen her family, instead relying on the companionship of her dog Bams for comfort.
“I know I still won’t be able to see [my family] face to face even after bringing the baby home because I don’t want to risk exposing her to anything, and that’s something I think about, but I try not to get too sad about it.”