Where the Safety Net Won’t Catch Us: How Obamacare Fails Black Women on Maternal Health


This piece is published in collaboration with Echoing Ida, a Strong Families project.

Click here for all our coverage of the health insurance exchange rollout as part of the Affordable Care Act.

I am what I like to think of as a “young and fun” 20-something. I am a healthy young adult with a decent education and income, and I feel safe in my neighborhood. But the growing sense of my own mortality haunts me. Specifically, what haunts me is that I am a Black woman living in the United States, and I hope to create a family by giving birth some day. As a reproductive health advocate, and someone who is particularly interested in maternal health, I am all too aware of the weight of the evidence against me. When it comes to seamless and successful conception, pregnancy, childbirth, and recovery, the odds are not in my favor.

I am the product of a nation in which Black women—regardless of their income or education levels—are more likely than their white counterparts to experience poor pregnancy outcomes.

  • Overall, the rate of maternal mortality among Black women is three times that of white women (28.4 per 100,000 live births and 10.5 per 100,000 live births, respectively).

  • The rate of maternal mortality among Black women in New York City, at 79 per 100,000 live births, is worse than that of some of the most under-resourced countries.

  • Black women are also more likely to give birth prematurely and to have infants with low or very low birth weight.

  • Black women are two times more likely to suffer from severe maternal morbidity than their white counterparts.

Racial disparities in maternal health outcomes are intolerable; yet, they have been tolerated for decades. So while reproductive health, rights, and justice advocates celebrate the October 1 launch of open enrollment in the health insurance marketplace, I cannot help but reflect on how the Patient Protection and Affordable Care Act (ACA) fails me and so many women just like me.

It’s fantastic that ACA will put access to health care in the hands of millions more people and provide important preventive services and products, such as contraception, at no cost to the person seeking care. The renewed commitment to preventive health services via the ACA is important and should be celebrated, but not overestimated. While improving access to prenatal health care and maternal health services, ACA ignores the social, economic, and psychological factors outside of the health system that affect health and pregnancy outcomes. These factors are known as social determinants of health.

Simply put by the World Health Organization, social determinants of health are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” It is this unequal distribution of money, power, and resources that causes the most damage. Unnatural Causes, a four-part documentary exploring the social determinants of health, explains that those inequalities cause sustained exposure to stress, which is toxic to the human body and detrimental to a developing pregnancy.

As shown in the second episode of Unnatural Causes, existing as a Black woman in the United States causes enough exposure to the stress hormone cortisol to become toxic and disrupt normal physiological and biological processes—processes necessary to have a completely healthy pregnancy. Stressors such as neighborhood safety (or lack thereof), unstable or unsafe housing, overt and covert racism and discrimination, low political power, low wealth, and poor or missing social relationships can all affect a woman’s life and health.

In fact, insurance coverage of health-care services are only a small part of a larger and more complex equation that, according to HealthyPeople.gov, also includes the built environment, community context, economic stability, and education. Additionally, data suggests that insurance programs like Medicaid have not helped improve reproductive and maternal health outcomes. Indeed, disparities in adverse outcomes such as low infant birth weight have increased, and disparities in maternal death remain the same, despite advances in medical technology and an improved health-care infrastructure.

What Black women are facing is a problem that even stellar health insurance and health-care access (which ACA does not guarantee) cannot solve. It cannot be addressed by traditional thinking about access to medical care, health, and health policy, because such thinking is inadequate to deal with the problems that our country is facing. Health insurance reform cannot achieve better health outcomes for Black women and their children because it does not work toward justice. Even with the ACA in place, Black women will still be plagued by the chronic stress that comes with simply being Black in the United States.

Reducing and eliminating disparities requires some innovation, creativity, and risk-taking. We have to take a comprehensive, intersectional approach that works to eliminate injustice and, as University of California, Los Angeles OB-GYN Michael Lu and his colleagues say, “undo racism.”

In order to close this gap in maternal health, they believe “[w]e cannot eliminate racial disparities in birth outcomes without addressing racial disparities in education, healthcare, housing, employment, the criminal justice system and the built environment.” The good news is that we can do something. A good place to start is to change public policy.

Only bold policies and reforms addressing institutional and systemic flaws that produce inequality will make the big difference we as advocates seek. This is what reproductive justice advocates understood when they rallied together to change the discourse and take action almost two decades ago. Now, we see many more adopting this intersectional approach in one form or another. For example, the Center for American Progress’ Fair Shot campaign acknowledges the intersection of economic security and reproductive health and signals a shift in the policy approach to health and well-being.

We cannot achieve good reproductive and maternal health outcomes by simply focusing on health-care services. We must have economic justice, social justice, and environmental justice to achieve reproductive justice. And we must have reproductive justice to make progress as a society. We cannot move forward by leaving some communities behind.

Change is challenging, and it takes time, but it is imperative that we make Black women’s maternal health an advocacy and policy priority. We have what it takes to get the work done. We can improve Black women’s maternal health, and when we do the lives of American women will be improved; as Martin Luther King, Jr. wrote, “Whatever affects one directly, affects us all indirectly.”

Let’s start by raising awareness of these egregious disparities and poor health outcomes, and by having a dialogue with advocates and thinkers from other fields. Eventually, we will succeed, and in 20 or 30 years our daughters won’t have to write the same. They can rest assured, confident with the knowledge that their race won’t cost them their lives.

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Follow Elizabeth Dawes Gay on twitter: @edawesgay

  • Kelly Jessop

    This article is racist, sexist garbage.