In 2016, Cindy McMillan was shocked to learn that babies born to women of color in her home community in Buncombe County were three times more likely to die in their first year than white babies.
Now, she works to improve health outcomes for women of color and their babies, as the executive director of Sistas Caring 4 Sistas, a community-based doula service in Asheville.
The White House recognized Black Maternal Health week in April as a reminder of racial disparities in maternal health care, but disparities in Black maternal health remain a problem in North Carolina and the United States. Black women and childbearing people are three to four times as likely to die of pregnancy-related complications than white people, according to the Centers for Disease Control and Prevention.
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A number of reasons contribute to the racial disparities in maternal mortality, such as access to health care, underlying conditions and structural racism, the CDC says.
One recent study from the CDC found that Black women were more likely to have chronic high blood pressure and had the highest rate of pregnancy-related high blood pressure of any racial or ethnic group measured.
Doulas might be able to address some of those disparities.
Doulas are nonmedical trained professionals who provide “physical, emotional and informational support” to pregnant people before, during and after birth, according to Doulas of North America (DONA) International, a doula certifying agency. Research shows that having a doula involved with a birth reduced the incidence of delivery via cesarean section. The rate of birth complications and medical interventions during delivery also were fewer when a doula was involved in the process.
In North Carolina in 2019 (the most recent year for CDC data), nearly seven out of 1,000 infants died, according to the CDC, putting it among the 10 states with the worst infant mortality outcomes. A review published last year of the years between 2010 and 2019 found that the Black, non-Hispanic infant mortality rate in North Carolina was 12.5 per 1,000 live births, even as the overall infant mortality rate for North Carolina was at an all-time low of 6.8 deaths per 1,000 live births.
For McMillan, a Black woman, the high rates of infant mortality were personal, part of her motivation to start Sistas Caring 4 Sistas
“It really hit me hard because I had experienced really, really bad pregnancies,” McMillan said.
McMillan said she almost lost her life during one pregnancy. Almost 20 years ago, she gave birth to twins. Only one baby came home with her from the hospital.
“I couldn’t believe that health care systems or providers could treat someone the way that they treated me,” McMillan said. She recalled being pressured to tie her tubes after giving birth to her fourth child. Now, she wonders if she would have made the same decision if she had felt like she had a choice.
McMillan had taken it upon herself to be in the room with family members who were giving birth, so they would not have to feel alone.
She and the other doulas at Sistas Caring 4 Sistas cater to their clients’ needs, working with them at almost any point in their pregnancies and assisting them in everything from navigating the health care system and teaching how to breastfeed to exploring how to address food insecurity.
The organization was born out of the desire to help other women like her, starting in McMillan’s local community center. Now they have partnerships with large organizations such as Mountain Area Health Education Center and UnitedHealthcare, which recently gave the organization a $25,000 grant.
Michelle Bucknor, chief medical officer at UnitedHealthcare, said Sistas Caring 4 Sistas stood out because they are community based.
“Where we know that good work is occurring in the community, we want to build that capacity and support that capacity,” Bucknor said, “not just in maternal health strategy when it comes to social determinants overall.”
The social determinants of health are the way factors such as race, ethnicity and income impact health outcomes. Access to healthy food and clean water, the space to exercise, and having clean air and water can all impact health outcomes down the road, as can racism and discrimination.
Regardless of education and socioeconomic status, Black pregnant people have worse pregnancy outcomes than their white counterparts. A Black pregnant person with a college education still has a pregnancy-related mortality ratio five times higher than white pregnant people, according to the CDC.
Funding from UnitedHealthcare and other funders allows the doulas at Sistas Caring 4 Sistas to provide their services for free — so pregnant people in the Asheville community who need them the most don’t have to worry about the costs.
The mission resonated with Bucknor.
Even though she is a trained pediatrician, Bucknor worried about the care she would receive as a Black mother giving birth in a community in the Midwest that had some of the highest rates of Black infant mortality in the country.
“These were babies I care for. Some of them didn’t survive through their first year, and I knew it wasn’t medical,” Bucknor said. “This is a community issue.”
The doulas at Sistas Caring 4 Sistas work to bridge the gap between community and health care, where their health has historically not been prioritized. The doulas’ goal is to empower clients by giving them the time and space to make decisions for themselves in intimidating medical settings.
“When you think of health care systems, you trust your health care provider because you’re not the expert in medicine,” McMillan said. “But you are an expert in your body.”
Using their relationships with local hospitals, the doulas have been able to work with medical professionals to get clients the answers they need.
“Those are pieces that were missing,” McMillan said.
Building relationships and bridging gaps doesn’t stop with medical professionals. McMillan said they’ve identified key problems in her community, such as housing insecurity, by listening to members of the community.
Now, her organization is focusing on developing a housing community for families experiencing homelessness.
“These outcomes in the United States with Black maternal health is unreal. That should not be going on,” McMillan said. “These are preventable outcomes. Any provider, any community should be, like, really paying attention to that. Because these are setting the stage for our future.”