It Takes a Village: How Caring About Black Women Can Transform Maternal Care
“You don't have to go it alone; there are people out there who got you if you're willing to open up,” says Dr. Venice Haynes.
Editor’s Note: I hit send before I was finished finessing this piece! I have now added the footnotes. the finalized URL slug, and the last copy edits. I am very sorry about the early send, and for popping up in your inbox back to back like this. I’m committed to clear writing, and I wanted to send the true finalized version once it was done. — Julia
Toward the culmination of the Reagan Administration, about a year or so after Toni Morrison won a Pulitzer Prize for her 1987 novel Beloved, the esteemed author sat down with Time Magazine correspondent Bonnie Angelo to discuss how racism causes many of the fractures seen within American society.
And Reagan was a man obsessed with gluing the country back together by dismantling care systems he believed kept people living in poverty. At a 1976 campaign rally, he introduced America to the myth of the Welfare Queen, a racist caricacture of a Black woman who supposedly “used 80 names, 30 addresses, 15 telephone numbers to collect food stamps, Social Security, veterans’ benefits for four nonexistent deceased veteran husbands, as well as welfare. Her tax-free cash income alone has been running $150,000 a year.” In 1983, he’d address the nation via radio, about the rise in the number of single mothers, which, supposedly, jumped from “31 to a tragic 47 percent among blacks.”
“Too often their children grow up poor, malnourished, and lacking in motivation. It's a path to social and health problems, low school performance, unemployment, and delinquency,” he said. Three years later, he’d dog whistle that the rising number of “child mothers and absent fathers” would lead to a “permanent culture of poverty.”
His rhetoric was setting the stage for bigger harm. He’d use this narrative to justify rolling back public benefits and painting Black mothers living in poverty, especially those parenting alone, as undeserving of government support. During his first term, Reagan would oversee extensive cuts to maternal and child health funding. It’s believed that 600,000 people lost Medicaid, 609 hospitals closed, and more than half were in rural areas. “Negative effects were soon evident in the health of pregnant women, children, and adults with chronic disease. There was an increase in women receiving no prenatal care,” said Dr. David R. Williams, a professor of public health at Harvard University, in 2017. “The overall decline in infant mortality slowed, and an increase in infant mortality in poor areas of 20 states was evident between 1981 and 1982. There was also an increase in preventable childhood diseases in poor populations.” By the end of the Reagan era, the life expectancy for Black Americans had dropped.
This was the backdrop of Morrison’s conversation with Angelo, which, eventually, came to a question about the Black mothers Reagan so vehemently attacked and used to fuel his assault on care. “This leads to the problem of the depressingly large number of single-parent households and the crisis in unwed teenage pregnancies,” said Angelo. “Do you see a way out of that set of worsening circumstances and statistics?”
“Well, neither of those things seems to me a debility. I don't think a female running a house is a problem, a broken family. It's perceived as one because of the notion that a head is a man,” said Morrison in response. “Two parents can't raise a child any more than one. You need a whole community—everybody—to raise a child. … People need a larger unit.”
Morrison was getting at the necessity of assembling a village to raise a child, and dismissing the ludicrous idea that a mother, Black, white, single, or otherwise, doesn’t need robust support to birth and raise her children. Besides, community-oriented child rearing, from preconception to birth and beyond, is a very Black way of being—it’s something we’ve always done. It has also often fallen on us to correct the political harm inflicted upon our communities, a truth that led Dr. Venice Haynes, the Senior Director of Research and Community Engagement at United States of Care, as she and her team brought The 100 Weeks Project to life.
“A lot of my public health training has been with community engagement approaches and research,” she said. “I've been able to maintain that thread throughout my career. It's what I truly enjoy. I like to say I'm a people person, specializing in listening to voices that are not otherwise heard or considered, especially when it comes to health.”
The 100 Weeks Project redefines maternal health care by expanding the traditional view of pregnancy and postpartum support, and weaves in the value of a community-oriented approach. The project centers the real experiences of birthing people, particularly Black women, and juxtaposes them with what should be happening at each clinical stage. Instead of focusing solely on the 40 weeks of pregnancy, this initiative outlines a comprehensive 100-week journey that includes four key phases:
Preconception (approx. 4 weeks): The period when individuals consider, plan for, and navigate the decision to become pregnant.
Pregnancy (40 weeks): The clinical and emotional experience of carrying a pregnancy to term, with varying levels of support and access across communities.
Labor and Childbirth: A critical transition marked by wide disparities in care, especially for Black women.
Postpartum (52 weeks): A full year after birth, which is often under-resourced despite being when the majority of maternal deaths occur.
While Dr. Haynes and I don’t get into Ronald Reagan, we do discuss the need for anti-racist, community-oriented policy, bright spots in the maternal health journey, and the value of choosing to be child-free so that we can pour love into the mothers and babies that are already here. It has been edited for length and clarity.
Julia Craven: Let's start off with a run-through of the journey map and the four periods within it.
Dr. Venice Haynes: In our talking to people across the country about healthcare generally, the issue of maternal health kept coming up. So we decided to take a deeper dive into that because we know the stark stats for Black women in the maternal health space. In some areas of the country, Black women are three times more likely to die from giving birth. We wanted to hear more directly from people to understand what was going on.
We dove in and listened and realized that a lot of times we approach maternal health by looking at the 40 weeks of pregnancy—and it's so much bigger than that. There are a lot of questions and considerations that are happening as women are determining if they want to get pregnant, if they can get pregnant. There's a lot happening in what we call the preconception phase. Of course, there are the pregnancy, childbirth, and labor phases, but there are also postpartum phases that we have in the past relegated to three months after you have the baby, and then you move on in life.
In talking to people, we realized we need to expand our view of the maternal health journey. If we look at that month before pregnancy, think four weeks, and then the pregnancy period, which is generally 40 weeks culminating in childbirth and labor. And now with the extension of postpartum to one year that’s 52 weeks, that will extend out to a hundred weeks. That's how we came up with our 100 weeks framework.
The women we spoke with also talked about some of their experiences with the healthcare system, good and bad. But what is really cool about this journey map is it's not just their stories. We layered it with what's supposed to be happening at the clinical level. One of my favorite parts of this is the bright spots because a lot of times when we talk about the Black maternal health crisis, it's all doom and gloom and we definitely need to keep talking about that, but there's so much good work happening at the community level and all different levels to address barriers to a positive maternal health journey. We thought it was critical to capture that too.
The bright spots are what I loved so much about the project. One thing I constantly run into when I'm reporting or writing on Black maternal health and wellbeing is too much emphasis on the doom and the gloom. Of course, that is relevant—we need to talk about it and fix it. But I'm always much more interested in how communities are fighting for their right to have a healthy and happy birthing experience. Could you share some examples of programs or models that are working really well?
The Irth App is one of my favorites. I love that one because I think about how many times we talk to people, myself included, and folks in my household, who are trying to find a doctor. They have to sift through so much: Who's in my network? Who's in proximity? How far do I have to drive to get to them? Then if you’re a person of color, you're thinking about trying to find a racially concordant1 provider that can speak your language, that looks like you, that you think you can vibe with. The Irth App is like Yelp. You can find providers, but then you can give feedback to other people who are looking. We need that for our people.
My friends at Family Solutions in Orangeburg, South Carolina2, have been providing wraparound services for over 20-plus years, all the way up until, I want to say, two years postpartum. Their model is amazing—like home visits and the way they partner with businesses in the communities to gather supplies and make sure that the women in their area have everything they need for the entirety of their birth journey and postpartum period. They have the WIN network in Detroit3, which has been doing some really amazing things, and is also focused on wraparound services and education across the birth journey. They include fatherhood and the entire “village” in it.
There are some amazing examples out there. I believe that we don't always have to reinvent the wheel on interventions and solutions. We can take a look at what's working and try to replicate it and, more importantly, keep funding these organizations to do this important work. I can't say that enough.
Just to go back to the map for a second. It highlights these very pivotal moments within the maternal health experience. It juxtaposes what's actually happening at the clinical level with what should be happening. Could you walk us through some critical points of intervention? I'm wondering if you could break down where interventions could be made and what interventions can be made to make this experience what it should be. Big question, I know.
One of the things that is top of mind for me is women who are in maternity care deserts. I think about the planning, I think about prenatal visits, and having to take off work, and driving an hour to get there. Then, having to wait for the clinician to potentially not be there because she's at another clinic seeing patients, and how that deters a woman from keeping up with her prenatal visits because of logistics. And then, when it comes time for childbirth, you have to plan to have your labor induced because you don't want to have your water break and then drive an hour to the nearest birthing center.
If you're not in those areas, you're probably not thinking about that. But that's a very real thing, and some of the women told us stories about having to consider them. So, in terms of interventions, we need to keep top of mind that everybody's context and surroundings are not the same. Interventions need to be tailored. You have to pay attention to the needs and the happenings in those respective areas to be able to effectively meet them. Yes, you can take a program or intervention and copy and paste, but there's no guarantee it's going to work because that might not be that community's problem.
In terms of how we turn out more racially concordant providers, I don't really know how to immediately solve this in this day and time, other than to elevate the need—only because the pipeline for people of color going into medicine and specifically OB/GYN is a long one. The necessity, training, and scope of practice of doulas and midwives can absolutely fill the gap for a lot of the mistreatment, the ignoring of pain, and the being treated like a second-class citizen that happens when we step foot in doctors' offices and hospitals.
That's an area that doulas and midwives are stepping up to. It cannot be the sole intervention here, but it is demonstrated that things are significantly improved when those services are present and available. We need much more awareness about postpartum symptoms and screening for them. We need lactation consultants, doula services, and places that women can go to get the information they need, especially as new mothers. We're hearing that women are not feeling like they have a place to go or somebody will take the time to answer their questions. So they often suffer in silence. We have to stop that because the statistics show that approximately 65 percent of deaths happen in the postpartum period, and that’s alarming.
There are interventions across the entire journey that we can look at, but it starts with listening, which is why I love this project so much. If we pay attention and are intentional about what we're trying to do, if we really want to solve this, we can—if we just listen to women and pay attention to what they're saying they need.
What specific policy shifts would you be interested in seeing that would help create a more equitable health system? I know I'm asking these huge sweeping questions this morning, but I am curious: What policies do you think would be beneficial to making the maternal health experience more equitable and happier?
There are so many. Oh my gosh. I think I alluded to this, but how can we train more clinicians of color? I know that's not a policy thing, and that takes so, so long, and with the rollback of affirmative action, that's stacked against us—but that is something that could help. We need to take a look at the criteria of the birthing-friendly hospital designations and hold some accountability to hospitals that have the designation. Imagine if we have a robust criteria for how a maternity ward gets that designation awarded to them, and we hold their feet to the fire to making sure that it's not just some minimal requirement, it's making sure that they're meeting the needs of people, whether it's through reviews or whatever the case may be. And they have to go up for renewal. They have to demonstrate that they have met these criteria.
We need to expand Medicaid. And I know that sounds so backwards when we are threatened with even having Medicaid at all. But I'm coming out with some more work that examines the landscape of postpartum care state by state. A lot of these policies are going to be held at the state level, and we really have to step up with the coverage for services because we hear time and time again that healthcare is unaffordable, and having a baby is unaffordable.
Employers can step up as well in terms of providing more resources, such as paid leave, doula coverage, breastfeeding support, etc., for women postpartum. We heard a heartbreaking story about a woman who had a stillbirth, but because she did not bring home a baby, she was not afforded postpartum care. She had to return to work as normal and still process all of that. And there's nobody there to catch her when she's clearly suffering.
Many people don't understand just how game-changing it would be to expand Medicaid to cover more people. And so many have this idea that Medicaid is just for poor people, and that's unfortunate because that care could really save a lot of lives.
That's true. Forty-one percent of births in the United States are covered by Medicaid. That’s almost half. It would be amazing what people could realize [the point you made], but at this point, we are faced with trying to maintain the status quo. Unfortunately, the five out of the seven states that have not expanded Medicaid are in the South, which, not coincidentally, correlates with where some of the highest maternal morbidity and mortality rates are happening.
I’m interested in hearing more of your thoughts on the South and other states where the politics are not conducive for living a healthy life, which is probably the kindest way I can put it.
I keep coming back to, “We need to pay attention.” I am on the energy of we need to care about women. And, on one hand, you are taking away our rights to have an abortion, but on the other hand, you're not giving us the services, the coverage, the support we need to have a child. Where do we go from here?
It is hard enough as it is to be a woman, to have a baby. But then you layer on regional differences like the South and the Midwest, where a majority of the maternity care deserts are. If you are a woman of color, if you are a black woman, layer that on too. It's complicated, but if people are not willing to pay attention, the energy I am on is that we could have done something about this a while ago if we really wanted to.
What is it going to take for people to pay attention and to put more resources, energy, and effort into building birthing centers in maternity deserts, especially in the wake of hospital closures? Women are feeling this, and they're telling us about it. They're feeling like they have to go it alone. They're out there by themselves. And for all intents and purposes, without the support that they need, they are.
There are people and organizations out here doing the best they can to adjust. But there comes a time when the powers that be are probably not going to do what we need to. This is why lifting the bright spots and organizations that are trying to do something about it as much as we can will probably be where our more immediate solutions are. Doubling down on community-led efforts to bridge some of those gaps in maternity deserts is going to have to be the way to go because I am not confident that the government is going to do what they need to do to be able to bridge these gaps.
Hard agree. What advice would you give to Black mothers and Black mothers-to-be about navigating a healthcare system that isn't designed for them?
I will say I am not a mother, but I'm surrounded by them—some phenomenal Black women who are really out here doing the thing. And we talk about this a lot, knowing what I know about the Black maternal landscape, where I am in life, I have opted not to have children, and pour into the women and children that are here. In the conversations I've been having, what they really love and thrive on is community and being able to open up and share their journeys, their feelings, their frustrations, their highs, and their lows with other women. So I would say building community, not keeping things to yourself, because more often than not, you're not dealing with your journey, your feelings, your questions, your considerations alone.
As an example, as I was weighing whether I wanted to have children or not, I had a vulnerable moment that I shared with another black woman, and she was like, “Oh my gosh, me too.” And I didn’t feel so bad anymore. It's amazing when you open your mouth and say you need help—of course, among trusted people. What can that conversation open up for you both in building community and with resources?
That conversation could lead to, “I know somebody. Let me hook you up with my doula.”
“Let me give you the number to such and such clinic, which does amazing work.”
Then it snowballs from there. That's how we have to take care of each other. So my biggest piece of advice is to listen to your sisters and women, have conversations, build your trusted community, and share your resources with each other. You don't have to go it alone; there are people out there who got you if you're willing to open up.
Thank you for sharing that. As a Black woman who has also decided not to have children, I'm always like, “I can't wait to be so-and-so’s baby's auntie and pour into that child.” So I really appreciate what you said. It is an important aspect of maternal health; it's the communal side of it, where we’re deciding not to have children for the sake of, like you said, pouring into the moms and children who are already here.
Yes, this is exactly what I'm talking about. Sometimes, I feel guilty talking about mothers and motherhood and all of that, but I have been with so many women on their journeys. It is the village. It's the village we have to get back to.
Absolutely. So, what are the next steps in your research, and how can people stay engaged with you and your work?
Right behind this journey map is a state-by-state landscape analysis for the state of postpartum care. It's going to be interactive maps where you can click on and see various themes that have come up. Again, all based on our listening and publicly available data to capture where states stand on postpartum mental health, access to information via perinatal health providers, various coverage areas, like Medicaid, and the fetal mortality rates.
A lot of times, we're not talking enough about late-stage pregnancy. So look out for that.
Continue to check our 100 Weeks website. We are constantly updating information there, and there's a ton of policy-related information and resources there. We're constantly looking for partners in this work. How can we keep listening, keep gathering stories, and keep putting out information for people to keep having these conversations in an effort to build better policy to the extent that we can and find better solutions?
Racially concordant care is when the provider and the patient share the same racial background. Racial concordance mitigates implicit biases in health services. It also fosters trust, healthy communication, and the likelihood of patients following medical advice, thereby improving their overall well-being.
Family Solutions is a program from the South Carolina Office of Rural Health.
The Women-Inspired Neighborhood (WIN) Network: Detroit is a program of the Detroit Regional Infant Mortality Reduction Task Force."