Advocating for Patients of Color as a Labor and Delivery Nurse

Editor’s Note: This article is being updated with new information as it becomes available.

Black pregnant people in the U.S. are dying at rates far higher than non-Hispanic white pregnant people. Maternal mortality is higher in the United States than in any other developed country. What’s more, many of these deaths are avoidable.

An American Journal of Public Health study re-examined the maternal deaths of non-Hispanic Black women from 2016 and 2017. The study found that Black women are 3.5 times more likely to die from pregnancy-related complications than white women. This fact spotlights the racial health disparities plaguing the U.S. healthcare system today.

First, let’s be clear: Maternal deaths are preventable. Why, then, are Black pregnant women dying more than other women? Factors like chronic health conditions, lack of access to health insurance and postpartum care, and systemic racism play a significant role.

Black women need safe care. They also need reassurance they will survive their pregnancy and the months that follow, along with their child. Labor and delivery (L&D) nurses can help by educating pregnant people of color about their risk factors.

This article discusses the risks of maternal death in non-Hispanic Black women, how L&D nurses can advocate for patients of color, and ways to end maternal mortality in communities of color.

Maternal death among non-Hispanic Black women in the United States has been steadily rising. Through the Pregnancy Mortality Surveillance System (PMSS), the Centers for Disease Control and Prevention (CDC) has monitored pregnancy-related death since 1987. They define pregnancy-related death as the death of a woman while pregnant and one year after giving birth.

Between 2014-2017, according to the PMSS, there were 41.7 deaths per 100,000 live births for non-Hispanic Black women, the highest of all races. Non-Hispanic American Indian or Alaska Native women came in second with 21.8 deaths per 100,000 live births, and non-Hispanic Asian or Pacific Islander were third with 13.8 deaths per 100,000 live births.

The risk of death by race/ethnicity is due to many preventable factors. Risks include:

The leading cause of maternal death among non-Hispanic Black women is cardiovascular disease. This includes hypertension, diabetes, and chronic heart disease. It also includes strokes. Cardiovascular conditions account for over half of maternal deaths.

Women are delaying pregnancy. For those suffering from chronic diseases, delaying can put them at a higher risk for maternal mortality. The American College of Obstetricians and Gynecologists identified four additional risk factors:

The lack of access to care in the United States disproportionately impacts:

Access to care affects how many pregnant individuals die due to birth and pregnancy complications. Evidence shows Medicaid expansion contributes to a lower maternal mortality rate, while states without Medicaid expansion have an increase.

Racial and ethnic minority women may benefit from Medicaid expansion. Non‐Hispanic Black mothers had 16.27 fewer maternal deaths per 100,000 live births in expansion states. States without Medicaid expansion continued to have more deaths.

Currently, 50% of all births in the United States are covered by Medicaid. Due to the Affordable Care Act and federal law mandates, most pregnant people are covered by Medicaid more than 60 days postpartum. However, the Supreme Court ruled states cannot mandate Medicaid expansion.

Twelve states have not expanded coverage, and two states have passed but not yet carried out the expansion.

The CDC defines maternal death as death during pregnancy and up to one year postpartum. Maternal death rates have increased, with most occurring after pregnant individuals have given birth. Some are calling this stage after birth the “fourth trimester.”

The fourth trimester is a significant period of health risks. Many do not follow up with their obstetrician or primary care provider for a number of reasons. They include:

For women with higher levels of education and who live in low maternal mortality states, racial and ethnic disparities continue to exist. Research has found that Black women with higher incomes are still more likely to die from pregnancy-related issues than white women. This suggests systemic racism and implicit bias are factors for maternal death among non-Hispanic Black women.

Dr. Peggy Roberts, a board-certified women’s health nurse practitioner, explains that maternal mortality is higher among Black women because their symptoms are often dismissed or ignored. This bias, where Black women are not taken seriously by healthcare providers, was highlighted by tennis champion Serena Williams’ health scare after her pregnancy in 2017.

“In order to address the racial disparities,” Dr. Roberts explains, “the healthcare system must first admit that it exists, provide mandatory implicit bias training for healthcare professionals, and create advocacy committees in the hospitals to address this epidemic.”

Representation among L&D nurses is essential for the successful pregnancy of people of color. Studies show patients receive better care and have better outcomes when their healthcare team is diverse.

Dr. Roberts believes nursing representation is important because of the lack of trust people of color have toward the healthcare system.

“The healthcare team should represent the diverse population in which they serve,” Dr. Roberts says.

Representation among healthcare providers saves lives. Data suggest that Black patients requested more preventive care when their physician was Black. In fact, Black newborns cared for by Black physicians experienced a 40% lower mortality penalty than Black infants receiving care from white physicians, according to a 2021 National Academy of Sciences report.

L&D nurses are the eyes and ears of pregnant people. They are in the best position to advocate for their patients, especially those of color. Ellie Beatus, a family nurse practitioner, was an L&D nurse for more than seven years. She describes L&D nurses as an extension of the pregnant individual. They stay by the pregnant person’s side and guide them to ensure safe delivery.

Keeping the line of communication open for patients of color is one way labor and delivery nurses can help advocate for their patients. Although L&D nurses are with their patients only during and after labor, they can still educate on risk factors, especially those after delivery.

Currently, 40% of women do not keep their postpartum appointments. Building a relationship with patients as an L&D nurse can lead to more follow-up appointments. These appointments offer life-saving prevention during the “fourth trimester,” a significant period of health risks.

To advocate for patients, Beatus says it’s important for L&D nurses to carry out the wishes of the patient. They should monitor the safety of both the baby and patient so both can have a successful outcome.

Dr. Roberts explains that L&D nurses can support patients by focusing on collaboration, even when patients disagree with the plan of care recommended by their doctors.

“It is the responsibility of the L&D nurse to be a liaison between the patient and the healthcare team for the safest collaborative approach,” Dr. Roberts says.

Being a new L&D graduate can be frightening. Not only are L&D nurses caring for pregnant patients, but they are also caring for their unborn babies. New L&D graduates should be able to advocate for and educate their patients on the risk of maternal mortality among people of color.

Dr. Roberts advises staying up to date on the current guidelines and recommendations set by the American College of Obstetricians and Gynecologists and the individual healthcare practice.

“Ask questions,” Dr. Roberts says. “Learn about the adverse cases in your institution, including what happened and what could have been done differently.”

Beatus advises new nurses to take a thorough history of their patients on the patient’s first visit. As pregnancies evolve, it’s important to stay with patients throughout the process to better notice changes and intervene to prevent any negative outcomes.

“Not only is the person in front of you significant, but their previous health history may help identify things that you should monitor a little bit more in-depth through the laboring process,” Beatus says.

Nursing organizations and hospitals are responsible for recruiting labor and delivery nurses of color to increase representation in healthcare and help support pregnant people of color. Governmental changes also need to play a role in preventing maternal mortality in the United States.

The Black Maternal Health Momnibus Act of 2021, co-led by nurse and congresswoman Lauren Underwood, was signed on Oct. 4 by Governor Gavin Newsom of California. Senate Bill 65, the California Momnibus Act, builds on “existing legislation to comprehensively address every dimension of the maternal health crisis in America.”

This bill is created to increase research and data collection on racial and socio-economic disparities. The bill is specific to the higher rates of maternal and fetal death in communities of color, and addresses all avenues that lead to reproductive care in the current maternal health crisis in the United States.

Last month, Governor Newsom also signed Assembly Bill 1356 and Assembly Bill 1184. AB 1356 is a bill specific to increasing access to reproductive care for women in California. AB 1356 is a bill specific to protecting the privacy of patients seeking reproductive care as well as their providers.

How can nurses and L&D nurses get involved?

With 3.8 trillion spent on healthcare, it is unacceptable that maternal mortality rates are higher in the U.S. than in any other developed country. Just as postpartum care is important, preconception check-ups and education should be encouraged.

In the preconception check-up, providers and nurses can discuss conditions such as depression, high blood pressure, and obesity before pregnancy. Preconception check-ups are another way to help advocate for the care and safety of pregnant people of color.