Marie, a longtime Boston resident, entered her second pregnancy fearful and anxious. Her first pregnancy and birth happened during the height of the pandemic. The experience was traumatic and ended with life-threatening bleeding that required an ambulance ride, emergency surgery and separation from her newborn. In the months that followed, she navigated unstable housing and had trouble getting her medications, compounding her recently diagnosed postpartum depression. Her eyes welled with tears as she told her story to her new care team. Her birth care providers had made her feel abandoned and discriminated against, she explained. And because of pandemic restrictions, she couldn’t get enough family support either.
Stories like Marie’s are all too common for Black birthing individuals in Massachusetts. Our state’s prestigious medical institutions draw patients from all over the globe, but many residents who live within a few miles of these same hospitals and research labs experience a very different health care ecosystem.
Despite cutting-edge treatments and near-universal health care, Massachusetts still tolerates a status quo that delivers profoundly disparate access to care and leads to vastly different clinical outcomes based on race and neighborhood. One of the most obvious manifestations of these health inequities is outcomes for pregnant Black women and birthing individuals.
According to preliminary data compiled by the Boston Public Health (BPH) Commission, for every year between 2017 and 2021, Black Boston residents experienced the highest rates of low-birth-weight births, preterm births and infant mortality compared to all other racial and ethnic groups. Since 2017, health outcomes related to infant mortality, preterm births and low birth weight, have worsened for Black residents, despite citywide improvements in birth outcomes.
Despite cutting-edge treatments and near-universal health care, Massachusetts still tolerates a status quo that delivers profoundly disparate access to care and leads to vastly different clinical outcomes based on race and neighborhood.
In 2021, according to the BPHC, the average rate of infant mortality among Black residents was three times the rate for white residents and more than twice the citywide average. Black residents also had the highest rate of low-birth-weight births in 2021 (13.4% compared to the citywide average of 8.4%) and experienced the highest rate of preterm births (13.8% versus the citywide average of 9.2%).
It’s important to note that Black maternal mortality and morbidity transcends socioeconomic status: Wealthy, resourced Black birthing people experience the same fatal outcomes as their low-income counterparts. One national study found that even the richest Black birthing individuals and their babies face two times the fatality rate as the richest white birthing individuals and their babies.
The Black maternal population struggles more than its white counterparts beyond birth, too. In 2020, 35.6% of birthing parents in Massachusetts experienced symptoms of postpartum depression (PPD). Black non-Hispanic birthing parents (16.3%) were more likely to experience PPD symptoms “often or always,” while only 7.2% of White non-Hispanic birthing parents reported the same.
Black maternal health is a public health emergency. In a state rich with medical talent, resources and enlightened leadership, it’s crucial to ask why we tolerate these disparities when we have the means to eradicate them. The answer is embedded in the systemic racism that shapes where we live and our access to green spaces, affordable and nutritious food, and high-quality educational opportunities. The continuum of discrimination in economic opportunity and education that manifests in health treatment and outcomes begins in deep-rooted generational inequity long before Black birthing individuals even become pregnant.
That said, we are beginning to see some progress. Health Equity Compact, a coalition of more than 71 leaders and experts from various racial and ethnic backgrounds representing Massachusetts’ leading health care, public health, business, academic, philanthropic and labor organizations. The Compact plans to promote health equity through statewide policy and institutional reform and introduced An Act to advance health equity on Beacon Hill earlier this year.
Many of the state's leading health care institutions are also helping to model and expand treatments that deliberately address health care inequity in both prenatal and postpartum care for Black birthing individuals. Mass General Brigham’s Birth Partners Program, for example, pairs Black and Indigenous birthing individuals with doulas. (A recent Massachusetts study showed use of doulas to be associated with a 39% reduction in cesarean births, reduced use of pain medication, and increased breastfeeding rates). And the Boston Public Health Commission’s Healthy Baby Healthy Child program and the Boston Healthy Start Initiative, both of which provide early intervention and treatment for symptoms of postpartum mental health disorders in Black birthing individuals.
But there is much more work to be done. The time has come for Massachusetts to eradicate health inequities through actionable institutional and policy changes. We must apply the same innovation, commitment, and shared responsibility that has made our state a national leader to ensuring an equitable future for all of our residents.
Allison Bryant, M.D., M.P.H., is an associate professor at Harvard Medical School and senior medical director for health equity at Mass General Brigham. Liz Miranda is a state senator and the legislative sponsor of An Act to advance health equity. Bisola Ojikutu, M.D., M.P.H., is the commissioner of public health and executive director at the Boston Public Health Commission.