Abstract
Maternal mortality rates in the United States have increased by 58%, unlike 157 other countries where rates have been decreasing over 30 years. U.S. infant mortality rates are, on average, 71% higher than those in comparable countries. 1,2 Rates for Black women are three times higher than those for White women whereas, the mortality rate for Black infants is more than twice that for Whites, a disparity that is wider than it was in 1850. 3 Counter to hypotheses that income and educational disparities are behind the racial differences, babies born to well-educated middle-class Black mothers are more likely to die before their first birthday than babies born to low-income White mothers with less than a high school education. 4
Behind the Numbers
Traditional models of prenatal care have failed to eliminate racial disparities in maternal and infant mortality. These programs are often built on a deficit model, with the underlying assumption that some people, in this case Black women, who are pregnant are deficient in some way and need to be “fixed.”
Strength-based models have been developed that address the social determinants of health, in addition to biomedical factors. Recent publications from the National Academies 5 and the Journal of Women's Health 6 examined social determinants of health related to Black mother and infant morbidity and mortality, including variation in quality health care, underlying chronic conditions, structural racism, and implicit bias. Findings suggest that many preventable maternal deaths result from clinician, facility, and system factors such as inadequate training, missed or delayed diagnosis, delayed or ineffective response to emerging concerns, and poor communication and coordination among clinicians. 1 Chinn 7 concluded that no discussion of maternal health equity among Black women is complete without considering the impacts of historical and current institutional- and individual-level forms of racism and discrimination and the intersection of gender and race.
Rethinking Evaluations
Although there has been increased attention on the impact of societal factors in the current environment, most evaluations of maternal and infant health programs continue to focus almost exclusively on the necessary, but not sufficient, individual-level variable of pregnancy outcomes. They also do not include adequate attention to the impacts of racism on situations, treatments, and the possibility that programs were developed under a deficit-based model.
More useful evaluations of maternal and infant programs, however, apply a racialized lens coupled with culturally responsive and social justice-oriented frameworks, methods, and practices that address inequities and structural factors impacting the lived realities and outcomes of Black women, their families, and the communities in which they live, work, and socialize.
In a culturally responsive evaluation (CRE), the cultural context in which an evaluation takes place is taken into account and requires evaluators to critically examine culturally relevant, but often neglected variables, across the entire evaluation process; a racialized lens pays attention to the ways in which race shapes problem definition and solutions as well as particular groups' access to opportunity. 8 Using a racialized lens in evaluations of maternal and infant programs is necessary since race and racism are often not explicitly considered in examination of these programs, yet it is a relevant issue. To apply this model, issues such as the existence of differential treatment, unequal access, and discrimination must be factored into program development, program implementation, and program evaluation. 8
Conclusion
Evaluators of maternal and infant programs focusing on Black women and infant health should follow a template that comprehensively assesses the program. The template considerations include the following: Pay explicit attention to community and individual issues and the cultural contexts in which the program is embedded. Consider the impact of traditional definitions rigor on evaluations. Traditional definitions of rigor are socially constituted and reflective of mainstream presumptions and social hierarchies in a specific time and place.
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A focus on rigor, without acknowledging its bias, is insufficient for learning what works for different groups in diverse contexts. Collect data regarding the extent to which policies, practices, heath provider attitudes, and messages explicitly or implicitly reinforce stereotypes and differential treatment and outcomes by race. Collect data on environmental and structural factors including differential treatment that can contribute to preventable negative pregnancy outcomes. Document and explore the efficacy of strategies undertaken to repair significant historical mistrust of the health care and social services within the context of maternal and infant health programs; evaluators can accomplish this, in part, by examining the extent to which the program included culturally responsive, community-driven, and anti-racist approaches to identify and address racial inequities and disparities in their efforts to improve maternal and infant outcomes. Collect, analyze, and report findings of maternal and infant health program evaluations in ways that avoid masking racial disproportionalities or disparities that can ultimately impact Black women's experiences and their maternal outcomes.
Evaluations of maternal and infant health programs need to document both program process and outcomes. CRE, implemented through racialized and social justice lens, is an approach particularly suited this work. A racialized lens helps the evaluator correct ways in which race negatively shapes problem definition, program development, and implementation, as well as particular groups' access to opportunity. Relatedly, a social justice perspective continuously places equity at the center of evaluations, with close attention to disparities. Program evaluations from this perspective consider equity, diversity, and inclusion as indicators of program quality. Furthermore, evaluators must continuously reflect on their values, assumptions, and beliefs, particularly those related to race, and how they might influence the planning, implementation of programs, and reporting of outcomes.
Footnotes
Authors' Contributions
Conceptualization, writing—original draft, and investigation by P.B.C. and V.G.T. Writing—review and editing by G.B.
Disclaimer
The views expressed in this article are those of the authors and do not necessarily represent the views of Howard University or the Rutgers Robert Wood Johnson Medical School.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.