In mid-April, nurses in Wichita, Kansas, ratified their first-ever union contracts with two Ascension health system hospitals. The victory followed a similar win in March in Austin, Texas, when nurses at Ascension Seton Medical Center voted to ratify their first union contract with Ascension. Neither success came easily or quickly, say members of (NNU), the country’s largest union and professional association of registered nurses.

“I don’t think [Ascension] calculated on our determination and resolve to get the results we wanted, and our patients needed,” says Marvin Ruckle, NNU member and a veteran nurse who has worked at Ascension St. Joseph in Wichita since 1989, with 24 of those years in the Neonatal Intensive Care Unit. “Our community has been so supportive, coming out to our strikes, bringing us food and water. Workers from all the other unions around the Wichita area — steel workers, UPS, Spirit (airplane factory) — joined us. Most of these people have either been a patient or had family in one of our facilities and they know there needs to be change.

“This (contract) is an incredible step forward for nurses, so we can work with the hospital to make patient care better for our community,” Ruckle says. “But it shouldn’t have taken this long. We were determined, we kept pushing, and all Ascension did was drag out the process.”

One of the nurses’ most significant wins was safe staffing ratios enforceable through a nurse-led Professional Practice Committee. In Austin, hundreds of nurses spent more than a year in contract negotiations and organizing efforts, participating in two strikes to focus attention on their demands including guaranteed lower nurse-to-patient staffing ratios. At all three facilities, Ascension management responded to the nearly 2,000 nurses’ historic one-day joint strike on June 27 with a three-day lockout.

Mission-Driven Ascension

Based in St. Louis, Missouri, Ascension is one of the largest health systems in the U.S., boasting 140 hospitals and 40 senior living facilities in 18 states and the District of Columbia. Becker’s Hospital Review listed Ascension as No. 2 in its 2019 list of 100 of the largest hospitals and health systems in the U.S. and the largest nonprofit health system by hospital count. The nonprofit Catholic health system’s stated mission is to deliver “compassionate, personalized care to all, with special attention to persons living in poverty, and those most vulnerable.”

A deeply researched analysis from the National Nurses Organizing Committee and NNU, “,” questions how closely Ascension hews to that mission, particularly in communities with high poverty rates and a disproportionate number of Black and Latino residents. Ascension, the report states, is one of the nation’s worst offenders in closing obstetrics units and obstetrics services. Over the past decade, Ascension has eliminated obstetrics services at 16 hospitals and slashed more than a quarter of the labor and delivery departments that it had been providing in 2012, a rate three times higher than the national average of 6 percent.

Since 2022 alone, Ascension has closed five maternity wards, all health care markets where Ascension maintains a monopoly or near-monopoly on health services. Half of the hospitals where Ascension closed labor and delivery units are in counties with a higher proportion of low-income residents and people of color, and higher rates of infant mortality than the national average (also known as “persons living in poverty, and those most vulnerable” — see Mission Statement above).

Profits over Patients?

By now, the statistics are familiar to anyone paying attention: the U.S. has the highest rate of death among pregnant women and infants of any wealthy country; maternal mortality is more than 10 times and infant mortality almost double the average among comparably wealthy nations. It is no longer even a nasty secret that Black women are nearly three times as likely to die in childbirth as white women.

As “Dangerous Descent” points out, for the first time in two decades, infant mortality has risen in the U.S., largely due to pregnancy-related complications, which experts attribute to limited access to specialists who deal with complicated pregnancies. According to the Centers for Disease Control and Prevention, more than of pregnancy-related deaths in the U.S. are preventable — and healthcare leaders have a major role to play in improving these outcomes. Tragically, many systems focus their eye most keenly on the fiscal bottom line rather than the fundamental health of their patients.

Hospital consolidation has been on the march over the last two decades, with more than 67 percent of U.S. hospitals now belonging to a larger system, compared to 45 percent in 2000. NNU’s report cites numerous studies that have shown that such highly consolidated markets can lead to price increases and diminished patient outcomes. Hospital corporations say such consolidation creates “efficiencies” that enable them to cut costs. What they don’t say as loudly is that steps such as eliminating and obstetrics services — both major casualties of hospital cost-cutting — also improves their profits. In practice, consolidating labor and delivery limits access to care for many patients in low-income areas who may not have vehicles or good access to public transportation. Increased distance to medical care can result in missed prenatal appointments or an inability of patients to get to the hospital in time to deliver their babies safely.

According to the , more than 400 maternity services closed in the U.S. between 2006 and 2020. Between March and June 2022, 11 health systems announced they were closing their obstetrics services. When birthing units close, obstetricians and nurse-midwives are more likely to go elsewhere, exacerbating the epidemic of maternity care deserts in the world’s largest and most robust economy.

“What was really striking to us,” says Elana Kessler, author of NNU’s “Dangerous Descent” report, “is that this is a mission-driven hospital system under the Catholic church that is to care for the poor and to create a more just society. Their actions are not in line with that mission statement. By closing labor and delivery units in Medicaid-heavy areas with higher proportions of Black and Latino patients, they’re hiding behind their mission while they’re increasing their profits.”

Health reporting news site stated in a 2021 investigation that Ascension, “a wealthy, religious, tax-exempt health system,” had migrated toward behaving like a Wall Street firm, using its wealth to create a sophisticated investment strategy that includes a partnership with the private equity firm, TowerBrook Capital Partners. Ascension stands out from other nonprofit hospitals that have dabbled in private equity investing in the sophistication and expansiveness of its $1 billion partnership with TowerBrook, the STAT investigation found.

On its 2021 federal tax return, Ascension reported that CEO Joseph R. Impicciche received a salary of $13 million. In 2022, the reported that Ascension had spent years reducing its staffing levels to improve profitability even though the chain is a nonprofit organization with nearly $18 billion in cash reserves. At that time, its charity care accounted for 1.9 percent of operating expenses (against a national average of 2.6 percent).

Even with the additional revenue from its investments, Ascension pursued cuts to safety-net hospitals in Washington, D.C., and Milwaukee, Wisconsin, abruptly closing its Labor and Delivery unit in December 2022, leaving Milwaukee’s south side, home to a large immigrant community, completely without a hospital to deliver babies. The move prompted a scorching letter from Wisconsin Sen. Tammy Baldwin, who demanded answers from Ascension on its questionable priorities that funnel cash to its investment funds and executives, putting providers and patients at risk. In her letter, Sen. Baldwin called on Ascension to reinvest its cash reserves in hospitals that serve vulnerable communities and to increase pay and improve working conditions for its “burned out and overextended health care workforce.”

In an April 19 email response to Early Learning Nation magazine, Sen. Baldwin stated that Ascension had replied to her letter. Ěý“While I’m encouraged that Ascension appears to be taking the communities’ concerns seriously and working to rebuild relationships,” she wrote, “I remain concerned that their business practices appear more like a private equity firm than a nonprofit hospital whose stated mission is to serve the public.”

Understaffed NICUs and Obstetrics Units

“It’s been like working in a MASH unit,” Ruckle said, describing his experience in Ascension St. Joseph’s NICU. Mobile army surgical hospitals (MASH) units, which were phased out in the early 2000s, were known for their primitive conditions, grueling work schedules and frustrating lack of resources. As reported in “Dangerous Descent,” nurses at multiple Ascension hospitals have noted the perpetual crisis caused by staffing cuts and equipment shortages.

“It’s heart-wrenching to go home and wonder if you were able to help that critically ill baby as best you could and worry that they aren’t going to have the best outcome,” he said.

The result for nurses can be not only stress and frustration but, according to Zenei Triunfo-Cortez, one of NNU’s presidents, moral harm.

“As nurses, we have an obligation to advocate for our patients, to do what’s best for our patients,” she says. “But the situation we’re being put in, especially Ascension nurses, is that we know we have to do the right thing and are being prevented from doing so because of the situation in our hospitals. Then we suffer from moral injury. Our hearts are breaking because we want to do what’s best, but our employers are not providing what we need to do so.

“We start asking, ‘Is this really worth my health?’” says Triunfo-Cortez, who has been a registered nurse for 44 years. “The majority of our nurses will be out there fighting for our patients and fighting for what’s right, but it does make us question.”

Recommendations from NNU

Pointing out that Ascension enjoys hundreds of millions of dollars in tax breaks thanks to its nonprofit status yet continues its abandonment of low-income mothers, parents and newborns, NNU and the National Nurses Organizing Committee recommend systemic changes that would align Ascension with its mission:

• Come to the table and listen to nurses; staff every unit to ensure the best care for patients.
• Commit to reopening closed labor and delivery wards.
• Provide obstetric services at all new hospitals Ascension opens or acquires.

Ascension has the opportunity and resources to become an industry leader, says Kessler, the report’s author. “As nurses advocating not only for nurses but for the patients they serve, we know that safe staffing and readily accessible care are completely entwined in the work nurses do — they’re one and the same.

“Ascension will say, ‘Consolidation is part of our business strategy. It’s better for the patient,’ but at the end of the day,” she says, “it doesn’t happen that way. It creates barriers for patients to face — transportation, child care — and when there is not ready access to obstetrics services, pregnant patients are less likely to get prenatal care, which then has a cascade of harmful effects.”

´Ą˛őłŚąđ˛Ô˛őžą´Ç˛Ô’s 1 in 50 Report

In late April, Ascension released a in which it reported that one in 50 U.S. babies is now born at an Ascension hospital, no doubt in part to what The Wall Street Journal (WSJ) cited as the corporation’s role as the “most active dealmaker” in its hospitals’ expanding into wealthy areas while shunning poorer ones. Nonprofit hospitals now account for half the $1 trillion U.S. hospital sector. Across the sector, the °Âł§´łâ€™s investigation found, though they receive local, state and federal tax breaks in exchange for providing charity and benefiting communities, nonprofits are less generous in providing aid than their nonprofit rivals.

Though the Ascension report states that its commitment is “rooted in the loving ministry of Jesus as healer” and the 32-page report details positive health outcomes throughout the system, NNU’s Kessler says the report doesn’t tell the full story of how those numbers arrived.

“Outcomes for patients no longer served by Ascension wouldn’t be included in the hospital’s data, so the report is incomplete,” she says, “failing to consider the impact on communities where Ascension has shuttered obstetrics services under the corporate strategy of ‘consolidation.’

“Ascension asserts that one in 50 babies are born in their care, which only underscores the importance of Ascension keeping obstetrics services open for the thousands of expectant mothers they serve each year.ĚýFurthermore, a snapshot of data from one year, in one health system, doesn’t tell the whole story of the impact of ´Ą˛őłŚąđ˛Ô˛őžą´Ç˛Ô’s decision to close services. It should also be noted tĚýcould weigh the data in favor of showing better than average outcomes.”

“There’s a good amount of research looking at associations between the neighborhood environment and various health outcomes,” says Julia G. Carter, lead author on the study, , published in JAMA Obstetrics and Gynecology. “When I was reviewing the literature, I saw a lack of research on the mother’s subjective experience, which is what our study looks at.”

Because individuals who live in the same community can encounter the same environment in radically different ways, Carter says the research team from Northwestern University’s Feinberg School of Medicine wanted to go beyond the data about exposure to crime and other adverse conditions to look at how the mother’s view of her personal safety affected her and her infant’s well-being.

The researchers took their data from the (PRAMS), a project of the Centers for Disease Control and Prevention (CDC) which, along with state, territorial and local health departments, collects targeted, population-based attitudes on maternal attitudes and experiences surrounding pregnancy. The survey asked set questions of respondents in the participating 46 U.S. states, territories, District of Columbia and New York City, which creates data on 81 percent of all live births in the U.S. Individual states have the option of selecting additional questions to deepen their understanding of their own populations.

For their study, the Northwestern researchers analyzed responses PRAMS had gathered from 2016 to 2020 from the states that had asked respondents how they perceived their neighborhood safety.

Eight states — Illinois, Louisiana, Minnesota, Missouri, Pennsylvania, Rhode Island, Virginia and WisconsinĚý — asked respondents, “During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?” Answers were then categorized as always or often unsafe, sometimes unsafe, rarely unsafe and never unsafe. To assess interpersonal physical and emotional abuse, one item asked whether respondents had been pushed, hit, slapped or physically hurt by another individual in the 12 months before they got pregnant. After 1829 exclusions, 29 987 respondents were included in the Northwestern study. Most of the respondents (78 percent) reported that they never felt unsafe. At the other end of the scale, 3 percent said they always or often felt unsafe.

The researchers then analyzed respondents’ birth outcomes including low birth weight, self-reported depression during pregnancy or postpartum, attending more than eight prenatal care visits, attending a postpartum visit, and breastfeeding for at least eight weeks.

After controlling for maternal age, race and ethnicity, and other sociodemographic factors to test the independent significance of perceived neighborhood safety, the researchers found that, compared with respondents who never felt unsafe in their neighborhoods, those reporting that they always or often felt unsafe had nearly 25 percent higher odds of having a low birthweight baby and 100 percent higher odds of perinatal depressive symptoms. The group that felt unsafe had 10 percent lower odds of attending more than eight prenatal care visits.

Although the Northwestern researchers’ cross-sectional study didn’t assess the factors that could determine why a pregnant person might choose not to seek prenatal care, their study cited an in-depth Canadian published in the BMC Journal of Pregnancy and Childbirth that analyzed the motivators associated with inadequate prenatal care among eight inner-city Winnipeg, Manitoba, neighborhoods. Researchers from the University of Manitoba found that, although the women in their study lived in the same group of disadvantaged neighborhoods, psychosocial, attitudinal, economic and structural barriers and a variety of motivators, separated those women who received adequate prenatal care from those who did not. The study highlights the diversity among inner-city women with respect to their experiences with prenatal care and their perceptions of factors that help or hinder them in accessing this care.

Psychosocial issues that increased the mothers’ likelihood of not receiving adequate care included feeling stressed, having family problems, being depressed and worrying that child welfare officials might take the baby. Being abused by their husband or boyfriend also prevented several of the women from obtaining adequate prenatal care. Structural barriers included not knowing where to get prenatal care or having a long wait to get an appointment. Problems with transportation or child care were mentioned by nearly half the women who didn’t receive adequate prenatal care.

The good news, Carter says, is that these factors have policy implications, which means they can be addressed. Solutions are more likely to be found in such initiatives as providing access to social workers who can help with scheduling and follow up, providing mental health resources, or addressing systemic issues such as the lack of bus stops near clinics.

A reverse image of the neighborhood perception study can be found in the paper, “,” published in the International Journal of Environmental Research and Public Health, which looks at the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes.

Researchers from the University of Albany looked at nearly 300 mother-infant pairs in small cities, suburban regions and rural areas in upstate New York. The neighborhoods were analyzed according to the (COI), a multidimensional indicator of a neighborhood’s favorable social, environmental and educational community attributes. The study, the first to analyze the COI in association with pregnancy health and birth size, demonstrated that positive neighborhood attributes cumulatively contributed to healthy pregnancies and favorable birth outcomes.

While the idea that better neighborhoods make for better health may seem like a foregone conclusion, the contrast among the studies underscores an important point. The factors that give one neighborhood a high COI score and make other neighborhoods a source of fear and concern for mother and child, are all malleable and subject to change.

In their neighborhood perception paper, the Northwestern researchers point out that social and economic interventions that combat neighborhood and domestic violence may be more beneficial in reducing adverse pregnancy outcomes than biomedical interventions. Reducing expensive, often counterproductive police crime-prevention initiatives and mass incarceration in favor of resources that strengthen low-income communities may go further to create a sense of safety not only for pregnant people, but for the entire community.

“The main question,” Carter says, “is what are we going to do about it? That is outside the scope of our study, but assessing the situation is the first step in having this conversation. There are still a lot of steps to make improvements and develop solutions.

“With these social determinants of maternal health, the truth is, there’s no quick fix. But to have the data and the commitment to collectively do something about it makes a big difference.”

Further Reading

ĚýChildren from neighborhoods perceived as unsafe by parents engaged in one less day per week in physical activity. Children from neighborhoods perceived as unsafe were less likely to use recreational facilities compared with children from neighborhoods perceived as safe, and children from less affluent families across rural and urban areas had half the odds of using recreational facilities compared with children from the wealthiest families living in urban areas.

Neighborhoods can be a potential source of psychosocial stressors associated with childhood asthma. Parents who perceive their neighborhoods as sometimes or never safe reported asthma at higher rates than those living in neighborhoods parents perceived to be always safe.

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn’t. Rather, it’s a reflection of the program’s limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

“Medicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it’s beneficial, it isn’t as good as private insurance,” says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. “Babies don’t get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn’t suffer because of their parents’ socioeconomic status.”

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, “,” was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality — almost half the rate of mothers with Medicaid — as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study’s first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

“From a biological standpoint for the fetus, that first trimester is when organogenesis occurs,” Johnson says. “The other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs — all the organs — are formed. It’s also a time for recognizing the mother’s baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.”

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don’t allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy — at a time when the clock is ticking for both mother and fetus.

“One of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they’re delayed in their prenatal care, or they haven’t received adequate care in those first months. They’re already behind,” she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

“Here in Alabama, a lot of our population is very rural,” she says. “Some must travel great distances to receive healthcare. When you’re trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

“A lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.”

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, “,” in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes’ 2022 report, “,” finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care — a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain — though not entirely — why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don’t receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and — a serious neonatal illness most common in premature babies, especially NICU babies who don’t get human milk.

Lifesaving Alternatives

These negative outcomes don’t have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers’ access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child’s first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person’s doctor and local providers to care for mother and child throughout pregnancy and the child’s first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

“Race is largely a social construct,” Travers says. “Increasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.”

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother’s socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients —a subject for future study, the researchers say.

The results reflected in these studies don’t point to Medicaid’s failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

“The draw of pediatrics for us as doctors is that when we’re working with children, we can lay the foundation for them to have healthy and successful lives,” Johnson says. “But if you don’t lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. Ěý“We’ve now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.”

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Child-related tax credits are typically modest in size, but the studies found that for low-income families, receiving this boost sooner rather than a year later can have all sorts of benefits: persistent higher family income, fewer dealings with the child welfare system, improved academic performance and increased earnings for children turned adults. The research is part of an emerging understanding of the first few months of a child’s life as a pivotal window for boosting low-income families and possibly children’s social mobility, a period where even relatively small cash transfers might be “changing something fundamental about family structure and well-being that has long-lasting consequences,” said Katherine Rittenhouse, an economist at the University of Texas at Austin and an author of one of the studies, in a 2023 interview.

Economists have long regarded family income during a child’s early years as a kind of Magic 8 Ball, the time when economic deprivation can predict a host of disparities that threaten to endure or deepen with time. But few studies have been able to pinpoint why: Is it simply money that makes the difference? Or is it something more murky, like differences in parenting, or neighborhood environments and schools?

For families with babies, tax data offers an elegant way to isolate the impact of receiving extra cash during a child’s first year of life. That’s because infants born in, say, December of 2023 can be claimed on this year’s taxes, providing parents with extra income through tax credits this year. But for babies born just a few days or weeks later in early 2024, parents must wait a full year to receive child-related tax credits. This creates a natural experiment that allows researchers to compare the impact of extra cash on families and children who are similar in all ways except one: some received child-related tax credits when their babies were a few months old, and some waited until their children were at least 15-months-old to receive the money.

In one such study published in 2020 in the reputable , researchers scoured federal tax data spanning four decades along with state-level education data to determine that low-income families who received the tax credit during their first babies’ first year, as opposed to later, had higher family earnings which persisted. Andrew Barr, a professor of economics at Texas A & M and an author of the study, said this suggests that something about receiving the credit during a child’s first year of life supports parental employment. (The study focused on low-income parents with first-born babies.)

The effects of extra cash during infancy were even more pronounced for the children. Children whose families received the child-related tax credits sooner went on to have higher reading and math scores, and lower suspension rates and higher graduation in school. Possibly as a result of those academic gains, the researchers speculated, their earnings were found to be 1 to 2 percent higher as young adults, and continued to increase as they aged.

The authors concluded that the tax credits not only paid for themselves through increased tax income, but delivered more bang for the buck than even the famed Perry Preschool Project of the 1960s, which was also found to boost participants’ future earnings, but cost far more per participant while serving a very small number of children.

In a different study using similar methodology, Rittenhouse of the University of Texas at Austin used California birth records to determine that for low-income families with first born children, tax credits received during a child’s first year appeared to prevent child welfare involvement, which is strongly linked to poverty. , Rittenhouse estimated that for low-income families, receiving a one-time cash transfer of $1,000 during the first few months of a firstborn’s life as opposed to a year later led to four percent less involvement with child protective services during the first three years of life and six percent fewer days spent in foster care. The effects endured until at least age 8, which is the last year studied. “Increasing payments to families during the first year of a child’s life may pay for itself in terms of reduced long-term maltreatment costs,” Rittenhouse wrote.

In both studies, the average tax credits amounted to less than $1,500, which researchers said likely made little difference to families’ lifetime earnings. But they did make up a sizable percentage of a family’s yearly income — roughly 10 percent in one study — which economists believe is key to their effectiveness.

After all, the months following the birth of a first child comprise a uniquely vulnerable, influential time of transition for families, one when “stress is high, expenses are increasing, and working is physically difficult or impossible for new mothers,” as Barr and his co-authors explained in the study.

Because of this intensity, the first year of life is also a time when a lot can and often does go very wrong. The Survey of Household Economics and Decision-Making identified a child’s first year as a time when parents reported being financially worse off and denied credit. The first year of life is also the age when a person in the U.S. is most likely to experience homelessness and also to enter foster care.

The chronic stress stemming from adverse events like these may be especially harmful during a child’s early years, when a child’s brain grows most rapidly and consistent, positive relationships with caretakers are particularly important to healthy development.

Even a little more cash during this tenuous time of transition may go an unusually long way to protecting financially strapped families from derailing, potentially devastating events like eviction or unemployment, which can snowball. “It’s when an extra few thousand dollars can have a big effect,” said Rittenhouse.

Take reliable transportation — something many depend on to work. One study found that more than 40 percent of families who received the earned income tax credit for low-income families have a major car repair within six months of filing taxes. For some, that extra cash from the tax credit could be the difference between having a way to get to work, or not. “Having what might seem a modest financial buffer might be enough to allow [parents] to repair their car, and maintain connections to the workforce, and keep things going in a way that results in better outcomes for them as a family and then the child as well,” said Barr. “This one-time transfer kind of allows you to somehow keep your job, or get a job or do better at your job.”

Recognizing the pivotal nature of a baby’s first year, other developed countries invest in infants by providing paid family leave for parents to bond with babies and by funding child care. For decades the Finnish government has sent expectant families filled with toys, clothes and even a mattress that transforms the cardboard box it arrives in into a crib.Ěý

Here in the United States, where we have none of this, a handful of pilot projects have been trying to make the case for no-strings-attached cash to new mothers. Since January, all mothers in Flint, Michigan can receive $1,500 while pregnant, plus $500 a month for the first year of their baby’s life. Meanwhile, researchers conducting , in New York City, and Baby’s First Years are studying the impact of cash on new mothers and their children. Baby’s First Years is particularly interested in measuring child .

Projects such as these are often small and, for the time being, focused on potential short-term effects of cash transfers. By contrast, the tax studies offer compelling, large-scale, long-term evidence that investing in infants pays off big. “We now have strong evidence that providing income or welfare supports during early childhood improves the outcomes for kids throughout their life course,” said Rittenhouse.

Black women experience in maternal care, including . The medical racism that Black women experience contributes to disproportionately high rates of maternal mortality. Just look at the stats: Black women are -related causes than white women according to the Centers for Disease Control and Prevention (CDC). Shockingly, the CDC also reports that of pregnancy-related deaths are preventable.

Numerous studies show that . While their roles are different, both doulas and midwives offer vital support before, during and after birth that can combat the Black maternal health crisis. Midwives are trained medical professionals who provide prenatal care, monitor physical and emotional health, and perform labor and delivery in a variety of settings including hospitals, homes and birthing centers. The midwifery model of care is holistic and client-centered, and . Doulas are advocates that ensure clients’ needs are respected, and they make active, informed decisions about care. Doulas can create birthing plans, offer techniques for pain management during labor, and provide continuous physical and emotional support. Their presence is proven to improve maternal health outcomes and .

Being paired with a birth team that is reflective of background, values and culture is important, and helps to build trust and contribute to more equitable care. For Black women, that connection can be lifesaving. Yet, and according to some estimates .

Niambi Bloom (LSW) is one of only two Black birth doulas in Colorado Springs. She first discovered this maternal care desert while searching for her own doula during her first pregnancy. She found only one Black doula based in Denver, more than an hour away. Ultimately, she chose a local doula and had what she describes as a “textbook home birth” where she was surrounded by a midwife and a doula who she felt genuinely cared about her. Bloom chose to become a birth doula to help positive birthing experiences like her own become the norm. She also wanted to give other Black women what she did not have, care from a Black doula. Bloom now helps to lead training sessions about maternal health disparities to new groups of prospective doulas. It was during one of these sessions that Bloom met a Black woman who was training to become a doula in Colorado Springs. Now, the two work together but still have not found other Black birth doulas in the area. According to Bloom, “It’s just us.”

Building a more diverse maternal care workforce is essential to providing more equitable care, and it’s a necessary component to combating Black maternal health disparities, but there are barriers that prevent both recruitment and retention of Black birth workers. Tyla Leach, a labor and delivery nurse and childbirth educator, believes a major barrier is the sheer amount of money, time and energy it costs to become trained and remain in practice. A found that almost all doulas find their work to be emotionally fulfilling, but few consider it to be financially rewarding. According to Jazmin Williams, a full spectrum doula and the Founder of , “Birth work is not a revenue-based service. It is not a revenue-based profession. We aren’t getting rich off supporting our community…But we know the necessity of having a doula that is reflective of your background, reflective of your culture that knows how to become an advocate with you… to amplify your voice rather than talk over for you.” She added, “We do provide a lot of sliding scale assistance and I’m pro bono, but we also have families of our own and that’s how we came into practice, so we really have to look at our care pricing that is also sustainable for us.”

The for their work. Most private insurance providers and Medicaid programs do not cover doula care, which often means clients can pay up to thousands of dollars out of pocket for these services. The CDC, estimates that over . Failure to include Medicaid coverage for doula care makes a vital resource to combat maternal mortality largely inaccessible for those who are most at risk. A growing number of states are pushing for Medicaid reimbursement for birth doulas to address the problem. According to , “the goal of Medicaid coverage of doula care [was] threefold, according to advocates: support people who are giving birth, provide culturally congruent care and compensate doulas fairly for their work.”

Necessary Policy Change: How They Did It

In 2022, Washington lawmakers passed to establish birth doulas as a health profession in Washington state, creating a process for state certification and thus a pathway for Medicaid reimbursement. The success of HB 1881 is as a national model for how legislators should directly involve and advocate with birth workers.

• The , a Queer, Trans, Black, Indigenous and People of Color-led (QTBIPOC) organizing group bolstered by , was instrumental in the creation of the bill and worked in lockstep with legislators to lobby for its passage. Members of the Coalition shared their perspectives to ensure the bill combats harm, addresses community concerns, and that the certification process does not shut out doulas who are already practicing.
• They were instrumental in creating a certification process that is voluntary, meaning doulas who choose not to become certified are still able to practice and support their communities.
• They also advocated for a competency-based model for certification and training that values ancestral knowledge, and differs from courses offered at large certification organizations that have historically .

Sage Maenad Kissiah-Grove, a member of the Coalition, and a birth and postpartum doula, credits HB 1881 with establishing and opening up the certification process “for people who come from all kinds of backgrounds in birth work, people who have been trained ancestrally, people who have self-trained and people who have not trained through these big organizations.” She added, â€œFor their training to be from people who look like them and who have their same experiences is huge.”

Washington State Senator T’wina Nobles, a Black woman and mother of four, worked alongside the Doulas for All Coalition to rally support for the legislation and to create a clear pathway for its passage in the State Senate. She believes that doulas “really are the leaders” in this work, and that people who are most impacted and most connected to birth work deserve their voices to be heard. Nobles sees herself as an amplifier who focuses on “allowing the experts, the doulas and midwives and folks who do the birthing work, to lead and let me know what they need.”

This year, Nobles plans to introduce legislation that builds on the success of HB 1881 with Senate Bill 6172, which will allow birth doulas up to $4500 in Medicaid reimbursement rate, the highest in the country.

What’s Next?

Federal Way Birth Center celebrated its grand opening in November. For Faisa Farole, it is just the beginning. She envisions a future in which FWBC will serve as a community hub and provide support beyond childbirth. â€œI want the center to be not just a place where we are providing mentorship to aspiring Black midwives, but also a place where the community can come and get lactation education and childbirth education,” said Farole.

She added, “I want it to be something that the community is using, and not a place where the doors are closed.” She also sees the center working in collaboration with nonprofit organizations who support BIPOC (Black, Indigenous and People of Color) communities, and she already has spoken with the about teaching in the space.

Farole is also the founder and executive director of (GPS), a nonprofit that provides free community-based doula services for Black, immigrant and refugee families. She also has trained more than 100 doulas who combined speak more than 17 different languages. She sees her own nonprofit working closely with the center, and offering GPS clients the option to give birth at the center if they choose. Farole is optimistic about the future of her center, as well as other initiatives that will help more Black women “answer the call” and provide vital support for their communities.

Jazmin Williams was fortunate to be on a Black birth team with a Black birthing person, Black midwife, Black doula and a Black pediatrician. “It’s rare to have an entirely Black birth team…It’s an incredible experience and one that I’m thankful for,” said Williams. “It fills my heart to know that is possible, and that we can do that.”

All Black women deserve a birthing experience where they feel respected, their choices are honored, and their lives are protected. There is beauty, joy and strength in birth, and those experiences should be the norm. What is happening in Washington is cause for celebration and hope. We can support Black birth workers and center them in legislative advocacy. We can build a more diverse maternal care workforce and ensure doulas and midwives are paid living wages. We can save the lives of Black women and create safe, healthy birthing experiences that are rooted in empowerment instead of trauma.

The Federal Way Birth Center is the first Black owned freestanding birth center in Washington state. It is the first of its kind, but hopefully it will not be the last.

It depends.

• Can incarcerated people be shackled during labor? It depends.
• Can women breastfeed or pump after delivery? Will anyone see to it that their infant receives this milk? It depends.
• Are pregnant people in custody with opiate addiction given medical assistance to detox, or are they left to go cold turkey on their own? It depends.
• Can an incarcerated woman have access to an abortion? It depends.
• Are pregnant, birthing and postpartum people treated with dignity and humanity while behind bars? It depends.
• Do we even know how many pregnant, birthing or postpartum people are behind bars in the U.S.? Actually, that answer is a straightforward No.

Whether incarcerated pregnant people have adequate nutrition, access to obstetric care or even such necessities as maternity clothing depends on what state they’re in, whether they’re in a prison or jail (more on that distinction later), and sometimes simply on the whims of jail staff or local sheriffs and deputies.

According to the , the capriciousness of reproductive care for pregnant, birthing and postpartum pregnant people in custody comes to us via a patchwork of decentralized and overlapping criminal legal systems throughout the U.S. comprising thousands of federal, state, local and tribal systems that together incarcerate more than 2 million people. Around 173,000 of that number are women or girls, primarily people of color, mostly young, and most arrested for non-violent offenses. The U.S. has the highest number of incarcerated people in the world and is second only to Thailand in the number of women behind bars.

Until recently, the pregnancy status of these incarcerated women had not been updated for decades, making it impossible to say with any certainty how many pregnant people were behind bars, how they were being cared for and the outcomes of their pregnancies. The federal First Step Act of 2018 now requires the U.S. Bureau of Justice Statistics to collect data on pregnancy outcomes from federal prisons, but no such requirement is in place for state prisons and jails. Any data at all on the thousands of women in local jails is spotty to nonexistent.

In 2019, Dr. Carolyn Sufrin, a national expert and advocate for reproductive care for incarcerated women, and her multi-sector research team at Johns Hopkins University School of Medicine and School of Public Health published , a significant study that collected data from 2016 to 2017 from 22 state prison systems, the Federal Bureau of Prisons, six jails and three juvenile justice systems, representing 57 percent of females in prison and 5 percent of those in jail. The study found that at any given time, 3 to 4 percent of females were pregnant when they entered U.S. jails and prisons.

An obstetrician-gynecologist with a doctorate in medical anthropology, Sufrin ran a women’s health clinic for six years as an OB-GYN at the San Francisco County Jail before going to Johns Hopkins. She found that the hard data she needed to study maternal health, including pregnancies, miscarriages and abortions behind bars, didn’t exist. She launched the initiative that became the PIPS study, the first-ever systematic study of pregnancy outcomes for women behind bars in the U.S.

“Part of why we know so little is that, as a society, we’ve just ignored these women,” Sufrin says. “We either pretend they don’t exist, or else people believe it’s such a small number of women, ‘Who cares?’ But how do we know it’s a small number unless we study it?

“There’s a saying, ‘Whoever isn’t counted doesn’t count,’ so the lack of data signifies how little we care about pregnant people, especially those at the margins of society.”

As the PIPS project concluded, Sufrin founded the (ARRWIP), which continues to conduct research on reproductive health care issues among incarcerated women. She says she became committed to this specialty as a first-year OB-GYN resident in Pennsylvania when she delivered the baby of a woman from the local jail who was shackled to the hospital bed throughout labor and delivery. Until that moment, she writes in her excellent book, “Jailcare: Finding the Safety Net for Women behind Bars,” like most Americans, she had given little thought to the idea that there were pregnant people behind bars, nor the complicated reality of that fact.

Shackles and Health Care

If the idea of shackling a pregnant woman in active labor seems medieval — or cruel and unusual punishment at the very least — welcome to large swaths of the U.S. Despite well-established medical risks, as of July 2023, only 40 states, the District of Columbia and the federal government have banned restraints in labor and delivery; some have banned the practice at other points in the pregnancy and postpartum period. In Maternal and Child Health Journal, November 2022), authors Camille Kramer et al. report that pregnancy policies and services in prisons and jails vary widely, with little consistency in compliance with anti-shackling legislation even in states where it’s banned. Most facilities station an officer inside the hospital room during labor and delivery, and nearly a third don’t even require that it be a female-identifying officer.

Though state prison systems hold twice as many individuals as jails, the PIPS study reports that more women are held in jails than in state prisons, a statistic that carries profound consequences for these women and their families. The distinction between prison and jail is that prisons are long-term confinement facilities the federal or state government monitors, often by an entity the government contracts. People in prison typically have been convicted of a felony and sentenced to one or more years. Jails are short-term facilities managed by a local or county government. More than 60 percent of women held in local jails have not been convicted of a crime and are awaiting trial, often because they can’t afford bail. A whopping 80 percent of women incarcerated in the U.S. are mothers, and most are their children’s primary caretakers.

The 1976 Supreme Court ruling in Estelle v. Gamble established health care as a constitutionally protected right for incarcerated people, but it didn’t prescribe mandatory services, standardization or oversight, creating the present system of health care roulette for those behind bars. Providing care for incarcerated women presents multiple unique challenges for any institution; caring for pregnant women in custody significantly raises the stakes. Pregnancies are often unplanned and complicated by a lack of prenatal care, a woman’s neglected health before incarceration, maternal trauma, poor nutrition, substance abuse, mental illness, limited social support and low socioeconomic status — all in a correctional system designed for men.

Post-Dobbs Pregnancy Behind Bars

Before the Supreme Court’s ruling in Dobbs V. Jackson Women’s Health, access to abortion already varied widely from state to state and among prisons. After the Court removed the constitutional right to abortion, the choices for pregnant incarcerated women have become even more precarious. Sufrin’s research found that even in states where abortion was legal, some prisons and jails had either official or unofficial policies that prevented incarcerated women from accessing abortion.

Under Roe v. Wade protections, incarcerated pregnant individuals at least had a constitutional right to abortion just like everyone else in the U.S. Despite this guarantee, abortion was not accessible to many in custody. Post-Dobbs, things are likely to get worse for those who are pregnant behind bars.

“We don’t know yet the full impact of the Dobbs decision because it’s hard to study this population,” Sufrin says. “But abortion access for incarcerated individuals was already constrained. How much this is going to impact abortion access in restrictive states is still to be determined.

“What I’m more concerned about is the ripple effect this is going to have on other aspects of pregnancy care in custody. We’ve already seen in abortion-restrictive states like Texas that non-incarcerated people brought to the hospital for obstetric emergencies like bleeding from a miscarriage or their water breaking early are being turned away from care where an abortion procedure would save their lives. They’re turned away because of how the law is written or because physicians fear what might happen if they misinterpret it. Women are basically being told to come back when they’re at death’s door.

“I’m concerned about the impact on incarcerated pregnant people with complications because they will be sent back to prison, which is ill-equipped to handle obstetrical emergencies. We’re likely going to see more pregnant individuals overall in the United States who are going to be sicker, and that may also be true in custody.

“None of this has been studied, so these are just hypotheses.”

When Jail Means Safety

Though it may not be intuitive, Sufrin says the “thorny reality” is that jail can improve outcomes for incarcerated pregnant people and their infants and can increase their chances for successful reintegration into the community. Jail is the new safety net, she writes in “Jailcare.” Women in jail represent one of the most marginalized and vulnerable groups in society. Indigent, addicted mothers too often can only access prenatal care behind bars. Though not all jails provide an environment that supports these women, those that do offer medical and prenatal care, treatment programs, improved nutrition and the relative stability that they’ve lacked can provide a safer, healthier alternative to the lives these women experienced on the outside.

Make no mistake, Sufrin says. Jail is still a place of punishment. The fact that it’s better behind bars for some people than being in the community isn’t so much an endorsement of jail as it is an indictment of our abandoned and ineffective social systems that have broken down and utterly failed these people relegated to society’s sidelines.

“That the system of incarceration has become an integral part of the country’s social and medical safety net is peculiar to the U.S.,” she writes, “and represents one of its greatest tragedies, the whittling away of public services for the poor coupled with an escalation in the number of jails and prisons with custody of that same population.”

“It’s still jail,” she says.

Now, reading Jennifer Banks’ “Natality: Toward a Philosophy of Birth,” I have some insight into why. It wasn’t just about avoiding unpleasantness, mentally putting our hands over our ears to shut out the world (though, judging by the number of wine glasses seen in our Zooms, there was plenty of that as well); it was that we needed some creation in our lives. Amid all that death, we needed birth.

Birth is humanity’s greatest unexplored subject, Jennifer Banks writes in her excellent “Natality: Toward a Philosophy of Birth.” Banks, a senior executive editor at Yale University Press, begins to explore the subject by looking back at humanity’s earliest writings, where, in 2300 BCE, the first identified author sang hymns to the goddess of childbirth, linking birth to creativity, divine powers and her hope for change in the world. In Banks’s introduction — which, for my money, by itself is worth the price of admission — the author writes that birth, for all its recurring presence in the written record, has played second chair to death as humanity’s defining experience. Mortal creatures who wrestle with our own mortality, we are born and then pffft let birth recede into memory, “to that forgotten realm where uteruses, blood, sex, pain, pleasure and infancy constellate.”

In flipping the script, Banks writes that birth is immense, that birth has existential, moral and theological significance at least as great as death. “What does it mean that the greatest power humans have had—the power to create another human being — has been relegated in nearly all periods and all places to a secondary status, turned into a task to be performed by an underclass of people assigned that task on account of their gender?”

The book isn’t a paean to some sentimental or idealized image of motherhood — which, as Banks writes, can be “superficially championed but deeply undermined by mothers’ cultures” when it comes time to pay the bill for the maternity ward, offer maternity leave, feed the mothers’ children or come up with child care. The book is instead an investigation of birth itself — not just childbirth, but birth as creation and creative renewal; an embrace of life and the recognition that each of our births indelibly shape not just our own lives but human life itself. In a provocation that is both wide-ranging and deep, she asks for a set of principles different from the “death-drive that runs deep in Western societies,” imagining a culture less reconciled to its own extinction, “rooted in gestation, intimacy, vulnerability, growth, creativity, reciprocity, change and otherness.”

Banks explores the idea of birth through the works of seven prominent Western thinkers: Hannah Arendt, Friedrich Nietzsche, Mary Wollstonecraft, Mary Shelley, Sojourner Truth, Adrienne Rich and Toni Morrison—who have wrestled with the idea of birth in their own eras and shaped our understanding of our own humanity. She offers their thinking as a powerful antidote to the nihilism with its fatalism, paralysis, cynicism and despair that are the “prevailing features of 21^st century life.”

Hannah Arendt knew a thing or two about nihilism and despair. Born in 1906 in Germany to a family of left-leaning, prosperous Jews, a circumstance that ultimately would see her stripped of citizenship and belonging, with her simple right to exist taken away. During her childhood years while she was running outdoors, reading books and “blithely singing off key,” she and her family were being turned into the “scum of the earth — an undesirable” by anti-Semitic propaganda.

Arendt had been interested in birth before the war, writing that birth and “the miracle of our creative beginnings” are what shape humans and give us our capacity to act creatively in the world. After the war, despite surviving years of unimaginable loss and betrayal, she continued to engage with the idea of birth, now as less of an existential concept than a political one: creative renewal as an act of resistance. She wrote of the connections between birth and freedom and found one English word to encompass that thinking: “natality,” the “miracle that saves the world,” one that decades later gave Banks the central theme for her challenging book.

Arendt’s writings after the war are her attempts to process that cataclysm — how the people she had grown up among and loved had turned against her and her people. Banks’s rich chapter on Arendt could easily be overlaid onto much of our contemporary world. Alienation from one another, dehumanization, racism, cynicism the “fateful repudiation of Earth the Mother” — all fertilize the totalitarian impulse that thrives when people come unmoored from each other. Humanity’s capacity for action, for new beginnings and an embrace of the world repudiate that impulse for tyranny.

Banks gives each of the seven thinkers their due, spending time with each one as she explores their views on birth and their demonstration that each person “in simply being born, creates an opportunity for history to begin again.” She writes of Nietzsche calling for the end of what he saw as the Protestant enchantment with the afterlife toward the earthly, embodied life that comes after birth and imagining a new spiritual tradition embracing birth, life, creativity, sexuality and procreation. Wollstonecraft, with her “soul most alive to tenderness,” recognizes the contradiction of birth’s importance to society and how little value is placed on it. Shelley, with her “Frankenstein: Or, The Modern Prometheus,” created the hideous monster “a motherless human life engineered by ambitious male inventors.”

Banks describes how often Sojourner Truth repeated the phrase “care for one another” in her narrations, and her view that a woman giving birth is a “cosmically significant” event, with women as actors capable of changing their worlds. American poet Adrienne Rich saw birth as a source of human power, sacredness and mystery, but critiqued the institutional motherhood that grew up alongside capitalism and its beneficiaries — a legacy some might say explains why we can’t move the needle on getting child care today. Birth was an integral part of Toni Morrison’s artistic vision, from her first novel to her last, and Banks writes that her era, which saw the confluence of the women’s movement, the fight for racial justice and the postwar years produced one of the “richest periods in the history of writing about birth.”

Life is under threat in the 21^st century, Banks writes, but birth is constantly with us as well. Like Arendt, who had born witness to the Holocaust of neighbor slaughtering neighbor, still never lost “a shocked wonder at the miracle of Being.”

“Natality: Toward a Philosophy of Birth” is not an easy read. It takes some willingness and effort, especially for those of us not familiar with the thinkers whose work Banks shares. But in that it provokes us to think of natality — of birth, creation, nurture, belonging and care — as the antidote to dehumanization, nihilism and despair, it’s an important and beautifully written read.

The service is growing in popularity because it has been shown to make a dramatic difference in the birth experience for mothers, babies and families. A U.S. Department of Health and Human Services report published in December found that doula services drastically improved maternal health outcomes.Ěý “Doula-assisted mothers were four times less likely to give birth to a baby with low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding,” the report states. According to the , the one-on-one emotional support provided by doulas has been shown to reduce cesarean births, help shorten the duration of labor and improve the rate of spontaneous vaginal birth.

American mothers need all the help they can get. Though rates of maternal deaths have been declining in most countries, the U.S. has the of any industrialized country in the world, and the Centers for Disease Control and Prevention reports that “stark and unacceptable” racial and ethnic disparities persist in this maternity crisis. A large body of research suggests that doula support is a promising strategy to mitigate these disparities.

Medicaid each year — roughly 1.5 million births — and among the CDC’s policy recommendations to address America’s maternity crisis is to extend Medicaid coverage to make sure that no one in this country dies because of pregnancy. Because states have some discretion in how to use their Medicaid funding, some have begun following the evidence and offering doula services as a benefit to their enrollees.

Michigan has now become the latest state to reimburse doula services for individuals covered by or eligible for Medicaid insurance, joining 15 other states that have done so or are in the process of providing this benefit. In taking this step, the Great Lake State has made it possible for the approximately 45,000 Michigan Medicaid enrollees who give birth each year to access the gift of childbirth assistance that for years has been a luxury enjoyed by those who could pay for the service out of pocket or had great insurance.

Though Michigan has made strides recently in improving maternal and infant health, it still suffers from one of the nation’s highest infant mortality rates, with infant deaths among its Black and Native American communities more than double those among white infants. Black women in Michigan are three times more likely to die from pregnancy-related causes than white women — in keeping with similar national disparities.

To address these inequities, Gov. Gretchen Whitmer launched her initiative, allocating millions of dollars to improve birth outcomes and support birth equity. As part of this initiative, Michigan expanded Medicaid coverage for a full 12-month postpartum period, providing access to critical physical and behavioral health services, dental care, treatment for substance abuse, and more throughout the first year after pregnancy.

In January 2023, Gov. Whitmer announced that announced that Michigan would begin supporting expecting mothers by covering doula services for Medicaid enrollees. In making the announcement, Gov. Whitmer stated that a whopping 63 percent of maternal deaths in Michigan are preventable. (Michigan is by no means an outlier in these numbers: The in 2020 that more than 80 percent of pregnancy-related deaths from 2017 to 2019 in the U.S. were preventable.) To powerfully impact that situation, the state has put together a comprehensive program, a sort of one-stop shop that will spread the word about doula services, build the workforce, and provide ongoing resources and support for Michigan’s doulas.

A Solid Platform for Success

Doulas practiced in Michigan before the launch of the initiative, says Dawn Shanafelt, director of the Michigan Department of Health and Human Services Division of Maternal & Infant Health, who is leading the . “But with the program, Michigan will have a central location where families that have Medicaid insurance can find doulas available in their communities.”

The initiative also provides a registry for doulas that offers webinars, training and continuing education, as well as for enrolling as a Medicaid provider and guidance on billing for doula services through Medicaid. To become a provider, individuals must have completed Michigan Department of Health and Human Services-approved (MDHHS) training, and they can find these approved programs on the website. The initiative provides scholarships for those who want to take the training and become professional doulas — a strategy that both builds the workforce and offers economic opportunity within local communities.

A key component of the program is the Doula Advisory Council comprising 29 individuals, all doulas from across the state who represent the diversity of Michigan’s communities, Shanafelt says. The council will work to promote advancement of doula services statewide and advise the MDHHS on policies, applications and resources, as well as providing advice on content for continuing education and reviewing training programs to ensure they meet Medicaid requirements.

The health department is hiring two doula specialists to work with Shanafelt’s division to serve different geographic areas of the state. She says one of these specialists has been hired — a doula with 22 years’ experience — and a second is on the way.

Medicaid policy includes a maximum of six doula visits during the prenatal and postpartum period, plus one visit for labor and delivery in a hospital setting. The flat reimbursement rate is $75 for each of the six visits, plus $700 for attendance through labor and delivery.

A stumbling block for states accessing Medicaid funding for doula services has been the requirement by the federal Centers for Medicare and Medicaid Services that doula services must be recommended by a licensed healthcare provider. To address this, Michigan’s chief medical executive Dr. Natasha Bagdasarian has issued a standing recommendation that doula services are medically necessary and should be offered to families covered by Medicaid insurance.ĚýIn her recommendation, Bagdasarian wrote that doula services should be offered “immediately and on an ongoing basis to Medicaid recipients until such time as determined no longer necessary.”

Results Speak Volumes

Since professional doula services were first offered in 1970s, friction has existed with the medical community, with some doctors and nurses viewing doulas as encroaching on their territory, or just one more body to get in the way of their efficiency during labor and delivery.

“The way to change the mindset regarding who’s a part of the care team is by seeing excellent outcomes,” Shanafelt says. “By seeing that the patient or birthing person’s well-being improved by having a doula as part of their care team, attitudes change.

“Having the American College of Obstetrics and Gynecology recommend having an emotional support person such as a doula present because it is associated with better outcomes for women in labor makes a difference,” she says. “Doulas have been serving birthing persons for decades, even hundreds of years, so this isn’t a new concept. The difference is the recognition of the value and importance of the doula profession.

“The shift is partly a result of the research that’s been published (about the benefit of doulas), but most importantly, it’s come from listening to families. Families tell us what works best for them. They’re the experts. So, if you listen to the experts, you’re going to hear time and time again that doulas make the difference.”

RESOURCES

• , a nonprofit organization connecting Black families to certified Black doulas throughout the U.S. The maternal mortality rate among Black womenĚý, according to the Centers for Disease Control and Prevention (CDC).
• Survey of medical literature demonstrating significant benefit for birthing parents and their infants, notably for Black patients

FACT CHECK

• (Journal of Law, Medicine & Ethics)

Here are 5 top takeaways:

1. Racism is at the root of health disparities. Not all U.S. mothers and babies go through the same experiences in the same way. The infant mortality rate among Black newborns is more than twice that of white babies during the first year. Mothers of color die during childbirth more than three times as often as their white peers. “Racism is the root of where racial disparities begin,” said Sanchez Lloyd — whose work is an initiative of First Steps Kent.

Contrary to the hypothesis that economic circumstances can explain the gap, a conducted by the National Bureau of Economic Research shows that household income plays no role in determining maternal and infant health outcomes. Increasingly, these disparities are recognized as a problem with implicit biases within health care and other systems.

2. Educating physicians and clinical care workers is paramount. Required lessons and tools to investigate personal biases, power and privilege improve the quality of care. Recommended measures include using proper pronouns, pronouncing names correctly and appropriately addressing questions to fathers and other caregivers in the room.

Sanchez Lloyd explained that clinical workers need to “add more humanity and see the entire patient, beyond what is written on their chart.” These efforts make mothers feel they have a voice to advocate for themselves effectively. In addition to educating clinical partners, it is important to engage family and community support systems.

3. Fathers should be in the fold. “We want to break this narrative that Black fathers don’t exist or that they are not present.” Sanchez Lloyd said, “Continuing to approach this from a maternal child health standpoint, we’re leaving out a key ingredient: fathers.”

Outcomes improve when fathers are involved because mothers feel more supported. “You don’t have to be in a romantic relationship with the mother of your child to be a great dad,” she said. Strong Beginnings’ , covers unconventional topics historically left out of fatherhood and recently went virtual. The lessons range from family planning, and prenatal to 18 months after delivery. They ensure fathers feel supported by offering access to mental health therapists and other community resources.

4. Nonclinical, community support is essential. “Community-based prevention strategies help avoid hospitalization and long-term chronic illness,” Spencer explained. “We need to ensure that people have access to the resources they need,” such as housing and a living wage.

Community health workers and doulas are also part of the systemic response. “Community doulas provide physical, emotional and educational support to pregnant and postpartum people up to the first year of birth,” Spencer explained. “They are a reflection of the community. When people are assisting others in the community that they belong to, we tend to have better outcomes.”

5. Some states are making strides. States play an influential role in the implementation of effective, high-value maternity services, particularly through insurance regulations. Medicaid is the health insurer of over 40% of births in the United States and 66% of all births to Black mothers.

Virginia recently became the fourth state to reimburse doulas under their Medicaid program. As of Jan. 1, the Michigan Department of Health and Human Services recognized doula initiatives as being reimbursable. Several other states are in various stages of consideration, planning or implementation of Medicaid doula reimbursements. “There are some gaps, and doulas have shown that they can be present in those gaps, which leads to successful deliveries,” Sanchez Lloyd said.

But for Easton — and so many women around the country — things did not go as planned. She suffered postpartum depression, which made her return to work difficult. And when she did return and ask for reasonable accommodations for pumping breast milk, she was directed to pump in her supervisor’s office, in front of a window overlooking the main room, in plain view of other mail carriers.

Easton complained, but still used the room, keeping her back to the window. When her route changed and she switched offices, she made the same request: she needed a place to pump milk. “My shift started at 7:00 a.m.,” she explained. “By 1:00 p.m., I really needed to pump.” Her supervisors suggested she pump at Target or in the post office bathroom, and finally her supervisors gave her the option to pump in the basement.

I first interviewed Charnae Easton for a piece in Working Mother Magazine, published in 2021 before the magazine closed down (Working Mother no longer has online archives available). Easton had been right to push her employer to make reasonable accommodations — both for pumping and while pregnant on her mail route. She received compensation for their wrongdoing. But at the time, there still were not federal laws to protect pregnant and breastfeeding women for reasonable requests, including a location to pump breast milk.

Until now. In an 11th hour move as part of the $1.7 trillion , Congress included language that closes gaps in current law through the , guaranteeing space, time and privacy for nursing workers in all jobs. Prior to the passage of the PUMP Act, an estimated of working age were excluded from current nursing mothers’ provisions. Like Easton, their only recourse would be to have a sympathetic supervisor, or pursue legal action. In addition, the omnibus included the , a measure to allow pregnant people the ability to request reasonable accommodations at work. This can include anything from carrying a water bottle, taking breaks, allowing a cashier to sit in a chair instead of standing, or be exempt from carrying heavy items. As my Better Life Lab colleague, Vicki Shabo, explains in her : “This is a right other people with temporary physical limitations have had for years.”

PWFA and the PUMP Act were created to close a loop in the two pieces of federal legislation tasked with protecting the basic rights of pregnant women — the Pregnancy Discrimination Act and the Americans with Disabilities Act. In 2012, Dina Bakst of A Better Balance, a national legal advocacy organization, spelled out this problem in a : those two laws, as written, did not allow for accommodations in the workplace, since pregnancy itself is not considered a disability. After the 2015 landmark Supreme court case, Young vs UPS,Ěýaccommodations for pregnant women would be required, but only if the pregnant woman could find someone in their workplace with a comparable situation.

Researchers at A Better Balance what happened to pregnant women who sued their employers. Through their legal analysis, they found that overwhelmingly it was the lack of a comparable employee that meant pregnant women were denied accommodations and lost their case. “The standard was not working under PDA and workers were losing out,” said Sarah Brafman, the national policy director at A Better Balance.

A Better Balance, along with PWFA coalition co-chair groups — the American Civil Liberties Union, the National Women’s Law Center and the National Partnership for Women & Families — began growing the coalition of people calling for a change to the law. Momentum grew on the state level, with 30 states and 5 localities passing their own version of PWFA. But an unusual ally appeared in support of the legislation — business owners and Chambers of Commerce. “These gaps in the law meant that there was a lot of confusion for employers, and it led to litigation and conflict — expensive conflict. They wanted and needed clarity,” explained Brafman. Pregnant women were being pushed out of jobs, or leaving of their own accord, over requests for modest accommodations and confusion about what was required.

And while the job turnover also contributed to higher costs for employers, who had an incentive to retain capable employees, Brafman also points out that when women are pushed out of the labor force during pregnancy, it can be very hard to get back into the workforce.Ěý“The economic consequences can snowball for years,” she said. Such discrimination disproportionately affects the lowest wage workers and women of color, further exacerbating the discrimination and economic hardships they are already facing.

Both pieces of legislation appeared as amendments in the omnibus, a “nail biting experience” that Brafman said the coalition wasn’t sure would come to fruition until the last moment. The PUMP and PWFA bills had passed the House in October 2021 and May 2021, each with overwhelming bipartisan support of the Senate committee in May 2021 and August 2021, respectively, and it had taken community efforts and business community support. Additionally, 125 working mothers from 42 different states who had personally experienced pregnancy discrimination published a letter as a to bring PWFA to the floor for a vote. Similar advocacy efforts by groups that include the U.S. Breastfeeding Committee and many others, was required to get the PUMP Act over the finish line.

“It boiled over, it couldn’t be ignored anymore,” Brafman said. “The pandemic really awakened Congress to issues that working families were facing.”

But the work is far from over. “Passing the new federal law is the beginning, not the end,” says Brafman. An education and advocacy campaign will begin to work with employers, workers and the EEOC to educate people on why this law exists and how it can accommodate pregnant women. Employers need to understand how to comply with the law, just as pregnant women learn about their rights to basic accommodations, as enforcement mechanisms are put in place.

As with any other drastic legislative changes, it can take time to fully realize the effects. The bill provides protections for pregnancy, childbirth, lactation, related conditions, even allowing workers the ability to change their schedule for prenatal or postnatal appointments.

“This is a landmark civil rights bill. It is one of the biggest updates to our civil rights law in decades.This is a maternal health measure that will level the playing field for workers of color,” said Brafman. “The consequences of this will be very far reaching.”

“State leaders need to be prepared to do big things,” urged Executive Director and Founder Cynthia Osborne. The PN-3 team compared the progress of the 50 states and the District of Columbia on five policies that the evidence says are most effective at creating the conditions in which young children thrive, along with six strategies that help them get there.

States have different priorities and political contexts, and according to PN-3, “the level of resources a family has available to meet their basic needs varies substantially, from nearly $47,000 per year in the District of Columbia, to less than $23,000 in Georgia.”

“Federal dollars are needed to level those differences out,” ’s Elliot Haspel stated. As filter through the states and then dry up, sustainable revenue sources are needed. “Politicians aren’t taking it seriously enough,” Haspel said.

Here are our 5 top takeaways:

1.  Five states are five-for-five. Connecticut and Washington State joined California, Massachusetts, New Jersey and D.C. in implementing all five policies deemed most effective:

• No new states adopted and fully implemented Medicaid expansion this past year, but 11 of the 12 remaining non-expansion states introduced legislation to do so.
• ĚýParticipation in SNAP among those eligible has risen in recent years but still varies considerably by state.
• Only 56% of workers qualify for the federal Family and Medical Leave Act, and the policy largely benefits higher-income and white workers.
• Currently, 31 states have a minimum wage that is higher than the $7.75 federal level, with D.C., California and some cities already at or above $15.
• (EITC). According to , this is the most effective anti-poverty policy for children, compared to SNAP, Temporary Assistance for Needy Families (TANF) and state child tax credits. Currently, 21 states have a refundable state EITC of at least 10% of the federal credit.

2. PN-3 identified six strategies that states are using to boost equity:

• Specifically, the report mentions Developmental Understanding and Legal Collaboration for Everyone (; an initiative of the Center for the Study of Social Policy), and (a ZERO TO THREE initiative).
• , which, according to PN-3, “may allow more parents to work or complete education and training programs, and may support healthy child development when care settings are high quality and stimulate children’s early brain development.”
• Group prenatal care, exemplified by , a program running at approximately 350 sites across more than 40 states.
• , including traditional and virtual models, which proliferated during the pandemic.
• which can be based in a center or the home, providing nurturing and responsive relationships and improving the physical and mental health of parents.
• for infants and toddlers with disabilities or developmental delays.

3. The pandemic changed everything. Businesses, governments and families are all still managing the fallout from COVID. The child care sector, in all its various forms, is undergoing a workforce crisis that hits low-income families especially hard. Haspel noted that the price of child care is rising “faster than inflation, even in this inflationary era” and called for “permanent, dedicated and significant funding.” Hawaii state senator , noted that the unemployment rate there skyrocketed when tourism cratered. She has advocated for Medicaid expansion and a refundable, permanent state EITC as well as a Child Wellness Bill that would provide incentives for checkups. “COVID changed work,” said , state senator of the Maryland General Assembly, who shared that becoming a father reconfirmed his commitment to paid leave.

4. Change doesn’t happen overnight. The panelists described the process by which legislation is proposed and debated in the states. Once it finally passes, implementation can take years. Bipartisanship can accelerate change. , state senator of the North Carolina General Assembly, belongs to the Republican Party. “Every child,” he said, “should have the opportunity for a healthy birth and a great life.” He mentioned Medicaid expansion as a policy solution he supported, stipulating, “Medicaid should be robust but temporary.”

5. Business leaders should wield their influence. member Bridgette Roman quoted Nelson Mandela: “Our children are our greatest treasure. They are our future. Those who abuse them tear at the fabric of our society and weaken our nation.” , state senator of the Colorado State Legislature, concurred that the business community has an important role to play on children’s issues. , state representative of the Louisiana House of Representatives, credited for its advocacy.

focused on solutions for the perinatal phase, which goes from pregnancy through the first year postpartum. Nine innovators presented, then a roundtable zeroed in on Colorado’s recently passed package of birth equity bills, which highlighted how social entrepreneurship can drive policy innovation.

Promise Venture’s Vance Lewis, senior program manager and Awara Mendy Adeagbo, head of strategic initiatives) moderated the virtual event. Adeagbo referred to her personal health journey on the way to giving birth to her baby son last year, saying, “Having a positive birth outcome should not be a matter of luck. The maternal and infant health crisis… is unconscionable and it’s preventable. We can turn this tide by centering the perspectives, experiences and needs of BIPOC communities in a strength-based, holistic way.”

Here are our takeaways from :

1. The history is shameful. , Black moms are dying at 3 to 4 times the rate of their White counterparts. The statistic is the product of a long history, from slavery and Jim Crow through the disinvestment and policy choices of today. In recent decades, politicians and the media have, in essence, blamed the victim through a narrative that questions mothers’ decisions.

According to Kiley Mayfield of the , this focus on individual behavior has distracted us from systems of oppression that have been in place throughout the nation’s history. Marqi Taylor, founder of Philadelphia’s called out “centuries of racial malpractice” that have led us to the point where people of color often don’t trust the medical institutions where they live, which is why activists have formed alternative communities.

2. Birth centers and doulas listen to women and birthing people. ’s mission is to develop “abundant community birth infrastructure.” Safe, culturally relevant midwifery, explained Leseliey Welch, improves maternal health outcomes and reduces the number of caesarean deliveries. Char’ly Snow of said birth centers not only save lives, they reduce insurance costs by $2,000 per birth.

The solution isn’t expensive technology but rather caring, trusting relationships. Twylla Dillion of and Tia Murray of made similar arguments for birth doulas who help women navigate the experience, advocate for them and make them feel supported.

3. Data counts—but what kind? Echoing Lewis, who cited the human right to “maintain personal bodily autonomy,” Kimberly Seals Allers, of (that is, the word Birth minus the B for Bias) declared, “Bias-free care should be a human right.” Describing the Yelp-like app for pregnancy and new motherhood, Allers asserted, “Community-driven feedback loops lead to more respectful and equitable maternal and infant care.” Tracy Warren of made the case for better data informing decisions in government and by institutions.

4. Let communities lead. On July 6, the State of Colorado signed a groundbreaking establishing basic human rights standards in perinatal care for all people (including those who are incarcerated), aligning perinatal care data and systems for equity and continuing the Direct-Entry Midwifery program. (According to the , a Direct-Entry Midwife is “an independent practitioner educated in the discipline of midwifery through apprenticeship, self-study, a midwifery school, or a college/university-based program distinct from the discipline of nursing.”)

Show+Tell celebrated the work of , which championed the package. Founder and director Indra Lusero stressed the importance of listening to community members and letting their priorities dictate strategy.

5. Stay tuned for further progress. Activists and advocates continue to push for local and national solutions. Joy Spencer of talked about building dignity through income supports where paid parental leave is missing. Led by Alma Adams (D-NC) and Lauren Underwood (D-IL), the U.S. House of Representative’s Black Maternal Health Caucus recently unveiled the . The legislation aims reverse the tragic history of BIPOC perinatal health through targeted public investment.

In light of the after over 17 years, the editorial team and other contributors shared their reflections, an overview of the journal and its . Isabel Sawhill, senior fellow at Brookings, moderated the discussion among the following panelists.

• Robert Doar, president and Morgridge Fellow in Poverty Studies at the American Enterprise Institute
• Chris Wimer, co-director of the Center on Poverty and Social Policy at The Columbia School of Social Work
• Darrick Hamilton, Henry Cohen Professor of Economics and Urban Policy and founding director of the Institute on Race and Political Economy at The New School
• Diane Schanzenbach, director of the Institute for Policy Research and Margaret Walker Alexander Professor of Human Development and Social Policy at Northwestern University
• Tim Smeeding, Lee Rainwater Distinguished Professor of Public Affairs and Economics at University of Wisconsin-Madison

Below are our top three takeaways from the presentation.

1.Ěý Paid maternity and family leave matter. Journal editor Anna Aizer said, “Over half of U.S. mothers with infants are employed, and yet we lack a national paid maternity leave policy.” The U.S. is an outlier compared to European countries, though eight states have developed maternity leave policies.

“Paid maternity leave results in fewer premature births, increased on-time vaccination and reduced diagnoses of ADHD [attention deficit hyperactivity disorder] among school-aged children,” Aizer said, “The lack of access to paid leave to care for family members in an emergency this past year has harmed both family outcomes and economic recovery efforts.”

2. Income support is essential. For families with little savings and no income source other than employment, a loss of a job or work hours can trigger loss of child care, housing and health insurance. The absence of money can potentially compromise important child development processes and outcomes. Wimer said, “From the family stress perspective, it can compromise parent mental health, increase stress and increase harsh parenting.”

proposes to improve stability and support young children through the crisis and beyond. Smeeding explained, “Both the Future policy brief and The National Academy Report push for more subsidized child care, extending the child tax credit to all families to be paid monthly and a higher earned income tax credit (EITC).” Hamilton said, “If we want to, we could reduce the work requirement of EITC and literally eliminate poverty and expand the EITC phaseout all the way up to middle income, so as to lift more families up to middle class.

3. Stability promotes healthy development. Aizer said, “Poverty is the main determinant of instability in a young child’s life.” Before the pandemic, 17% of young children were living in poverty.

After acknowledging the pandemic and the emergency situation that we must respond to, Doar said, “I do have some concern of taking this situation and using it to develop big, significant, long-term changes that we will live with after we’re passed the pandemic.” He added, “I’m not comfortable with a big increase in the tax credit that isn’t explicitly attached to work,” citing concerns of long-term diminishing returns for families and the labor force. “I want to be in a place where we’re reducing child poverty, and I think that requires a combination of employment and assistance.”

While parents are working, it is key that they have access to high-quality child care. The pandemic has been devastating to the whole industry’s infrastructure. While diagnosing the damage and advocating for rebuilding, Schanzenbach said, “Keeping the role of caregiving along with economic resources for young children front and center is key.”

If Dr. Catherine Monk and her research team have their way, these visits soon will routinely include high-quality psychological interventions as well, based on researchers’ growing awareness of the effect mental and emotional stress during pregnancy can have on the mother’s health and the baby’s brain development.

Monk, professor of medical psychology in the Departments of OB/Gyn and Psychiatry at Columbia University Irving Medical Center, directs the department’s research laboratory, where a team of researchers focuses on the earliest influences on children’s development by connecting perinatal psychiatry, developmental psychobiology and neuroscience to study child development in utero.

Their research increasingly underscores the direct links between a mother’s psychological and emotional wellbeing, and changes taking place in her developing child’s brain.

As one strategy to help women and prevent mental health risks for their future children, Monk leads a new integrated care program, Women’s Mental Health @Ob/Gyn, that embeds mental health care practitioners within obstetrics and gynecology, and employs all the tools at their disposal to help reduce stress levels in their pregnant patients.

Adult psychiatric illness and mental health issues such as depression are known to be profoundly affected by the genes a person inherits and by the quality of care they receive as a child. Researchers now know a pregnant woman’s stress, anxiety and depression can create a “third pathway” for mental health concerns, Monk says.

The precise mechanism of the damage to the child’s neural development isn’t fully known, but numerous animal models and epidemiological samples indicate that distress-based changes in pregnant women’s biology are associated with negative cardiovascular, metabolic and psychological effects in their children. The release of cortisol, adrenaline and other stress hormones creates a chemical stew that can alter the brain chemistry of the fetus: Reduce the mother’s stress and lessen the harm to the developing child.

Though the womb is a baby’s first home and as influential as any they will ever have, researchers are just getting started probing its mysteries. “About 20% of pregnancies end in miscarriage, which is usually in the first trimester. Is that because of such a big stress effect that the baby doesn’t make it?” Monk says.

“The second trimester is a time of phenomenal brain development, but the synaptogenesis (the development of neural circuits) really peaks in the third trimester. In the third trimester, we start seeing early births, and stress possibly plays a role in those. We are in our infancy in terms of parsing out which trimester is particularly relevant to what exposure.”

One dramatic effect that is known about stress — and that illustrates its profound influence in utero — is that fewer male babies are born to women who are physically and psychologically stressed. On average, about 105 males are born for every 100 female births, but one study Monk and her colleagues conducted measured 27 different indicators of psychosocial, physical and lifestyle stress, and found that about a third of the women were experiencing “clinically meaningful” high levels of mental stress and sub-clinical levels of physical stress. Among these women, the male-to-female birth ratios were dramatically altered, 40/60 and 30/70, respectively.

After social upheavals such as the 9/11 terrorist attacks, the relative number of male births decreased, Monk says. Studies have shown that males fetuses are more vulnerable to adverse environmental conditions. This suggests that highly stressed women are less likely to have male babies because they lose the pregnancy, often without even knowing that they were pregnant.

“Many researchers want to study women who are pregnant during our current, very stressful period,” she says. From the COVID pandemic itself to job losses, loss of health insurance, concerns about family members, changes in hospital labor and delivery policies, a woman’s inability to have her caregivers with her for the birth or with her at home afterward, the Year 2020 wins the stress sweepstakes for just about all of us, and especially so for pregnant women. What this will mean for babies born during this time will bear close watching — and interventions whenever and wherever they can be made.

Despite the fact that 10 to 15% of women in the U.S. experience depression in pregnancy or postpartum — and up to 30% when substance abuse and anxiety are factored in — most pregnant women encounter barriers to accessing mental health services. Most insurance companies don’t cover behavioral health care or do so adequately, so women have to go outside their network for it — if they are able to get it at all. The consequences are not only devastating for the depressed woman and her developing child, they are costly for society.

Important Interventions

Monk emphasizes that, though prenatal stress has these effects on the developing child, it isn’t in itself a life sentence for the baby. Important interventions such as regular obstetric visits that keep a close eye on the mother’s blood pressure, weight and other health indicators can make a big difference, as can making sure the woman receives adequate nutrition and supplemental vitamins, particularly iron and zinc.

The care and warm interaction both a mother and baby receive during the postpartum period can also go a long way toward mitigating prenatal harms. As it turns out, social interaction is good medicine for both mother and child. ĚýĚýĚý

The good news is that none of the prenatal and postpartum interventions Monk and her team recommend are massive, intrusive or burdensome. Their Women’s Mental Health service deploys two psychologists, two social workers and two psychiatric nurse practitioners — one of whom is a doula — to meet their pregnant patients’ emotional and mental health needs.

Another intervention is called (Practical Resources for Effective Postpartum Parenting), which Monk describes as “very light-touch” — six sessions in which a coach prepares women for the postpartum period with mindfulness tools so they can find groundedness and calm when they need it. We provide education about what to expect with their baby coming, and provide a lot of tools for them to feel confident in being able to take care of the baby.

“The mother’s calm can then help the baby be its calmest self, too.”

Monk says the pandemic has required that these PREPP sessions now be conducted via telemedicine, but that has created a silver lining in showing that even prenatal visits can be successfully conducted through smartphones. This is especially important for women who are economically, socially or geographically disadvantaged — which all too often means women of color.

As with other effects of intergenerational stress and poverty, Black women and other women of color are disproportionately affected by both physical and psychological stress, which makes interrupting the pattern particularly important. Even families that don’t have computers at home usually have a smartphone, so the ability to reach these women through telemedicine opens up a whole new arena of accessibility for populations without access to the internet.

Though social distancing is one of the primary keys to controlling the spread of coronavirus, following distancing orders during these times can be especially difficult for pregnant women. Family and friends should never underestimate their ability to stay connected and make a dramatic difference simply by calling, Zooming, FaceTiming and using technology in whatever ways they can to provide the social support that is so essential for a woman during her pregnancy and in the postpartum period.

Monk says her intention is that the Women’s Mental Health @Ob/Gyn project will serve as a model for embedding mental health care into America’s obstetric practice nationwide and eventually pave the way for including behavioral health services in primary care settings more generally. When families are able to access counseling and psychotherapy as easily as they can get a strep test or cholesterol screening, that will be one giant step for a healthy — and mentally well — human future.

Sabra Bell remembers what it was like to be pregnant and low on funds. “Extra cash would have been useful,” she says. “I would have paid off my debts and bought a nice stroller, crib, breast pump, baby clothes and more.”

Today, Bell and other mothers are drawing on their personal experience in their work as researchers on the Abundant Birth Project, an ambitious pilot seeking to reduce the incidence of premature birth in San Francisco.

Starting in 2021, the program will distribute a monthly income supplement of $1,000-$1,500 per month to 100 low-income black and Pacific Islander pregnant women. Payments will continue for the duration of a woman’s pregnancy and then for the first two months of the baby’s life.

Kara Dukakis, an early childhood development senior program officer at , which is one of the pilot’s funders, champions the Abundant Birth Project for the way it explicitly acknowledges racism as a factor in these women’s lives. “An incredibly important part of the pilot is that women of color are hired to be the researchers,” she says. “Because they have lived the experience, they can truly empathize with the women the project supports.”

Maile Chand, another researcher who has “been there” herself, adds, “Not only will this financial opportunity help San Francisco black and Pacific Islander families better provide for their children, but it will also transform the emotional and physical state mothers are in going into their birth.”

The Science Behind the Project

The Abundant Birth Project is grounded in both science and respect for moms. Thanks to advances in medical science, premature babies have a far greater chance to survive and thrive than ever before, but it’s still ideal for a pregnancy to last 40 weeks, or close to it. Cognitive deficits and physical disabilities frequently accompany preterm births, and black women give birth prematurely, as white women.

“The strain of ongoing financial insecurity,” says Dr. Zea Malawa, director of Expecting Justice, “contributes to chronic stress and is associated with premature birth. Although San Francisco has programs to address poverty, they are not enough to close the gaps. The high rates of preterm birth experienced by the black and Pacific Islander community require a more urgent and upstream intervention.”

The Abundant Birth Project builds on of Jackson, Mississippi, which distributed $1,000 monthly for 12 months to 20 women. , was found to help women to improve their nutrition, prepare for baby and engage in self-care to moderate the effect of stressful life events. Reduced incidence of low-birth-weight infants and pre-term birth also resulted.

Free Money? What’s the Catch?

There is no catch.

Unlike conditional cash transfer programs, which distribute money only when subjects adhere to certain behaviors (for example, attending school or visiting the doctor), the program commits to awarding stipends without stipulation.

“Most public assistance programs have complicated eligibility requirements,” says Deborah Karasek, a researcher with the at the University of California, San Francisco, which is partnering with on the Abundant Birth Project. “However well intentioned, these requirements often prevent black and Pacific Islander pregnant women from obtaining the resources they need—and they tend to exacerbate mistrust in the system.”

The Abundant Birth Project, in contrast, provides direct, unconditional cash aid—returning to women the power to make their own decisions.

Pregnancy can simultaneously bring great joy and acute stress. Even for mothers with a steady partner, financial resources and robust social networks, this time can be overwhelming, even traumatic. Pregnant women without these assets are susceptible to mental and physical health threats—and this is before a new person suddenly enters the picture, demanding food, attention and medical care.

The Abundant Birth Project won’t make everything right for the moms and babies it touches—but it’s a start.

Among African American mothers and babies, the crisis is even more acute. Across the income spectrum, from all walks of life and all levels of education, Black women die from preventable pregnancy-related complications at three to four times the rate of non-Hispanic white women. The death rate for Black babies is twice that of infants born to non-Hispanic white mothers.

The (CAP) reports that African American mothers are twice as likely to have an infant who dies by the baby’s first birthday, and are twice as likely to experience life-threatening pregnancy-related complications known as severe maternal morbidity (SMM), compared with non-Hispanic white women. Although other women of color — notably American Indian, Alaska Native and some Latina communities — also experience an appalling increased risk of poor outcomes, data show that racial disparities between Black women and non-Hispanic white women are the most glaring.

In the U.S., a pregnant woman’s health, her baby’s ability to thrive, survive and even her own chance at life, depend to large degree on her race and geography, says , senior policy analyst for early childhood policy at CAP. An CAP released late last year analyzed vast racial disparities state-by-state in infant health outcomes throughout the nation in both infant mortality and low weight birth.

“As more research has come out over the years, one thing becoming increasingly evident is that these disparities in maternal and infant mortality are mostly rooted in racism,” says Novoa, who authored the issue brief for the report. “The reason we can say this is that, even when you control for social-economic status, education or access to resources, all those factors, we still see that Black women and infants have worse health outcomes on average.” Racism — not race itself — and the systemic barriers fueled by both explicit and implicit bias are the drivers of these outcomes, she says. Structural racism compromises health.

In CAP’s state-by-state analysis, geographic disparities are stark; racial disparities are starker. For example, white babies born in New Jersey die at a rate of 3.4 deaths per 1,000 births, which is comparable to Germany’s infant mortality rate. But Black babies born in Wisconsin are dying at nearly five times this rate: 15 deaths per 1,000 births — a rate higher than that of Syria. With , users can explore the infant mortality rate and the percentage of babies born at low birth rate by race, ethnicity and state to see where and for whom the infant health crisis is most severe. Available data show estimates for five demographic groups: white, Black or African American, Hispanic, Asian or Pacific Islander, and American Indian or Alaska Native, and users can compare two groups to see how outcomes differ by race and ethnicity across states, except in some states where the sample sizes were too small to yield precise estimates.

What Birth Weight Really Measures

A baby’s weight at birth is a major determinant of their chance at surviving and thriving in life. Low birthweight is defined as when a baby is born weighing less than 5 pounds 8 ounces; babies are considered premature if they are born before 37 weeks’ gestation. Though some low birthweight babies are healthy, and some are born small because their parents are, many others have serious short-term health problems that need treatment, such as trouble eating, gaining weight, staying warm enough and fighting off infections. Low birthweight babies can have breathing difficulties and later development difficulties. Again, in the U.S., race has a distinct impact on an infant’s birth weight, with nearly twice as many Black infants being born at a low birth weight as non-Hispanic white babies.

, a pediatrician and senior fellow for the , stresses that low birth weight in itself is neither a death knell nor destiny. With plenty of medical, family, nutritional and other supports, underweight and premature babies can recover and thrive, particularly given the almost miraculous developments in recent years in neonatal care. But when that preventive care and those needed interventions don’t come into play, he says, the result can be a dangerous vulnerability that affects brain development, brain function and a variety of physical issues for the child’s lifetime.

“Unfortunately,” he says, “when a small, premature baby is born into an environment of stress and poverty, we have ‘double jeopardy.’” If you have low birth weight and, simultaneously, a context of, poverty, family stress, discrimination, insecurity and insufficient nurture, then unfortunately, that double jeopardy grows exponentially — 1 + 1 = many more than 2 — meaning it’s additive into future vulnerabilities. The majority of time, if the environment is strong, supportive, simulating, safe and secure, there’s a lot of natural recovery, resilience and healing capacity for a low birthweight baby. But that’s not the usual story.

“And then, unfortunately as this vulnerable child does not experience a strong and supportive environment of relationships, their development falls off its trajectory and is increasingly more difficult to bring back on track,” Willis says.Ěý “In our current culture, once a child falls start falling off track, there are too many forces, attitudes and belief structures that make it very hard to recover — not the least of which is often insufficient treatment services. If you have a 4-year-old child who is struggling, has trouble paying attention because his environment is stressed and there’s not been enough attention to nurturance and building essential capacities, the stressed and unsupported child may start ‘acting out’ in pre-school and get kicked out. And that begins a spiral toward greater and ongoing difficulties. From the family standpoint, they’re worried about his/her future. From the child’s standpoint, he is developing his behavioral and social habits and patterns of being. And from the teacher and environment, the child is a problem — and now you’re off to the races. The bad-kid track.”

The Costs of Low Birth Weight and Prematurity

The societal costs of premature birth are substantial, but those dry numbers can’t capture the devastation low birth weight and prematurity bring to babies, mothers and families. For every baby who fails to thrive, there is a mother who experiences the stress of dealing with a child in precarious circumstances or a father and extended family that have to deal with getting time off to care for the mother and child and the multiple layers of worry, stress and economic hardship that can involve.

“These young infants may have to spend significant amounts of time in the neonatal intensive care unit (NICU), and that’s costly,” Novoa says. “It’s financially costly for the healthcare system. It’s also costly on a micro level for individual families. Parents with newborns in the NICU often want to be with their baby at the hospital, but many parents have to go back to work right away because they don’t have paid time off of work. Even parents with paid leave often burn through it and have to take unpaid leave or go back to work sooner than they’d like. In either case, financial and job-related stress can compound the emotional stress—including sadness, guilt, fear—that parents experience when they have a preterm or low-weight baby.”

Again, the load of stress weighs especially heavily on Black women and women of color, according to the CAP report. The stress isn’t garden-variety worry, Novoa says. It’s a physiological burden of emotional and mental anguish, decades of bracing for fight-or-flight from the tigers of economic hardship and psychosocial adversity that create a form of premature aging called “weathering” that increases Black mothers’ susceptibility to numerous negative health outcomes. Being devalued on a daily basis quite literally wears a person out.

Addressing the Disparities

But just because this is the current state of affairs throughout the U.S., Novoa says, doesn’t mean it has to be. The interactive report shows the steps various states have taken to improve infant health on three interrelated domains: healthy families, economic and work supports and infant health outcomes. Addressing the infant-maternal health crisis in the U.S. is an all-hands-on-deck moment, she says, and will take a variety of approaches. But the improvements observable in states that have made policy changes show that implementing evidence-based policies and investing in family support programs can go far in ensuring that all infants have the opportunity to thrive.

“We know addressing these disparities is something that will require changes to our current healthcare policy,” Novoa says. “We also have to think expansively about what we are doing to support families and parents better beyond healthcare. We want to talk about the opportunities the states have to do things better, not just about what’s wrong. Each state has room for improvement and most states are doing something well. Louisiana, for example, has expanded Medicaid, and it has a modest, refundable to help low income families. So even though a state may not have great health outcomes yet, there is a glimmer of hope that some state policymakers have taken appropriate, right action on this.”

Avoiding the Good-Bad Paradigm

A pitfall in looking at how dire the situation is would be to fall into a right-wrong, good-guys/bad-guys view of the situation, both experts say. The CAP created the interactive report as a tool to help citizens and political leaders see the gaps and where improved policies can have an effect.

“Solving this will take an any-and-all-in approach,” Novoa says. “We’re encouraged to see how this information is gaining momentum at both the federal and state level. I’ve been working on this issue for a few years and it’s heartening to see the attention that policymakers are paying to these issues since I’ve started.”

Just the fact that we are having the conversation now is encouraging news, Willis says. “We’re talking out loud at many, many levels about the realities of structural racism that have been the foundation of this country and are still disruptive to child flourishing.

“There are some policymakers and the public who appear not to care about the challenges of so many families. This segment of society believe that people create their own destinies and believe that national and state polices best support self-determination. But knowledge from the research is building about the impact of poverty on health and wellbeing and the effect of racism on health outcomes — and this means impacts on the economic and workforce of the future for our country. The youth in this county seem to have a stronger sense of equity and the importance of supporting the wellbeing of all.Ěý They see that building the capacity of our next generations for our nation’s economic vitality is essential and I’m hopeful we’ll see major shifts soon in social policy.

“The situation we’re facing is tragic,” he says, “but it is also full of hope and opportunity. We know the forces that drive both vulnerability and resiliency. But we also know how to assure the wellbeing of all young children. Now we have to do it at a scale that meets the challenge. I find that thrilling for the future.”