Addressing the Crisis: How Cultural Competence Training Can Combat Black Maternal Mortality

Black mothers die from pregnancy complications at the highest rates. Training the next generation of providers could curb this trend.

By Rama Esrawee

Bringing a child into the world evokes a variety of emotions: joy, vulnerability, and, at times, fear. Shalom Irving, a Black woman, likely experienced these emotions too as she lived through her 2016 pregnancy. 

Irving grew up in Portland, Oregon, the daughter of Wanda and Samuel Irving. She was an epidemiologist at the Centers for Disease Control and Prevention with a focus on how racial inequality, trauma, and violence result in poor health. In her own words, she vowed “to create a better Earth.”

Yet, her journey was overshadowed by a different reality. Irving developed high blood pressure, swollen legs, and mild headaches three weeks after giving birth to her daughter, Soleil. She sought medical help—she was hypertensive, with her blood pressure reaching alarming levels—yet she was repeatedly sent home from the emergency room. Irving passed away at home in January 2017.

Irving’s death is not an isolated tragedy but, rather, a reflection of the racial disparities that persist in the American healthcare system. According to the CDC, Black women have a three times higher risk of dying due to pregnancy and delivery complications than white women. This disparity is not rooted in biological differences, says the Journal of Women’s Health, but instead in racial biases within America’s healthcare system. Irving’s death, like that of so many other Black mothers, emphasizes the need to address these disparities in maternal healthcare. Maternal mortality among Black women is more than a public health crisis—it is a human rights issue that demands reform, starting with how we educate providers.

Anxiety, disengagement and distrust

Many of us grew up dreading trips to the dentist, fearing the potential pain. For Black women, however, there is more than just this fear. It goes much deeper: It’s not just about the procedures but about the fear of not being fully seen as human in their interactions with the healthcare system. This ongoing fear of dismissal and mistreatment in the Black community is rooted in systemic distrust. A 2022 Pew Research study found that nearly 49 percent of Black adults believe healthcare providers are less likely to offer them the most advanced medical care. The same study showed that 47 percent of Black adults think hospitals prioritize the well-being of other racial groups over theirs.

For Black mothers, this mistrust in medical professionals often leads to hesitancy to seek care or adhere to medical advice due to their past experiences of bias. A study published in Health Affairs found that race-specific mistrust in healthcare providers is linked to greater anxiety and a lower probability of seeking treatment for Black women, emphasizing the unique burden they face—one not experienced in the same way by their white counterparts.

“We hear horrible stories about Black women who go in with a problem and are turned away from care because of people who don’t believe them. That should never be the case.” says Carmen Marsit, the Rollins Distinguished Professor of Research at Emory University.“We think a lot about that in public health: how do we get public health to people where they are?”

Training future healthcare professionals in medical schools to empathize with and build more equitable relationships with Black patients is a crucial first step in tackling the systemic issues contributing to Black maternal mortality.

A lack of cultural competence—a healthcare provider’s ability to understand the cultural and social needs of patients—often leads to inadequate treatment when Black patients seek care. A survey by the American Medical Association reported that 50 percent of healthcare providers acknowledged the need for cultural competence training to combat racial biases. The National Institutes of Health also found that only 34 percent of medical schools included training on racial and ethnic disparities in their curricula. As such, doctors may unintentionally contribute to the very disparities they aim to address without understanding the experiences and needs of Black women.

“With folks not having enough education that is culturally competent, tailored to the different communities that they may potentially serve, future clinical providers could miss things such as postpartum depression, which appears more in Black women”, says Candice Gary, an associate in the Rollins School of Public Health at Emory University.

Creating training to create change

Gary emphasizes that cultural competence training can reduce several health issues for Black mothers. Reshaping the way healthcare providers are trained is a vital part of addressing the maternal health crisis, though it must be accompanied by other systemic changes, such as educational incorporation early in medical training. Educating future healthcare providers will help bridge the gap between healthcare disparities and build a system in which Black mothers are not only heard but understood.

Cultural competence training can also help healthcare providers address the racial inequity ingrained in America’s healthcare system. Understanding the racial inequities of the past is not only essential for acknowledging the harm done, but for ensuring it doesn’t continue. The history of racially targeted experimentation on the Black community is a painful chapter that still impacts maternal mortality in the healthcare system today. For example, J. Marion Sims, who is widely referred to as the “father of modern gynecology,” operated on enslaved women without administering anesthesia because he believed that Black women were incapable of feeling pain. A study published by the American Journal of Public Health in 2020 found that over 60 percent of Black women reported that the legacy of forced sterilizations and other forms of racialized medical exploitation has contributed to their deep mistrust of modern healthcare systems. 

“Standards were developed without minority pregnant and birthing people in mind. When their symptoms don’t fit what a doctor was taught to be critical, they’re not receiving needed care since their symptoms don’t match up to racially exclusionary medical history,” says Gary.  

The history of both social and medical racism in the United States underscores the high burden of maternal mortality among Black women, making cultural competence training an essential tool in reforming the system to address the root causes of these disparities. This training must include lessons on the history of racial exploitation in the medical field to help healthcare providers understand the long-standing trauma that impacts Black women today.

Some argue that federal action, rather than cultural competence training, is the most effective tool in addressing the Black maternal health crisis. Yet, there have been various attempts to deracialize the American healthcare system and maternal mortality rates that have failed. 

Before she became Vice President, then-Senator Kamala Harris introduced the Maternal CARE Act in 2019, which would incentivize healthcare providers to be trained on implicit biases, which includes both cultural competence training and historical context for medical discrimination, as an attempt to reduce maternal mortality in women of color. The Maternal CARE Act has yet to be fully enacted into law due to a lack of political support in Congress, despite its proposed policies, such as grants for racial bias training and funding for pregnancy medical home programs. Ultimately, its struggle to gain traction highlights a broader issue: federal initiatives aimed at addressing racial disparities in healthcare often face significant barriers in the legislative process. These challenges not only delay change but also reveal that relying solely on policy-driven solutions with a lack of political support is ineffective in aiding the issue of Black maternal mortality. 

In contrast, medical schools can offer a more direct and immediate approach to addressing racial health disparities through cultural competence training. They can build trusting relationships that encourage Black mothers to seek care without fear of dismissal by equipping future healthcare professionals with the skills to understand the needs of marginalized communities. Healthcare providers are not only taught to address their own biases but are also empowered to adopt more empathetic care practices through cultural competence training. Unlike federal legislation, cultural competence directly confronts the historical racism embedded in the healthcare system by educating providers on the legacy of medical exploitation, which enables them to understand the trauma Black women have endured through healthcare. This fosters an environment where Black mothers feel heard and respected, which can ultimately lead to more consistent and timely medical interventions, thereby reducing the risk of maternal mortality.