Celebrating Juneteenth

By Maningbè B. Keita Fakeye, Ph.D., health equity research manager, Deloitte Center for Health Solutions, and Deloitte Health Equity Institute, Deloitte LP

Juneteenth commemorates June 19, 1865—the day slaves were declared free in Texas, more than two years after President Abraham Lincoln issued the Emancipation Proclamation.¹ While Juneteenth wasn’t declared a federal holiday until 2021,² some Black families have been commemorating the end of slavery in the United States for generations. The women who gave birth are often the heart of those families. But Black women in the US are three to five times more likely to die from pregnancy-related deaths than white women,³ and significant differences persist even with higher education.⁴ It takes teamwork and a comprehensive approach to address the social and structural drivers that contribute to this issue. Understanding the history of Black maternal health—and the historic contributions of Black birth workers⁵—could help inform the design of solutions that reduce health inequities and save lives.

I recently had an opportunity to speak with Ebony Johnson, MPA, CNP, director of Place-Based Investments at United Way of Greater Atlanta (UWGA). I also spoke with Uchenna “Uno” Jones, director of Health-focused Community Impact at United Way of Dane County (UWDC) in Madison, Wisconsin. UWGA and UWDC are two of four organizational collaborators for the Doorways to Health for Mothers of Color program—a two-year initiative to help local United Ways address maternal and infant health inequities experienced by Black women. Last year, the Deloitte Health Equity Institute announced it would support the initiative. This is critical work, Ebony says, because “women are the center of life.” Here is an excerpt from our conversation:

Maningbè (Mani): Birthing skills among Black enslaved people often came from generations of experience cultivated long before the transatlantic slave trade began. This knowledge was passed down to descendants born into slavery.⁶ How did traditional birth-work from the African continent influence childbirth during slavery? 

Ebony: Diverse cultures across the African continent viewed childbearing as spiritual and something to be revered. Midwifery in Africa was part of the celebration of life. The women in a village, typically the elders, cared for expecting mothers before, during, and after childbirth. There were ceremonies that welcomed the new child into the world. Many of those traditions were lost when slaves were transported across the Atlantic. During slavery, some women became midwives and took care of other slaves during the birthing process. Some of them also served as midwives for the families of slave owners.

Mani: In 1900, 95% of all births in the U.S. took place in the home. By 1955, 95% of all births occurred in hospitals, a transition largely driven by the medicalization of childbirth.⁷ Dr. Joseph DeLee, who is generally considered the father of modern obstetrics, saw midwives as dangerous⁸ and referred to them as “a relic of barbarism.”⁹ What was the impact on Black maternal health?

Ebony: Some of the misconceptions about how Black women experience pain originated during that period.¹⁰ Nursing midwifery became more accepted in the 1960s and ’70s, but they generally weren’t used by Black women. Today, only about 7% of certified nurse-midwives identify as Black.¹¹

Mani: As a labor and delivery nurse, what are some of the challenges you see? Is it possible to make maternal care more accessible and equitable for everyone?

Uchenna: During my 21 years of being a doula, I also became a labor and delivery nurse. I believe implicit bias can play a huge role in the care people receive.¹² I have seen that with my own eyes. People who work in health care need to be aware and help other health care professionals recognize their prejudices. We have to create room and space to address racism and biases. There are a lot of stereotypes about how women from different ethnic groups birth. Health care professionals should try to dispel those myths. It has a lot to do with knowing who they are caring for. At the end of the day, our job is to help every mom have a successful birthing experience. Addressing implicit bias requires culturally specific education and holistic, wrap-around pre- and post-natal care—everything from nutrition to education to care.¹³

Mani: Black women are two to three times more likely to die from pregnancy-related complications than white women, with most maternal deaths being preventable.¹⁴ But mortality rates can be significantly higher in some states. (See March of Dimes Maternity Care Deserts Dashboard, which was developed with Deloitte’s support). What contributes to this variability?

Ebony: Access to care is really, really important. In denser populations like Atlanta, there might be more overall access to health care services, but it might not be equitable access. Most of Georgia is rural. In some communities, specialty care might be more than 25 miles away. Women who need obstetrical care might not be able to travel two towns over. Health insurance also plays a significant role. Some states did not expand Medicaid eligibility as called for by the Affordable Care Act. Several years ago, [UWGA] initiated a program called Babies Born Healthy, which is focused specifically on Black women. The goal of that program was to help ensure that more babies are born at healthy weights. We also wanted to reduce premature deaths and maternal deaths. We worked closely with a local health system’s women triage center. Many of the pregnant women who came to the ER were in their second or third trimester and had not had any prenatal care. That makes a huge difference, particularly for women who are high risk. And it can have an effect on the baby’s weight and overall health.

Mani: Teamwork is critical to support this work. I am of Guinean descent and find that cultural proverbs provide helpful guidance and encouragement. One of my favorite African proverbs is, “If you want to go fast, go alone. If you want to go far, go with others.” How is United Way of Greater Atlanta working with others to affect change?

Ebony: We have long been a champion of ensuring that all women—particularly women of color—have access to equitable and quality care. Our work with the Babies Born Healthy program led to the creation of Centering Pregnancy and elevated our Community Health Worker Initiative.¹⁵ Working with our hospital partner, as well as federally qualified health centers, we connect expectant moms to regular care providers. We also connect them with health insurance, and we continue to support them post-partum. We are also working with Voices for Georgia's Children—an advocacy group that helped with state legislation that provides up to 12 weeks of postpartum care. The law also includes mental health support to help address postpartum depression and other postpartum mental health conditions. We are also working with the Center of Black Women’s Wellness, in support of our Doorways to Health collaboration with the Deloitte Health Equity Institute and United Way Worldwide. The Center of Black Women’s Wellness helps birthing people identify and access equitable care and social support during their pregnancy journey to improve healthy birth outcomes.

Mani: Are you optimistic about the future? Do you think we will begin to see some improvements in Black maternal health equity?

Ebony: Absolutely. We live in a time where biases are starting to diminish, bit by bit. Social media and other strategies are helping to amplify voices and more people can share their experiences. I feel society tends to romanticize childbirth. While bringing life into the world is a beautiful experience, we don’t often hear the difficult stories. More often than not, stories of women of color get buried. There is joy in childbirth, but there can also be pain and bad experiences. Working with others to help make those experiences better can impact the whole community. Access to stable housing, jobs with benefits, education, preventive health care, and quality food all have a considerable impact on the health of a mother and the health of a baby. If we want to have a collective solution, it is important to address the social conditions and systems that impact health. We all have our own perceptions of the way the world works. We can’t just offer a training session and decide everything is okay. It isn't just a matter of learning. It is also unlearning. It can take much more time to unlearn something that to learn it. Understanding history is half the battle.

Juneteenth is a celebration of freedom and family, but it also should be a reminder of the progress that still needs to be made to improve maternal health disparities. Addressing systemic inequities, and ensuring access to quality health care, can empower Black birthing persons to thrive. This is an opportunity to bring people together and bridge different sectors and skills. The progress we make can inform better health for us all.

The individuals’ participation in this article are solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the organizations mentioned, nor does Deloitte advocate or endorse the services or products provided by these organizations.

Acknowledgement: Nefertiti Wade

Latest news from @DeloitteHealth

Endnotes: 

¹ The historical legacy of Juneteenth, National Museum of African American History & Culture 

² A proclamation on Juneteenth day of observance, the White House, June 17, 2022

³ Maternal mortality rates in the US, Centers for Disease Control and Prevention (CDC), 2021

⁴ Racial and ethnic disparities continue in pregnancy-related deaths, CDC, September 5, 2019 

⁵ The National Association to Advance Black Birth

⁶ Africa before transatlantic enslavement, Black History Month Magazine, September 10, 2019

⁷ The reason childbirth is over-medicalized in America has its roots in racial segregation, Quartz, November 27, 2017

⁸ Professional Issues in Midwifery, Lynette Hamlin, Google Books, 2007

⁹ Hey there, baby, University of Virginia School of Nursing, March 1, 2019

¹⁰ Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, Proceedings of the National Academy of Sciences, April 4, 2016

¹¹ A look at the past, present, and future of Black midwifery in the US, Urban Institute, March 18, 2023

¹² Systemic racism, a key risk factor for maternal death and illness, National Heart, Lung, and Blood Institute, April 26, 2021; How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States, Journal of Women’s Health, February 2, 2021

¹³ Targeting bias to improve maternal care and outcomes for Black women in the USA, eClinicalMedicine, The Lancet, October 4, 2020

¹⁴ Solving the Black maternal health crisis, Johns Hopkins Bloomberg School of Public Health, May 12, 2023

¹⁵ United Way of Greater Atlanta

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