ANA on the FrontlineDiversity/Equity/InclusionMaternityPostpartumReproductive HealthWomen's Health
mother and baby

Not on our watch

By: Elizabeth Moore

Nurses have the power to turn the tide on Black maternal health.

The numbers are staggering. The United States, which spent $4.1 trillion on healthcare in 2020, has one of the highest maternal mortality rates in the world. According to the Centers for Disease Control and Prevention, Black women die post-birth at 3 to 4 times the rate of White women and other women of color, irrespective of education or income level.

There is increasing recognition that the racism, discrimination, and mistreatment experienced by many Black women have a distinct relationship to health outcomes, said the 2019 study “The Ethics of Perinatal Care for Black Women,” published in the Journal of Perinatal and Neonatal Nursing.

Tiffany Montgomery

Black women continue to report that concerns they express about their health during and after pregnancy frequently are dismissed by their healthcare providers. “Black women are frequently not listened to when we say we are in pain,” said Tiffany Montgomery, PhD, MSHP, RNC-OB, assistant professor in the College of Public Health, Department of Nursing at Temple University in Philadelphia. “One of the ethical principles of nursing is autonomy. People know their own bodies, so healthcare providers should not be the ones to decide whether or not a patient is in pain.”

The term “birth equity,” coined by Joia Crear-Perry, MD, founder of the National Birth Equity Collective, is “the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort.”

Nurses are uniquely positioned to promote birth equity and ensure that Black mothers in their care are listened to and respected. Nurse experts on Black maternal health are working to ensure that awareness leads to action, and action leads to better outcomes for all birthing people.

Realization and recognition

Rose Horton

“We all have biases,” said Rose Horton, MSM, RN, NEA-BC, executive director of women and infant services at Emory Decatur Hospital in Georgia. “They are not necessarily good or bad, but you have to recognize how they show up in your interactions.”

“The intention is not what makes an act racist or discriminatory,” Montgomery noted. “Think about the policies and traditions in this country and in our communities that result in racist outcomes. Anytime something is causing a healthcare disparity—that’s systemic racism.”

A critical first step for nurses to confront racism in healthcare is recognizing the role you play in the system, Horton said. “Once you understand you have a role, you can become informed about the words and actions that may be triggering to marginalized communities, and then make a commitment to do things differently with your patients,” she said.

The best care for every patient

Horton, who’s past president of the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), believes standardization of care will go a long way toward advancing maternal health equity.

“Standardization removes the variability,” Horton said. “We treat every patient the same way, using checklists, toolkits, safety bundles” and other resources. In 2022, AWHONN, an organizational affiliate of the American Nurses Association (ANA), is releasing “Respectful & Safe Maternity Care Evidence-Based Guidelines,” and has more resources available at

In addition to employing approaches such as standardization, nurses must commit to listening to and advocating for the Black mothers in their care.

Nurses have the opportunity to empower their patients, said Montgomery. “When something isn’t right, and you can see that, make sure the patient understands that they are allowed to make decisions.” For example, a birthing person may not feel comfortable with a recommended procedure but are worried they’ll be seen as a “bad mother” if they don’t go along with their provider’s advice.

“Tell them they can get a second opinion if they are unsure,” Montgomery said. Nurses need to embrace their role as advocates.

Patient advocacy should go beyond the bedside. “Lead by example,” Horton said, “and if you see something, say something.”

Montgomery added, “If a nurse isn’t comfortable speaking directly to a colleague, they should discuss the issue with a manager or call their organization’s anonymous hotline.”

Nurses leading the charge

As the nation’s largest group of healthcare professionals, nurses can significantly improve the health outcomes of Black mothers and their babies.

“Nurses have 24-hour contact with patients,” Horton said. “We see the nuances and subtle changes that may impact outcome.” In 2017, Horton began using the hashtag #notonmywatch on social media to build awareness of the effect nurses can have on Black maternal health. “Nurses are the ones who can spread awareness of bias issues, make recommendations, and hold colleagues accountable,” she said.

Nurses are involved in every stage of pregnancy, said Montgomery, who is chair of the National Black Nurses Association Women’s Health Committee, which provides opportunities to listen, advise, and advocate for patients every step of the way.

“There are 350,000 nurses working with the birthing community,” Horton said. “If just 20% of them made a commitment to improving Black maternal health, the results would be remarkable. Imagine what could happen with 100% compliance.”

Building mom-entum

On December 7, 2021, Vice President Kamala Harris hosted the first ever White House Maternal Health Day of Action. During the event, Harris and a slate of high-profile guests discussed racial disparities in maternal health, shared personal stories, and highlighted policy solutions, including those included in the Build Back Better Act, passed by the U.S. House of Representatives in November 2021.

The Build Back Better Act includes key maternal health investments from the Black Maternal Health Momnibus Act of 2021, introduced by Rep. Lauren Underwood (D-IL), an ANA-Illinois member, Rep. Alma Adams (D-NC), Senator Cory Booker (D-NJ), and members of the Black Maternal Health Caucus, pledging millions of dollars to communities to address social determinants of health, grow and diversify the perinatal health workforce, advance maternal health research, strengthen federal maternal health programs, and several other initiatives.

ANA endorsed the Momnibus in February 2021. “Racial disparities in healthcare have led to women of color across all educational and socioeconomic statuses having their medical issues ignored and dying in childbirth at alarmingly higher rates,” said ANA President Ernest J. Grant, PhD, RN, FAAN.

Although the Build Back Better Act was stalled in the Senate at press time, both Horton and Montgomery see its support, along with the Maternal Health Day of Action, as positive signs of progress.

Nursing Practice

“It was a watershed moment,” said Horton, who was tapped in 2020 to join the Biden administration’s Black Maternal Health Stakeholder Group. She believes that momentum will build as a result of the actions by the White House.

Montgomery was pleased to see the efforts of the Black maternal health advocacy movement finally get amplified at such a high level. “The Momnibus was first introduced 2 years ago, and now it’s gaining steam,” she said. “With all the money we have in this country and all the healthcare expertise, it makes no sense that we have the highest maternal mortality rate among industrialized countries. It’s time to give moms a fighting chance.”

Even without much-needed legislation, nurses can make a difference in their birthing patients’ outcomes by listening, learning, and incorporating standardized care.

Both Horton and Montgomery stress that there is no time to wait—Black mothers’ lives are at stake if the healthcare community doesn’t act.

“This is a state of emergency,” Horton said.

“Nurses need to remember that it’s not about us,” Montgomery said. “It’s about the women, the childbearing people in our care, the lives that need to be saved.”

—Elizabeth Moore is a writer at ANA


Association of Women’s Health, Obstetric, and Neonatal Nurses

Alliance for Innovation on Maternal Health

Centers for Disease Control and Prevention

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