Excerpted From: Katherine “Yenny” Wu Ho, Telehealth Solutions for Black Maternal Health, 33 Annals of Health Law and Life Sciences 145 (Winter, 2024) (222 Footnotes) (Full Document)


KatherineYennyWuSerena Williams is one of the most recognizable athletes in the world. She dominated tennis for years, amassing a huge fan base, fame, and wealth. However, despite having access to the best medical care in the country, she almost died when giving birth to her daughter, Olympia.

A day after giving birth via C-section in 2017, Serena Williams told her nurse that she wanted a CAT scan and heparin, fearing a blood clot in her lungs after having painful coughing episodes. Serena had a publicly reported medical history of her tendency to develop blood clots; a 2011 pulmonary embolism almost ended her life and her tennis career. Even after she experienced numbness and excruciating pain, her nurses refused to listen to her, concluding that the pain medication was “making her talk crazy.” Ultimately, she received the CAT scan after begging, but not before she tore her C-section incision open due to a coughing fit related to a blood clot in her lung. These medical complications required three additional surgeries ultimately caused a prolonged and painful recovery. Without Serena advocating for her own life and tests, she very well could have died.

Despite her wealth, Serena Williams faced skepticism from her providers during her treatment in the hospital pre- and post-partum. Countless additional examples exist of Black pregnant people who were failed by the healthcare system simply because a provider would not listen to their concerns. Multiple factors might explain why Serena and other Black birthing people face disparate hospital outcomes. This article will explore implicit bias and racial disparities in maternal health, arguing that increased access to telehealth in the maternal health sector may positively affect maternal health and mortality rates in the future, with telehealth being an essential tool.

Telehealth can help bridge the gap for those who are not wealthy and lack the power to advocate for their healthcare outcomes. Current laws and practices individually attempt to address the inequities that Black birthing people face, but often fall short and are not well integrated. Congress recently passed the Build Back Better Act, which includes grants to improve maternal health, but its effects have yet to be seen since many programs are still in their infancy. At the state level, public interventions in maternal health primarily occur through states' Medicaid programs, where states have largely limited access by restricting reimbursements, eligible providers, and types of services. At the local level, providers have begun integrating Black care models into healthcare systems, emphasizing Black care teams, support systems, and telehealth access. Federal and state programs need to mirror local efforts by bringing Black voices into decision-making processes and centering around Black patients to improve health outcomes.

Ultimately, telehealth solutions should supplement in-person care, enabling patients to access remote patient monitoring and services that might not otherwise be available. This article proposes the following potential solutions for improving maternal health outcomes through telehealth interventions: 1) a more comprehensive regulatory framework at the federal level; 2) financially incentivizing states to cooperate with the federal government regulations to streamline delivery of care; 3) encouraging states to adopt pay parity provisions for audio health care services; and 4) reducing implicit bias through state and federal grants to improve diversity, education, and training in the prenatal workforce. While telehealth may not seem easily accessible for lower income individuals, this article will demonstrate feasible solutions while considering the financial limitations of many patients.

Part I provides an overview of maternal health and racial disparities that accompany maternal health, focusing on implicit bias as a perpetrator. Part II provides an overview of telehealth, including the definitions, benefits, and potential limitations for minority birthing people. In particular, Part II explains how COVID-19 propelled the increased use of telehealth services and the regulatory actions taken to implement those changes. Part III highlights the current federal telehealth solutions to address maternal health outcomes, including efforts through the Black Maternal Health Momnibus Act, the Build Back Better Act, and new rules promulgated by federal agencies. Part IV addresses existing state telehealth solutions to benefit maternal health through Medicaid and private-payer plans. Part V addresses local healthcare system telehealth solutions to reduce maternal mortality rates and improve maternal health outcomes, which include community connections and Black patient centering. Part VI suggests solutions to streamline telehealth across the state and federal government and ways to strengthen care delivery to Black patients.

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In sum, Black birthing people are dying at alarming rates in the U.S. in comparison to White birthing people, and mortality rates in the U.S. are much higher than peer countries around the world. Black pregnant people suffer these risks and outcomes regardless of seemingly protective factors such as income, education, and age. In addition, these outcomes are affected by the presence of implicit bias in medical providers, with the bias leading to paternalistic attitudes, refusal to listen to Black patients, and recommendations of risky and unnecessary medical procedures towards Black birthing people. With the advent of increased telehealth usage due to the COVID-19 pandemic, there are many ways to approach positively impacting maternal health outcomes through telemedicine.

At the federal level, Congress has taken steps to invest billions into improving the infrastructure of broadband and improving Black maternity outcomes, specifically through provisions from the Momnibus Act. These include addressing social determinants, allocating money for educating and diversifying the perinatal workforce, and allocating money for telehealth programs. Due to the pandemic, the federal government passed many waivers at the advent of the pandemic to increase access to care. While this was mainly successful through Medicare, a solely federal insurance program, state Medicaid programs had much different outcomes. Due to a lack of federal definition of telehealth and telemedicine, state laws differ greatly across licensing requirements, inperson initiation appointments, coverage of telehealth services, and covered providers for Medicaid reimbursements. Pay parity differs for private insurers, and there is constant friction between the state and federal government. To increase access to care at the local level, all the evaluated states have health care systems which created telehealth maternal care programs, which are at varying stages of implementation and success. Overall, federal solutions signal a great step towards improvement in the future, but ultimately will take a long time before meaningful improvement is seen. At the state level, there is much room for improvement, especially in the regulatory space. The states have most of public insurance coverage of pregnancies, so Black pregnant people are most vulnerable at the state level. At the local level, it is necessary to reduce implicit bias within medical providers and to increase prevalence of Black centered care centers.

The proposed solutions at both the federal and local level serve to expand telehealth access to vulnerable communities, specifically Black birthing people, and over time, Black maternal mortality rates and morbidity rates will hopefully reflect these improvements across other races as well. As it stands, the death of Black birthing people is unacceptable, and it is undoubtedly rooted in a culture of racism and bias. More action should be taken at all levels of government and in all communities to support Black maternity, and telehealth is only one means of addressing the underlying and pervasive issues that ultimately cause such high rates of Black maternal mortality.

Associate at Wicker Smith. Ms. Wu would like to thank Professor Jake Linford at FSU for all his insights.