The expectant mother kneeled in the small inflatable pool as the father-to-be sat behind her, smiling.

“Just like a football,” midwife Marsha Ford coached, as the man practiced catching the baby for the couple’s upcoming water birth. “The face will be looking at you.”

As Ford guided the young couple in her office on the outskirts of Atlanta, a group of pregnant women and their partners watched from nearby couches.

Ford has worked as a midwife for twenty-four years, providing a personalized touch to childbirth that her clients, most of whom are African American, say is hard to find. But look beyond her gentle approach, and it’s clear Ford is on the forefront of a national battle: to keep these young mothers alive.

Fusion’s Nelufar Hedayat met up with Ford and others leading this fight for our documentary The Naked Truth: Death by Delivery, a look at the rising rates of maternal mortality in the U.S.

Among developed countries, the United States has one of the world’s highest rates of maternal mortality. The numbers have been on the rise since 1987, with some 17 pregnancy-related deaths per every 100,000 live births, according to the latest Centers for Disease Control data.

That might not seem like a lot, but the numbers put the U.S. behind most other developed countries, including places like Kazakhstan, Libya and Portugal, according to the World Health Organization’s 2015 estimates. It’s a situation all the more confounding considering we spend over $3 trillion each year on health care in the U.S. And it’s a part of the struggle for reproductive justice in this country that is often overlooked.

Centers for Disease Control

Break apart those stats, and the picture gets worse. Black women are nearly four times more likely to die in connection with pregnancy and birth than white women. (The Centers for Disease Control includes deaths related to the pregnancy up to one year after).

The disparity partially reflects socioeconomic gaps: financial inequality and an often-related lack of access to prenatal and other healthcare. But that’s not the whole story. It is also about race, and how race is experienced in the medical system.

Studies have found that black women are more likely to die from pregnancy-related causes than white women even when they are in the same socioeconomic bracket.

Fusion

These unequal numbers exist within the broader uptick in the national maternal mortality rate. Better records can explain some of that rise. Additionally, more pregnant women have chronic health conditions these days, including hypertension, diabetes, and chronic heart disease (which black Americans already suffer at high rates). Other factors include the rising obesity rate among pregnant women, more older moms, and a rise in cesarean section births, which have been linked to maternal death when not medically necessary.

And for many women, it can be a question of geography.

“There are not enough funds to keep the hospitals open,” Dr. Chadburn Ray told us. He is a member of Georgia’s Maternal Review Committee, established to examine the issue more closely in that state. “Oftentimes the perinatal ward is what’s closed first [after budget cuts].” Indeed, two-thirds of counties in Georgia do not have labor and delivery units, meaning many women must travel long distances to have a hospital birth.

Fusion

For black women, these risks are also set against the backdrop of racism. For example, in American counties with low poverty rates, black expectant moms still fare worse overall than their white counterparts, according to a report from the U.S. Department of Health and Human Services.

Dani McClain, a fellow at the Nation Institute, recently detailed the apprehension she felt entering her obstetrician’s office in Dayton, Ohio, even as a highly educated black journalist.

“I suspected that the all-white teams of receptionists, nurses, and doctors (OK, there’s a black receptionist at the office where I got my ultrasounds) first see a black woman, not an Ivy League graduate or someone whose job includes researching reproductive health—or any of the other characteristics that some may think would shield me from substandard care.”

Elizabeth Dawes Gay, a policy analyst with Atlanta-based Black Mamas Matter, an initiative dedicated to reducing maternal mortality among black women, characterizes the disparity this way:

“It’s because of the experience of blackness.”

She and other women behind the initiative are tackling the issue from several angles: public health education, policy analysis, and political advocacy.

After all, the mechanisms of how racism shapes the numbers are complex. A 2011 report from Amnesty International pointed to “discrimination and inappropriate treatment” from medical professionals as a major cause of the much higher rate of maternal deaths among black women compared to white women.

More generally, there is a growing body of evidence showing that many people, including medical professionals, falsely believe black people can handle more pain than white people—and that medical workers structure their treatment recommendations accordingly. In the context of birth complications, this could prove dangerous.

Then there’s the 2009 analysis published in the Journal of Behavioral Medicine describing the increasing number of studies linking the daily experience of racism to psychological stress and physical ailments.

Dr. Fleda Jackson, a PhD researcher and advocate in Atlanta who is tackling the issue of unequal birth outcomes, has spent much of her career trying to understand these links.

“The connection between race and maternal mortality really has to do with stress,”she explained. “And the particular kind of stress that African Americans encounter is around racism [and] sexism. So it’s the double jeopardy of being black and female, and what does that do in terms of a woman’s response both physiologically and psychologically if in fact there is no relief from those environmental circumstances.”

That’s where Ford steps in.

“We care and we show that,” she said of the benefit midwives provide to the birthing experience. “I’m not saying that OB/GYNs don’t care, but we as women and as midwives care, and we care holistically for the whole woman.”

Health professionals like Ford offer not only emotional and physical support from a place of cultural sensitivity, but also provide information and serve as women’s advocates in a health care system that can be confusing, difficult, and frustrating to navigate. This kind of helping hand may prove especially beneficial to women who are already apprehensive about the way medical staff will treat them.

As we found in Death by Delivery, though, the problem is multi-layered—and will require a host of players and strategies to make significant change.

Better data is a start. Many states, and even some cities, now have maternal mortality review committees which look at the numbers. And in recent years, states have begun to standardize their reporting. Increasing access to quality prenatal and birthing centers and improved training for doctors and support staff will also help. In January, the U.S. House of Representatives voted to have HHS identify areas of the country lacking maternal health care professionals. The Senate has yet to take up that bill. Last week, U.S. Reps. Jaime Herrera Beutler, a Republican from Washington, along with Michigan Democrat John Conyers filed a bipartisan bill to help states begin to address the inequities in maternal health. Conyers has sponsored similar bills in the past, but none has made it out of committee.

Robbin Davis, for one, knows first hand the stakes are too high to sit back and wait for things to get better on their own.

“She meant everything to me,” Davis said, wiping away tears as she spoke of her late daughter, Victoria Rexach, in her New York City apartment. Davis explained that Rexach died in 2014 of a hemorrhage following a premature vaginal delivery of twins. She was 31. Davis believes that due to her daughter’s medical history, she should never have been allowed to have a vaginal birth. Now, she worries about the odds facing her other children.

“It’s scaring me because I have daughters that can still get pregnant and still have children,” she said, sitting on her living room couch surrounded by photos of Victoria. “What is that going to mean for them?”

The Naked Truth: Death By Delivery airs on FUSION TV March 8 at 9 pm ET, part of Fusion’s special International Women’s Day lineup.