Esther McCant, a doula in Miami, has visited clients in sweltering apartments without air-conditioning. She has seen them exhausted from long days working on their feet in the South Florida heat. In 2017, she even helped one client, who was well into her third trimester, evacuate during a hurricane.

It was soon after she helped that client get safely to Georgia that she started thinking about the connections between climate change and extreme weather and the health of her clients.

“It was then that I realized there’s not really a lot of guidance for pregnant moms during those types of situations,” McCant said. “In general, it’s every family for themselves.”

McCant had become a doula partly out of a desire to help address another growing crisis.

The United States has the highest maternal mortality rate among developed countries, with nearly 24 deaths per 100,000 live births in 2020, according to national statistics. A recent report found a sharp increase in maternity-related deaths during the first year of the pandemic.

The crisis is particularly acute for Black women like McCant.

Black women are about three times more likely to die during pregnancy or shortly after birth than white women. They are also 50 percent more likely to give birth prematurely and to underweight babies, and their pregnancies are more than twice as likely to end in stillbirth. Hispanic and Indigenous women also have worse pregnancy outcomes than white women.

There are a range of factors that contribute to these disparities—among them, barriers to access to care, higher levels of stress owing to systemic racism, and discrimination in the medical system that leads to poorer care.

But experts are increasingly looking at climate-related environmental factors that also play a role in perpetuating the divide in maternal health. Exposure to extreme heat, hurricanes, flooding, and wildfires, all of which are becoming increasingly frequent and intense because of climate change, are linked to preterm birth, low birth weights, and other negative outcomes. Black and brown women are the most affected, researchers say.

“When you do the digital analysis [of birth records], the racial health disparities come through very clearly,” said Dr. Nathaniel DeNicola, an obstetrician/gynecologist and co-author of a 2020 report that linked some effects of climate change to negative pregnancy outcomes.

Black and brown communities are more likely to live in urban heat islands, work outdoors, and breathe in polluted air, he said. “The way cities were designed for decades [poses] a disproportionate health risk to many minority communities.”

It’s not just chronic exposures. Extreme weather, like flooding and wildfires, also disproportionately affects Black and brown women. DeNicola completed his residency in New Orleans in the aftermath of Hurricane Katrina and now practices medicine in Southern California, which is prone to wildfires. He said these events tend to correlate with more pregnant people needing emergency care.

“When there’s a natural disaster—a source of extreme stress—and you have to leave a city without knowing where you’re going to next, [that] increases triage visits and these adverse outcomes, like preterm births,” he said. (The paper did not find a direct link between environmental factors and maternal mortality.)

“With preterm delivery or low birth weight, we know that there are so many other issues that can develop throughout childhood and even into adulthood,” said Rupa Basu, an epidemiologist and co-author of the report. Those ailments include neurological and cognitive impairments, heart defects and respiratory issues, she said.

Yet there’s little federal or state guidance on how pregnant people can prepare for climate emergencies, such as extreme heat. A 2020 Buzzfeed report found that of the country’s 25 largest cities, only two—Chicago and Philadelphia—specifically included pregnant people in their online heat and safety plans. (Additional cities, including New York and Miami, have since added some guidelines for pregnant people.)

Policymakers are signaling a growing awareness of the need to account for pregnant people in climate plans. This year, the Intergovernmental Panel on Climate Change report issued guidelines for pregnant people for the first time, and the Biden administration—following the urging of advocacy groups—mentioned climate change as a gender justice issue.

Kelly Davis, executive director of KINSHIFT, a reproductive justice organization, says those are encouraging gestures that she’d like to see backed up by funding. “I’m really looking forward to seeing an increase in dollars related to the research around structural racism and exposure to environmental hazards during pregnancy and the postpartum period for families of color,” she said.

To that end, Representative Lauren Underwood (D–Ill.) has cosponsored a bill called the Protecting Moms and Babies Against Climate Change Act, which is part of a larger package of legislation aimed at reducing maternal health disparities known as the Momnibus. The climate bill would, among other things, fund research into the effects of climate change on pregnancy, increase postpartum access to Medicaid, and expand pregnant workers’ rights.

“It really does have the potential to save lives, but it’s just the first step,” Davis said. She said policy-makers are still only scratching the surface when it comes to understanding the impact of the environment on birthing people.

McCant, the Miami doula, is also a mother of four. She did not experience complications during her pregnancies or births, but she considers herself an anomaly. “I was fortunate to have a space where the lights stayed on and the AC was running,” she said. “For some folks, it’s not that simple.”

The majority of McCant’s clients are Black, and about 60 percent are on Medicaid. She said one of the biggest reasons clients approach her is because they don’t feel heard in the doctor’s office. “There are gaps in care,” she said. “[Clients] are spending seven, eight, maybe 15 minutes with their provider. That’s not enough time to provide an education on a particular issue.”

She said seeing clients through successive heat waves and hurricanes has given her an appreciation for the importance of proper guidance on how to stay safe and hydrated through inclement weather. To that end, she is connecting advocacy groups with an expanding network of doulas to train them on how to coach pregnant people through extreme heat and hurricanes.

“We are the trusted messengers for these families,” she said. “We want to make sure that we’re talking about [climate] and giving them really good information.”