More women die from pregnancy-related complications in the United States than in any other comparably developed nation. Around 700 women die from pregnancy-related causes annually in the U.S., with an additional 60,000 women suffering severe, pregnancy-related complications. Approximately three out of every five pregnancy-related deaths are preventable.
“In a country of this size and wealth and level of innovation, [this] is an injustice,” said panel moderator Dr. Laurie Zephyrin, Vice President of Delivery System Reform at The Commonwealth Fund. She continued, “This is also about race — black women and native-American women are more likely to die.” Indeed, across the United States, black women are three to four times more likely to die from pregnancy-related causes than white women and have higher rates of severe maternal morbidity. These disparities aren’t static — they’re worse at certain hospitals, reflect a range in causes of mortality, and are exacerbated with age.
Disparities also vary by region, explained Dr. Elizabeth Howell of Mount Sinai’s Icahn School of Medicine. In New York City, black women are 12 times as likely to die from pregnancy complications as their white peers. Black and Latina mothers are more likely to deliver in hospitals with higher morbidity rates for both Black and white women. Howell’s research indicates that this difference explains nearly half of the disparity in New York City. Now, she’s investigating what hospitals with these bad outcomes have in common. “It’s about more than resources,” says Howell. “It’s about culture, about the way we treat patients and handle adverse events and medical errors.” Working to eliminate implicit biases, improving communication, and engaging with the community can help address some of these issues.
What other factors contribute to racial disparities in maternal mortality? Shanna Cox, Associate Director of the Centers for Disease Control and Prevention’s Division of Reproductive Health, suggests that “weathering” may play a role. The weathering theory hypothesizes that as women of color age, they’re exposed to implicit bias, structural racism, under-resourced neighborhoods, and lack of care. These factors, and the chronic stress that accompanies them, all have negative health consequences that increase the risk of maternal mortality. Cox points out that women who immigrate to the United States from Africa or the West Indies have the same pregnancy outcomes as white American women. Within one generation, however, birth outcomes resemble those of Black women who grew up in the United States. In addition, traditional factors that should be predictive of better health outcomes are not. While white women with college degrees have better pregnancy outcomes than those without, black and Native American women with college degrees still have higher pregnancy-related mortality rates than do white women without college degrees.
What do these pregnancy-related deaths look like? The CDC’s report on pregnancy-related deaths finds that heart disease and stroke are responsible for the most deaths overall. Obstetric emergencies cause most deaths at delivery. Severe bleeding, high blood pressure, and infection are the most common in the week following delivery, with cardiomyopathy causing most deaths in the year after birth. Compared with white mothers, black mothers have a higher risk of dying from preeclampsia, eclampsia, cardiomyopathy, or embolism. For instance, while cardiomyopathy causes 10.3% of the pregnancy-related deaths experienced by white mothers, it causes 14% of those experienced by black mothers. As Cox points out, these numbers convey the amount and kinds of deaths — but not why they happened. “For any problem to be solved,” adds Cox, “robust data is needed.”
The data already point to concrete policy changes that could improve women’s health, as well as areas — like cardiomyopathy — where increased surveillance for at-risk populations might be necessary. A total of 25% of pregnant women have no insurance coverage before becoming pregnant, and while their pregnancy qualifies them for Medicaid, most of these women lose this access 60 days after birth — a time when cardiomyopathy problems are quite likely to arise. Crafting policies that keep women within the healthcare and social system could help prevent and catch problems that lead to pregnancy-associated deaths, explained Eugene Declercq, PhD, of the Boston University School of Public Health.
The maternal mortality crisis won’t be stopped without increased research and data collection. Good research, however, can’t happen without developing more standardized, patient-centered quality metrics for maternal healthcare. “Currently we don’t have very many, they don’t necessarily measure what women care about, and they don’t capture disparities very well,” explained Dr. Howell. Many existing metrics are designed to assess overutilization of services, while racial and ethnic minorities generally get too few services, rather than too many. “When we only focus on overutilization measures, we aren’t looking at this population,” said Howell. “We need to be thinking about disparities as we seek to develop improved quality measures.”
Ensuring that moms-to-be receive culturally-sensitive, patient-centered care leads to better outcomes for both mothers and their babies. Midwife Jennie Joseph runs Florida-based Commonsense Childbirth, providing maternity care along with psycho-social support. “The difference between regular care and patient-centered midwifery care saves lives,” says Josephs. The data backs her up. A study shows that none of Commonsense Childbirth’s Black and Latina mothers delivered preterm babies or low birthweight babies in 2006. Across Florida, the following year, 19.6% of black mothers and 13.4% of Latina mothers had preterm births. The pattern holds true for birth weight as well — across Florida, 13.6% of black mothers and 7.1% of Latina mothers had low-birth-weight infants. Perhaps helping in-hospital providers gain some of the skills that Joseph’s midwives possess could lead to better results as well.
Increases in maternal mortality are symptomatic of a larger, more complex problem. A women’s health crisis is unfolding in the United States, of which maternal mortality is but one part. “What we really need to do is have a focus on women’s health,” says Declerq. While pregnancy-related deaths increased by 16.7% from 2010 to 2016, the overall causes of death for women have increased by 22% in the past six years. There’s a need for better health for all women — pregnant and not pregnant alike.
This blog post was written by Sonya Sternlieb, science policy intern at Research!America.