The United States is one of only 13 countries in the world where the rate of maternal mortality — the death of a woman related to pregnancy or childbirth up to a year after the end of pregnancy — is now worse than it was 25 years ago. Each year, an estimated 700 to 900 maternal deaths occur in the United States. In addition, the C.D.C. reports more than 50,000 potentially preventable near-deaths. Black women are three to four times more likely to die from pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention. It’s partly why the overall rate of pregnancy-related deaths has climbed over the past two decades, making the maternal mortality rate in the United States the worst in any industrialized country, according to a 2016 analysis published in the journal The Lancet. “It’s basically a public health and human rights emergency because it’s been estimated that a significant portion of these deaths could be prevented,” said Dr. Ana Langer, director of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health in Boston. The reasons behind the racial disparities are many and complex, she said. Lack of access and poor quality of care are leadings factors, particularly among women at lower socioeconomic levels.
The Center for Disease Control (1999), though, points to the fact that 50% of pregnancies are unplanned. These pregnancies are associated with increased mortality for the mother and infant. “Lifestyle factors (e.g., smoking, drinking alcohol, unsafe sex practices, and poor nutrition) and inadequate intake of foods containing folic acid pose serious health hazards to the mother and fetus and are more common among women with unintended pregnancies” (Center for Disease Control, 1999, p. 849). In addition, the CDC estimates that half of the women that experience an unintended pregnancy do not seek prenatal care during the first trimester. But there’s a bigger problem, Langer said. “Basically, black women are undervalued. They are not monitored as carefully as white women are. When they do present with symptoms, they are often dismissed.” “Racism affects so many things before the patient even gets to the clinical encounter,” she said. “Both implicit bias and structural racism affect how women are cared for in the health care system.” The cards are stacked against them once they enter that system, she said, pointing to the report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” published by a division of the National Academy of Sciences.
The report’s researchers found that, among other factors, bias and stereotyping regarding people of color can impact the level of health care they receive. That differential treatment can happen through direct care or from communication gaps in which crucial details about a patient’s medical history fail to get passed along, Bryant Mantha said. “All told, some African-American women are probably entering pregnancy less healthy than other women,” she said. Childbirth educators are in a unique position to instruct women about the risks of unhealthy lifestyle factors and delayed prenatal care. Contraception information can be added to the curriculum to help women reduce their risk of unintended pregnancy during the postpartum period. In addition, childbirth education efforts must be extended to more women living in poverty. Childbirth educators can play a role in bringing our nation closer to the 2010 National Health Objectives to reduce the overall maternal mortality ratio to no more than 3.3 per 100,000.
High blood pressure and cardiovascular disease are two of the leading causes of maternal death, according to the Centers for Disease Control and Prevention, and hypertensive disorders in pregnancy, including pre-eclampsia, have been on the rise over the past two decades, increasing 72 percent from 1993 to 2014. A Department of Health and Human Services report last year found that pre-eclampsia and eclampsia (seizures that develop after pre-eclampsia) are 60 percent more common in African-American women and also more severe. There’s also a push to increase education about bias. “Some hospitals and health care systems have implemented training on implicit or unconscious bias,” Petersen said, “to think about how people’s backgrounds and unconsciousness may be affecting their care.”
Cases
Serena Williams knew her body well enough to listen when it told her something was wrong. Winner of 23 Grand Slam singles titles, she’d been playing tennis since age 3—as a professional since 14. Along the way, she’d survived a life-threatening blood clot in her lungs, bounced back from knee injuries, and drowned out the voices of sports commentators and fans who criticized her body and spewed racist epithets. At 36, Williams was as powerful as ever. She could still devastate opponents with the power of a serve once clocked at 128.6 miles per hour. But in September 2017, on the day after delivering her baby, Olympia, by emergency C-section, Williams lost her breath and recognized the warning signs of a serious condition.
She walked out of her hospital room and approached a nurse, Williams later told Vogue magazine. Gasping out her words, she said that she feared another blood clot and needed a CT scan and an IV of heparin, a blood thinner. The nurse suggested that Williams’ pain medication must be making her confused. Williams insisted that something was wrong, and a test was ordered—an ultrasound on her legs to address swelling. When that turned up nothing, she was finally sent for the lung CT. It found several blood clots. And, just as Williams had suggested, heparin did the trick. She told Vogue, “I was like, listen to Dr. Williams!” But her ordeal wasn’t over. Severe coughing had opened her C-section incision, and a subsequent surgery revealed a hemorrhage at that site. When Williams was finally released from the hospital, she was confined to her bed for six weeks.
Shalon Irving, an African American woman, was 36 when she had her baby in 2017. An epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC), she wrote in her Twitter bio, “I see inequity wherever it exists, call it by name, and work to eliminate it.” Irving knew her pregnancy was risky. She had a clotting disorder and a history of high blood pressure, but she also had access to top-quality care and a strong support system of family and friends. She was doing so well after the C-section birth of her baby, Soleil, that her doctors consented to her request to leave the hospital after just two nights (three or four is typical). But after she returned home, things quickly went downhill. For the next three weeks, Irving made visit after visit to her primary care providers, first for a painful hematoma (blood trapped under layers of healing skin) at her incision, then for spiking blood pressure, headaches and blurred vision, swelling legs, and rapid weight gain. Her mother told ProPublica that at these appointments, clinicians repeatedly assured Irving that the symptoms were normal. She just needed to wait it out. But hours after her last medical appointment, Irving took a newly prescribed blood pressure medication, collapsed, and died soon after at the hospital when her family removed her from life support.
The CDC now estimates that 700 to 900 new and expectant mothers die in the U.S. each year, and an additional 500,000 women experience life-threatening postpartum complications. More than half of these deaths and near deaths are from preventable causes, and a disproportionate number of the women suffering are black. Put simply, for black women far more than for white women, giving birth can amount to a death sentence. African American women are three to four times more likely to die during or after delivery than are white women. According to the World Health Organization, their odds of surviving childbirth are comparable to those of women in countries such as Mexico and Uzbekistan, where significant proportions of the population live in poverty. Irving’s friend Raegan McDonald-Mosley, chief medical director for Planned Parenthood Federation of America, told ProPublica, “You can’t educate your way out of this problem. You can’t health-care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.”
Nina Martin noted telling commonalities in the stories she’s gathered about mothers who died. Once a baby is born, he or she becomes the focus of medical attention. Mothers are monitored less, their concerns are often dismissed, and they tend to be sent home without adequate information about potentially concerning symptoms. For African American mothers, the risks jump at each stage of the labor, delivery, and postpartum process.
Neel Shah, an obstetrician-gynecologist at Beth Israel Deaconess Medical Center in Boston and director of the Delivery Decisions Initiative at Ariadne Labs, recalls being struck by Martin’s ProPublica-NPR series Lost Mothers, which delved into the issue. “The common thread is that when black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less,” he says. “It’s forced me to think more deeply about my own approach. There is a very fine line between clinical intuition and unconscious bias.”
The reasons for the black-white divide in both infant and maternal mortality have been debated by researchers and doctors for more than two decades. But recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595019/
https://www.hsph.harvard.edu/magazine/magazine_article/america-is-failing-its-black-mothers/