The tragedy of maternal deaths in the US
Dear Leading Ladies,
As the question looms about whether or not women in this country will continue to have the right to decide when and if they have children, we thought it important to look at the unequal care and consideration that pregnant women in this country receive. Perhaps no other problem is more emblematic of intersectionality – what the Oxford Dictionary defines as “the interconnected nature of social categorizations such as race, class, and gender, regarded as creating overlapping and interdependent systems of discrimination or disadvantage” – than maternal health care in the richest country in the world. So here goes.
There are 4 million births in our country each year. Approximately 700 women in America die each year during pregnancy, childbirth, or from subsequent complications. (Forbes, 2021)
There are 4 million births in our country each year. Approximately 700 women in America die each year during pregnancy, childbirth, or from subsequent complications. (Forbes, 2021)
According to statistics from the CDC in 2018, out of every 100,000 who gave birth and died, 37.3 were Black women; 14.9 were non-Hispanic white women; and 11.9 were Hispanic.
In other words, Black women are 2-3 times more likely to die than white women. Education, income and insurance does not explain it all, according to activist Dorian Warren, since Black women with a college education are at 60% greater risk for maternal death than a white or Hispanic woman with less than a high school education. (Dorian Warren on NPR’s The Takeaway. Dec. 10, 2021)
California has the lowest maternal death rate at 4.5 per 100,000; Georgia has the highest at 46.2, according to 2016 statistics. Massachusetts is at 6.1, the second lowest in the country. As of 2016, only 54% of counties in the US had Ob/Gyns and 44% had nurse midwives, according to the US Department of Health and Human Services, making access to quality prenatal and birthing care very difficult for too many women.
The US ranks LAST among industrialized nations in maternal deaths. That puts our maternal death rate at twice that of Canada and France; more than 5 times that of Germany and the Netherlands; and more than 15 times that of New Zealand. (Dorian Warren, NPR)
“Globally, we use this as a barometer of the health of the nation,” says Dr. Joia Crear-Perry of the University of California-San Francisco and President of National Birth Equity. She also sees a connection between maternal health and access to abortion. If abortion is outlawed and maternal health care does not improve, she says we are going to see more moms and babies die.
Racism is at the source of much of the problem. The care, or substandard care, that many pregnant Black women receive finds its roots in the legacy of one Dr. J. Marion Sims, often considered the father of modern gynecology. In the 1880s, he perfected his skills by practicing on enslaved Black women without using any pain medications. These were women who had no control over their own bodies. They were handed over to Sims, probably for a fee, as the doctor developed the speculum and ways to treat vaginal fistulas or disadvantage”. Some theorize that Sim’s work helped perpetuate the myth of Black immunity to pain.
It is no wonder that many Black women distrust the medical establishment. “Distrust in the healthcare system often results in reduced encounters with the system, which can be very harmful given the established association between late and inadequate prenatal care and poor pregnancy outcomes such as low birth weight, preterm birth, and infant mortality,” Wikipedia reports from a study in the World Journal of Gynecology and Women’s Health.
Add to that the compromised quality of the hospitals that many Black women have to receive their care from. According to a study conducted by Dr. Elizabeth A. Howell, racial and ethnic minority women deliver "in different and lower quality hospitals" than White women. According to Dr. Howell, hospitals where African American women were disproportionately cared for during birth, "had higher risk-adjusted severe maternal morbidity rates for both Black and White women in those hospitals.” In other research, reviewed in the Journal of Managed Care, “Of the 39 New York City hospitals included in the study, researchers found a 6-fold difference in risk of combined mortality and morbidity outcomes” between hospitals catering to Black versus white patients.
What is also true is that hospitalized Black women are given pain medication less frequently than white women. A 2016 study published in the Proceedings of the National Academy of Sciences of the US “provides the first evidence that racial bias in pain perception is associated with racial bias in pain treatment recommendations.” In other words, the authors found that doctors who believed that Black people felt less pain than white people then treated them with less pain medication. And there were significant numbers of medical professionals who believed that ridiculous old trope. So it is no surprise that, although Black and Latina women report more pain after childbirth, they receive fewer pain meds.
Many of the health issues that can lead to maternal death (such as being at risk for embolisms, developing diabetes, pre-eclampsia, infections before or after birth, even postpartum depression) can be treated successfully if caught early and carefully monitored, but that requires pregnant women to have good insurance and information, to trust their caregivers, and for the medical system to be responsive and caring.
It is important to acknowledge that “deaths during delivery are significant, but only part of the problem. Slightly more than half (52% of all deaths occur after the day of delivery, while almost a third occur during pregnancy.” (Commonwealth Fund) This problem is exacerbated by the fact that women on Medicaid are scheduled for fewer postpartum visits and follow-up than those with private insurance.
Besides death, there are other traumatic experiences related to birth that can have lifelong effects on a mother and family. For instance, Black women are 4 times more likely than white women to live in a neighborhood with high violent crime and high air pollution. These factors can adversely affect preterm birth, Dr. Heather H. Burris wrote for the National Institutes of Health. When discrimination leads to limited income and residential segregation, families can find themselves confronted by toxic environmental exposures that can then lead to low birth weights, learning disabilities, chronic lung disorders, and other stressors that can plague a family. “It’s going to require societal interventions to improve environments,” Burris concluded.
Clearly, maternal health care in the United States is a problem that demands remediation. And there are solutions. Birth Equity, for one, has created a multi-faceted outline for tackling the issue of racism in the care of Black pregnant and new mothers. More suggestions for positive change appeared in a May 2021 report in the journal, Obstetrics & Gynecology, which recommended that “vulnerable segments of the population, especially non-Hispanic Black women, need to be supported through comprehensive and sustained public health programs that address preconceptional health and chronic conditions (at the individual level), implicit racial bias among health care professionals (at the interpersonal level), quality of care in hospitals predominantly serving non-Hispanic Black women (at the community level), and paid parental leave and extended health insurance (at the societal level).”
So there it is. We need high quality universal health care; better training for health care workers to address their biases, conscious and unconscious; more opportunities for Black doctors and nurses in medical and nursing schools so that Black Americans can see caregivers who look like them and that they believe they can trust; and expanded parental leave to allow babies and parents to bond, to heal, and to become families.
Next time you see your ob/gyn, ask him or her what he or she is doing to help equalize maternal health care. Share a fact or two from what appears above. That might just stimulate some thought or action for your doctor to bring to a discussion with his or her colleagues.
Have a wonderful holiday. We are taking next week off, but will be back with a letter on December 29 to wish you a happy new year.
One full of hope, of course.
Therese
Judy
Mary
Beth
Leading Ladies Executive Team
Leadingladiesvote.org
ladies@leadingladiesvote.org