- The United States has the highest rate of maternal mortality in the developed world, and the rate among black women is higher in comparison to white women.
- 2020 candidates Kamala Harris and Elizabeth Warren blame the disparity on systemic racism and bias in medicine. Harris proposes spending millions on implicit bias training to combat the issue.
- Research shows that a more effective way to combat maternal mortality is to improve health care options in rural areas, offer toolkits to hospitals for pregnancy-related health problems, and revamp federally funded health care options.
Despite advances in medical science and technology, pregnancy-related mortality rates (PRMR) in the United States have been steadily increasing since the 1990s.
The U.S. has the highest mortality rate for pregnant and postpartum women than any other developed country in the world. U.S. women are three times more likely than Canadian women to die during or after childbirth, NPR and ProPublica explained earlier this month in a report that brought the issue new exposure.
According to a May report from the Center for Disease Control and Prevention (CDC) Foundation, approximately 700 women die due to pregnancy-related complications in the U.S. each year. Of those deaths, 60% are preventable.
The CDC says “patient-level contributing factors were commonly identified” as the causes of death, but “prevention strategies to mitigate these factors are often reliant upon providers and health systems.”
Contributing factors at the hospital or doctor level included a lack of standardized policies and clinical skills. The CDC also cited the failure of providers to consult specialists. The average maternal death was caused by 3.7 critical factors.
The PRMR for black women in the U.S. is 3.3 and 2.5 times as high as the PRMR for white women.
Pointing to racial bias as the reason for the high PRMR among black women
The PRMR for black women has been growing steadily since the 1980s. Some politicians, journalists and health care professionals say this rise is related to racial bias in medicine.
2020 presidential candidate Kamala Harris reintroduced her Maternal Care Access and Reducing Emergencies (CARE) Act on May 22 — which did not receive a vote prior to the end of the 115th Congress in 2018 — to implement a $150 million program to fight “deep racial disparities in care across the country,” according to Politico.
The proposal also “aims to create demonstration projects that will create incentives for providers to deliver integrated health services to pregnant women and new mothers and reduce maternal deaths.”
The program would fight “bias in maternal care by directing grants to medical schools, nursing schools and other training programs intended to improve care for African American women.”
Black mothers are dying at alarming rates from pregnancy-related causes in part because of racial bias in our health care system. Everyone should be outraged this is happening in America.
— Kamala Harris (@SenKamalaHarris) May 4, 2019
Fellow presidential contender Elizabeth Warren also blames racism for the high mortality rate among pregnant black women in the United States:
Black women are 3 to 4 times more likely than white women to die from pregnancy or childbirth-related causes. A major reason? Racism. It’s time to hold health systems accountable for protecting Black moms. https://t.co/WxVm56TGOB
— Elizabeth Warren (@ewarren) April 30, 2019
Vox and ProPublica collaborated to create a video in 2017 linking racial bias in medicine today to medical experimentation performed on slaves starting in the 17th century and forced sterilization that took place throughout the 20th century.
How does racial bias lead to the death of pregnant women and new mothers? New York Times Magazine writer Linda Villarosa, who has studied the topic of maternal mortality for years, wrote in a 2018 feature story that experiencing systemic racism can cause “toxic physiological stress,” which results in the most common conditions that lead to the deaths of many pregnant and postpartum women of color, including hypertension and pre-eclampsia. She further added that women of color tended to have their concerns or pain dismissed by doctors more often than women of other races.
Other causes of high pregnant mortality among black women
Many studies cite the insurance and healthcare differences between white and black women as reason enough to blame the racial bias of providers for the high rate of pregnancy-related deaths among black women in the U.S. More tangible studies, however, point to other causes that the government should focus more time and money on. (RELATED: Abortion Advocates Claimed Clinic Funding Cuts Caused Spike In Maternal Mortality — But It Wasn’t True)
Contributing patient-oriented factors that led to death were lack of access to clinical care, unstable housing, lack of (or inadequate) transportation, obesity and associated complications. Contributing health-care-provider factors were limited experience with OB emergencies, lack of personnel and lack of protocol or tools.
The top causes of death, totaling at 460 and 427 deaths from 2010 to 2015, respectively, were “other cardiovascular conditions” and “other non-cardiovascular conditions, like diabetes, lupus, or sickle cell anemia. Hemorrhage and infection (including sexually transmitted infections) were the third and fourth most common causes. Deaths that occurred six weeks to one year after birth were most common.
Black women are most susceptible to these causes. According to the American College of Obstetricians and Gynecologists, “the leading causes of death among non-Hispanic black women include complications related to cardiovascular disease, preeclampsia and eclampsia.”
Black women also have cesarean-section deliveries more than any other race in the U.S., which, while necessary in many cases, “are not without their own risks which can include higher rates of hemorrhage, transfusions, infection, and blood clots for mothers. For babies, the risks include higher rates of infection, breathing complications and lower breastfeeding rates,” says the California Health Report.
Black women — especially young black women — are also disproportionately affected by heart disease in comparison to white women.
While there is limited data specific to each state regarding pregnancy-related deaths caused by hemorrhaging and infection, there appears to be a correlation between women’s cardiovascular-related health problems and areas with large black or African-American populations in the U.S.
For black women living specifically in remote areas, the risks are even greater because living further away from care means less frequent doctor visits and more difficulty planning for delivery. Additionally, only 16% of black women with low incomes have insurance, versus 21% of white women with low income. One in four black women in the U.S. are covered by Medicaid.
Drastic rate of rural hospital closures
Rural hospitals also have fewer births, which affects both pay and experience for doctors who work at those locations.
The New York Times reported in 2018 that “at least 85 rural hospitals — about 5% of the country’s total — have closed since 2010, and obstetric care has faced even starker cutbacks as rural hospitals calculate the hard math of survival.” And only half of the country’s hospitals offer obstetrics care.
The Housing Assistance Council (HAC) says “nearly nine out of 10 rural and small-town African Americans reside in the Southern region of the United States. Rural African Americans comprise an even larger portion of the population in the southern ‘Black Belt’ communities of Alabama, Georgia, Mississippi, North Carolina, South Carolina and Virginia, as well as the Lower Mississippi Delta states of Arkansas, Mississippi and Louisiana.”
Louisiana, Georgia and Arkansas have among the top three worst maternal mortality rates in the country. Louisana has the third largest black population in the country, Georgia has the fifth largest and Arkansas has the 13th largest.
The Louisiana Department of Health noted a lack of access to health care providers or facilities was the most common contributing factor to pregnancy-related deaths.
In Alabama, which has the seventh largest black population in the country, only 16 of the state’s 54 rural counties offer obstetric hospital care; that number dropped from 45 out of 54 in 1980.
Mississippi, which has the second-largest black population, “has more rural hospitals at risk of closing than any other state in this country, meaning the most medically underserved state could soon lose even more doctors,” Mississippi Today reports. The article continues to explain that of Mississippi’s 64 rural hospitals, 31 — or 48% — are at “high financial risk, which is “more than double the rate nationwide.”
Warren has suggested that offering bonuses to hospitals that have the lowest PRMR among black women should get bonuses, “And if they don’t, then they’re going to have money taken away from them,” she said in a speech at the She the People Forum.
But punishing hospitals by taking money from them will not solve the issue of racial disparities in pregnancy-related deaths.
Brock Slabach, Senior Vice President for Member Affairs at the National Rural Health Association, was a rural hospital administrator for more than 21 years, and he says the number of rural hospital closures is higher at about 106 hospital closures since 2010, and it keeps increasing.
He said that the closures are the result of a combination of factors including low reimbursement and low volume of patients, which go hand-in-hand. “In a hospital in general, you have a fixed cost … regardless of the amount of patients. Overhead has to be compensated in some fashion,” he explained. (RELATED: Opinion: States Need To Stop Falling For The Boondoggle Of Medicaid Expansion)
Over 80% of hospitals in the United States have fixed costs to pay for electricity, staff salaries, buildings, equipment and more. When a hospital has too few patients to compensate for those fixed prices, everyone suffers. Professional liability costs, too, come at higher prices in remote hospitals because work is higher-risk, Slabach explained.
He also said patients who visit rural hospitals are more likely to have “multiple chronic conditions at the same time due to lack of timely access, cost of care, and the complication of health literacy of patients in rural areas tends to be less.”
Racial bias or reimbursement cuts and hospital closures?
The tragedy of high and increasing pregnancy-related deaths among women — especially black women — appears to be more due to a lack of healthcare in rural communities and reimbursement problems than racial bias in medicine.
It is clear, however, that racial minorities living in poverty do suffer the consequences of a lack of funding put toward rural hospitals more than white people living in poverty.
The bipartisan Preventing Maternal Deaths Act was signed into law in 2018. Original cosponsors included Democratic Michigan Rep. John Conyers, Democratic Colorado Rep. Diana DeGette and Republican Pennsylvania Rep. Ryan Costello.
The law allocates “$58 million for each of fiscal years 2019 through 2023” to direct the Department of Health and Human Services to create grants for the purpose of reviewing pregnancy-related deaths and supporting MMRCs in states and tribal nations across the country.
The law also says states are required to report and investigate “concerning maternal deaths” through the CDC. Yet it’s hard to tell whether the law has led to any improvements.
Slabach said his ideal solution to reduce deaths in pregnancy would be to “1. Stop the bleeding. Reverse the cuts, sequestration, bad debt expense and Medicaid expenses. 2. Look for a new model of care in rural communities … [such as] a combination of a health center and critical aspect hospital — like a clinic on steroids. 2. Be very aggressive on innovation. [We need] new payment models that will begin to address the problems.”
He concluded that the solution “almost always reduces to money.”
How California is working to solve pregnancy-related mortality
One unexpected bright spot defying the trends in pregnancy-related deaths is in the state of California. Since 2006, when California’s PRMR was at 16.9 births per 100,000, the state has cut its PRMR by over 50%, defying national trends. How?
Much of the progress can be attributed to the California Pregnancy-Associated Mortality Review (CA-PAMR). The project compiled the details of how every mother died over five years. Hemorrhage and pre-eclampsia were the two most common causes of death, the “vast majority” of which “could have been prevented through early recognition, teamwork and a list of well-rehearsed treatments,” Stanford University Clinical Professor of Obstetrics and Gynecology Elliott Main told NPR.
“The analogy would be if you had a cardiac arrest and everyone had their own way of doing CPR,” Main told NPR. “We’ve made big advances in emergency care by having some basic standardized approaches to emergencies. That’s what we’re bringing to maternity care now.”
The California Maternal Quality Care Collaborative provides toolkits, which include safety protocols for clearing blood clots and policies for limiting cesarean-section rates in first-time deliveries, to hospitals so they can review performance data (what works and what doesn’t).
The California Health Care Foundation also launched an initiative in 2018 to “lower the state’s c-section rate for low-risk mothers to under 23.9% by 2020.”
Programs such as those that have helped California fight the issue of maternal mortality and ideas proposed by experts like Slabach would likely have more of an impact than a $150 million program to fight “deep racial disparities in care across the country.”