Maternal Mortality: The Deep Social Roots of America's Race Gap - Isabella Health Foundation

Maternal Mortality: The Deep Social Roots of America’s Race Gap

By: Josh Lowe

Josh Lowe is a freelance writer and editor specializing in public policy and social affairs.

In America in 2018, 658 women died while pregnant or shortly following their pregnancy, according to the CDC. While shocking, that number was not unusual.  Maternal mortality is the sixth most common cause of death among US women aged 25-34. Pregnancy and childbirth, a period that should be about celebrating new life, is for too many still a time of mortal fear. 

And that fear does not fall evenly. The maternal mortality rate has been rising steadily across the population since 1999, but as of 2018, the number of deaths per 100,000 live births among Black women was three times greater than among White women. 

This stark disparity is a complex phenomenon. Its roots lie deep in the social determinants of health — supported by systemic racism and implicit bias. In this article, we explain the nature of this disparity, identify some of its drivers, and examine some potential means of closing it for good. 

What is the scale of maternal mortality, and how does it differ between racial groups?

How high you set the rate of maternal mortality depends on how you define the problem. Various options exist, but the WHO defines a “maternal death” as “the death of a woman while pregnant or within 42 days of termination of pregnancy,” excluding deaths from accidental or incidental causes. 

The CDC’s January 2020 reporting on the maternal mortality rate in the US, which covers the year 2018, cites this definition and gives a figure of 17.4 maternal deaths per 100,000 live births.

This report noted “wide racial/ethnic gaps” between different groups. The CDC’s rate for non-Hispanic Black women for the same year stood at 37.1 per 100,000 live births, compared to 14.7 for non-Hispanic White women and 11.8 for Hispanic women.

And the disparity becomes especially pronounced with age. In a 2018 systematic review by Ozimek and Kilpatrick of pregnancy-related deaths in the United States from 2006 to 2010, teenaged Black women were 1.4 times more likely to die than their White counterparts, Black women aged 20 to 24 years were 2.8 times more likely to die, and Black women in all other age groups were more than 4 times more likely to die from pregnancy-related complications.  

The recent maternal mortality rate is high compared to previous decades. The rate was sliding downward in the US up to 1987, reaching a low of 6.6 deaths per 100,000 live births. It then stabilized between 7 and 8, before beginning the climb to current levels in 1999. 

Changes in defining and reporting the issue will explain some of the increase. For example, the CDC says that the gulf between its current rate and its 2007 figure of 12.7 can be “largely” attributed to “changes in the way the data was collected and reported.”

However, a recent maternal mortality article argues that other comparable countries such as the United Kingdom and Canada have not seen similar rises, yet are unlikely to have much poorer data collection methods. 

Where do the social roots of these disparities lie?

To answer this, we first need to look back 400 years into the past, to examine the history of slavery in the United States.

In a 2018 article for the American Journal of Public Health, Deirdre Cooper Owens, PhD, and Sharla M. Fett, PhD, examine the “entanglement” of the American medical profession with this most shameful of businesses. 

As early as 1662, Fett and Owens argue, “colonial Virginia legislators made Black women’s childbearing a centerpiece of the system of chattel slavery when they passed a law stating that the status of a child would follow that of his or her mother.”

Later, in 1807-08, when the transatlantic slave trade was banned and the influx of new African people cut off, “slaveholders began to bank their future increasingly on the fertility of enslaved women,” Fett and Owens write. 

This coincided, they continue, with an increased interest in the reproductive lives and health of enslaved women among the U.S. medical profession. White doctors brought in to help enslaved women with difficult births often blamed those women for deaths that more likely were rooted in their physically taxing work and poor nutrition. Meanwhile, many gynecological techniques were developed in part through experimentation on enslaved patients.

How, Fett and Owens ask, can Black people today wholly trust a profession with such a history? And how can doctors today abandon the centuries-old habits of dismissing the complaints and concerns of Black patients?

What are the social drivers of disparities in maternal mortality today?

Recent research finds Black women are nearly four times as likely to receive 0-5 prenatal care visits as White women. The author, Elizabeth Howell, MD states, “No or few prenatal visits are associated with maternal death.” And, Howell finds, “delay of prenatal care initiation has been associated with endorsement of experiences of racism.”

It’s an example of how the mutual mistrust between Black women and the medical profession, identified by Fett and Owens, may be part of the explanation for the race gap in maternal mortality today, centuries after Virginia’s chattel slavery laws were put in place. 

Howell publishes a conceptual model demonstrating a range of drivers of racial and ethnic disparities in maternal mortality and morbidity. 

Alongside more familiar “health status” factors such as rates of obesity, she highlights “patient factors” like employment status or levels of self-efficacy, “community/neighborhood” factors like the quality of housing, “provider factors” including levels of implicit bias, and “system factors” like access to quality care. 

How can these disparities be overcome?

Howell emphasizes the importance of education of clinicians and staff. She argues teaching medical staff about good communication practices, enhancing their understanding of these racial disparities, and helping them to grasp their own implicit bias and the importance of shared decision making would all be valuable routes to explore. 

Meanwhile, she suggests exploring and studying new models of antenatal care, particularly care focused on high risk pregnant women. And, she writes, a focus on preconception care can help to identify risky factors and optimize health in advance of pregnancy. Significant disparities in receipt of postpartum care exist and models should be explored that could eliminate these disparities. 

Some researchers, Ozimek and Kilpatrick, meanwhile point to an international example. The U.S., they write, “lags in its system of standardized maternal mortality review compared with other developed nations.”   In the United Kingdom, maternal deaths are reported to a database and reviewed by a multidisciplinary panel of experts. The system has been credited with slashing maternal mortality among Black African women. 

Owens and Fett issue a call “to decolonize obstetrics and gynecology specifically, and American medicine more broadly, and to apply comprehensive anti-racist policies in the prevention of Black people’s deaths.” 

They point to the example of the California Maternal Quality Care Collaborative (CMQCC), which “has used data-driven approaches in an attempt to understand the root causes of maternal mortality,” thereby “demonstrating for Americans how a commitment to anti-racism work can save lives and acknowledging that any system built on the backs of the enslaved needs repairing.”

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