Preventing maternal mortality: We have to address the racism first

New standards to address the maternal mortality crisis will go into effect July 2020 and aim to improve how hospitals prevent, identify, and treat maternal hemorrhage and severe pre-eclampsia. Journalists from USA Today and ProPublica have documented this crisis and its impact on every day women. 

Even famous women like Beyonce and Serena Williams survived serious complications with their recent pregnancies, preeclampsia and a pulmonary embolism respectively

Shalon Irving, a scientist at the Centers for Disease Control, lieutenant commander in the U.S. Public Health Service Corps, died three weeks after the birth of her daughter from complications from high blood pressure

Their stories are shared as a way to discuss the high rate of maternal mortality in the U.S. and the even higher rates of maternal mortality experienced by different groups. These three women are African American, and their race matters, but not in the way you might think. It’s racism, not race. 

The U.S. has the highest maternal mortality rate compared to other high-income countries, 26.4 compared to the next highest countries’ rate of 9.2 per 100,000 births. Some women within the U.S. have maternal mortality rates much higher than the national average.

Black, Native American and Alaska Native women have 3.3 and 2.5 times the pregnancy related mortality rate as white women. These disparities are not fully explained by differences in health status, socio-economic status or patterns of health-care use.  

Three in 5 pregnancy related deaths are preventable. Federal agencies, state health departments, hospitals, and others are taking steps to prevent maternal mortality. There are multiple bills in Congress aimed at improving maternal health. Public health and other health professionals have the opportunity to inform maternal health policy; therefore it is essential we accurately describe the upstream factors that contribute to disparities in maternal mortality. 

Recently I listened to someone with a public health background describe maternal health disparities as affecting “the young, brown, and poor.” After they spoke, an audience member suggested the speaker take more care in how they described disparities.

Their advice was to avoid making statements that inadvertently reaffirm biases about race and health. I wish I had added my voice to her feedback to say, “it isn’t that they are young, brown and poor, it is the unequal distribution of adverse childhood experiences, educational and job opportunities, and access to health care based on age, race, and class.”

The more we learn about maternal mortality in the U.S., the more we understand how unequal experiences beginning in childhood and occurring over time lead to stress, trauma, health problems. We are learning how access to health care, treatment, and outcomes are unequal. 

For example, one research study found that black and white women had the same rate of 5 pregnancy complications, but black women were 2 to 3 times more likely to die than white women.  

Black women may be receiving care at lower quality hospitals and other research has identified differences in prenatal advice by race. However, other research has Native American and Alaska Native communities are living with the effects of historical trauma and areas with significant Native American populations have shortages of health facilities and health professionals. 

So how should we, public health professionals, talk about race and maternal mortality in order to inform policy? 

If we discuss race, without focusing on social conditions, we are supporting a historical narrative that blames, specifically black and women of color, for health complications during pregnancy. Worse, this uncritical presentation can incorrectly communicate that the disparity in maternal health is genetically or biologically inherent. 

Falsely equating race with biology (and genetics) has been a shameful chapter in Western and U.S. history health and social science. This idea has seen the recent resurgence and it is essential we do not allow this idea to seep into policy efforts to address maternal mortality. 

Legislation to improve delivery of evidence-based practices across hospitals is a good start as are efforts to identify, address, and reduce racial biases in the health-care setting. We should protect key provisions of the Affordable Care Act that prevent health insurance companies from denying women coverage based on pregnancy.  

Looking further upstream another remedy is legislation that extends Medicaid coverage for one-year postpartum to women with eligible for Medicaid based on income or pregnancy or legislation that requires health insurance plans to provide a special enrollment period for pregnancy.  

If we think about and discuss health disparities by race in the big picture and over the life-course, with a focus on racism as a root cause, it is more likely to lead to policies that can more effectively address disparities in maternal health outcomes. 

Bryna Koch is a doctoral candidate in Public Health Policy and Management at the Mel and Enid Zuckerman College of Public Health at the University of Arizona and a Public Voices Fellow with The OpEd Project.

Tags Health economics Health equity Healthcare quality Maternal death Maternal health Midwifery Population Race and health Reproductive health

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