The United Nations Committee on the Elimination of Racial Discrimination heard testimony this summer on severe inequities in maternal health outcomes. This is an important and longstanding conversation within the international reproductive health community. But there was something different this time — the discussion focused on the vast racial disparities in maternal health right here in the U.S.
The testimony was spurred by a new report, Reproductive Injustice, published by the Center for Reproductive Rights, the National Latina Institute for Reproductive Health, and the SisterSong Women of Color Collective. The report’s shocking statistics and the women’s voices behind them make clear that the U.S. has a long way to go when it comes to maternal health outcomes — especially for women of color.
It’s hard to believe that maternal mortality rates in the U.S. are greater than in 63 other countries, but it’s true. Here in the United States, the proportion of women who die during pregnancy and childbirth complications is worse than Libya, Iran, and Turkey — and it’s going up, even though the rates are declining in nearly every other country in the world. When it comes to racial disparities, the situation is even bleaker. Nationally, black women are almost four times more likely to die during pregnancy and childbirth compared to white women. Racial disparities in maternal mortality persist across all levels of income, age, and education.
These disparities highlight that we need to do better by all pregnant women and pay particular attention to pregnant women of color. We see three areas of particular concern, as well as some encouraging progress emerging in each category:
1. The problem itself is unclear.
We need to better understand why maternal deaths are occurring and then use what we learn to help prevent future deaths. An important step in this direction is making sure every woman’s death is carefully reviewed. Ideally, all 50 states would have a well-functioning maternal mortality review board — a group of clinicians, maternal health experts, and community leaders that meets whenever a death happens to determine what went wrong and then uses the information to improve clinical and public health practice.
Right now, only about half of states have review boards in place and just a few are operating optimally. But a new project is helping 12 state departments of health learn how to systematically review deaths and, even more importantly, translate the findings into concrete action to enhance care for women. As more states gather, share, and analyze data on deaths and complications — and then institute evaluation metrics based on these data — we will likely see improvements in quality of care and, hopefully, reduced disparities in maternal health.
2. There is a lack of standard care to manage obstetric emergencies.
A woman in Atlanta may not receive the same care she would receive in Albany because hospitals across the country do not have a standard set of guidelines to follow during an emergency situation. Even within the same city, quality of care may differ among hospitals. Unlike with a stroke, the care a woman receives when facing a life-threatening obstetric emergency may vary depending on doctor, facility, or zip code. We know that variation in care affects quality, which results in poorer outcomes. Without standardization, women suffer the consequences, including death and life-long health problems.
Fortunately, leading physician, nurse, and quality improvement organizations are now working together to ensure consistent, high-quality maternal health care. Through this new collaboration, hospitals in five states are implementing standard approaches for managing obstetric emergencies. The goal is that hospitals throughout the country will follow suit so that all childbirth complications in the U.S. are handled in the same way and every woman receives evidence-based care, regardless of who she is and where she delivers. Eliminating inconsistent care is key to closing the gap in poor maternity care outcomes.
3. Chronic conditions are on the rise.
Our fragmented health care system does not make it easy for a pregnant woman with diabetes, hypertension, obesity, and/or mental health issues to receive the comprehensive care she needs. In the U.S., many pregnant women of color and those from low-income areas are struggling with chronic conditions, which exacerbate a woman’s risk for pregnancy- and childbirth-related complications. Pregnancy presents a unique window of opportunity to link women to the healthcare system and monitor and manage chronic conditions. In addition, eligibility levels for Medicaid are lower during pregnancy, so women are able to seek health care that they may not have been able to afford previously, or in some states, when Medicaid coverage lapses six weeks after pregnancy.
The good news is that community-based organizations in cities with particularly poor maternal health statistics and high proportions of women of color, like Baltimore, Camden, NJ, New York City, and Philadelphia, are developing creative ways to link women with chronic conditions to prenatal and primary care. One innovative example is engaging community health workers to take on basic components of chronic disease management — including measuring weight, glucose levels, and blood pressure — and training them to make referrals when needed.
These community-based approaches make it simpler for pregnant women to get the support they need when they need it — and empower them to manage their health for the long-term. Some of these groups are also working with women before they get pregnant to improve their overall health, which ultimately improves their pregnancy outcomes. In this way, community-based organizations do not just help pregnant women in immediate need, but also play an important role in prevention.
Every pregnant woman has a right to a safe and healthy pregnancy and childbirth. It will take the combined efforts of clinicians, communities, government and business to tackle the diverse factors that contribute to poor maternal health. Only then will we make progress in overcoming disparities in maternal health outcomes and improve maternal health for all women in this country, no matter the color of their skin or where they give birth.
Priya Agrawal is an ob/gyn the Executive Director of Merck for Mothers, Merck’s 10-year, $500 million initiative to reducing maternal mortality. Linda Blount is the President and CEO of the Black Women’s Health Imperative, which advances health equity and social justice for Black women across the lifespan through policy and advocacy, education, research and leadership development.