The US is one of 13 nations experiencing a growing maternal mortality rate since the international community set as one of the Millennium Development goals in 1990 to reduce maternal mortality by three-quarters by the year 2015. Within that rate, Black women are 3 to 4 times more likely to die than white women. To address this shocking disparity, Presidential candidate Kamala Harris has offered the Maternal Care Access and Reducing Emergencies (CARE) Act. Senator Elizabeth Warren has also offered her own ideas for addressing this racial disparity. The one-pager accompanying the CARE Act explains,
“researchers, medical professionals, and the public believed high rates of … maternal mortality in Black women could be traced to income, education level, health care access, and even genetics. Today, however, there is [a] growing body of evidence …that racism and racial discrimination faced by Black women throughout their lifetimes contribute to higher rates of maternal mortality and morbidity.”
At the She the People Presidential forum in April, focused on women of color Elizabeth Warren offered, “[t]here is a specific problem, as you rightly identify, for women of color who are three to four times more likely to die in childbirth. The best studies that I’ve seen put it down to just one thing — prejudice.” It’s worth asking if this racialized framing of the problem as a disparity between Black women and other mothers, rather than expressly as a medical problem, impedes or aids in actually solving the problem. After all, there are no peer reviewed studies that consider bias or prejudice to be a primary cause of pregnancy related death.
The first thing to note about our maternal mortality rate is that we don’t know precisely how many women die from childbirth related causes. These deaths are relatively rare, occurring in approximately 700 to 900 out of around 4 million births annually. The National Center for Health Statistics stopped publishing data on maternal mortality in 2007 to allow states time to standardize official death certificates to collect consistent data. Prior to 2003, only 16 states had a checkbox for women that asked if they had given birth. Women who died from childbirth related causes were often missed unless they died during childbirth. In the 16 states collecting that data, the timeframe between delivery and death varied from anywhere between 42 days to a year. NCHS set the standard at one year and allowed states time to voluntarily add the check box. This process was finally completed in 2017. On adding the checkbox to more accurately track these deaths states found that rates nearly doubled. Adding the checkbox is responsible for some of the increase in maternal mortality, but not all. The other important factor to note is that deaths resulting from hemorrhaging, embolisms, and pre-eclampsia, a form of pregnancy related hypertension, which were the leading causes of pregnancy related deaths 30 years ago, have all decreased. In a sense, the US has made great strides in addressing the causes of maternal mortality when the Millennium Development goals were set, however they did not anticipate the rise in other causes.
Looking at a report on maternal mortality from the state Department of Health and Human Services, Marissa Evans and Chris Essig of the Texas Tribune found that the women most likely to die after giving birth included, “black women over 40; unmarried women; women who use Medicaid, pay for insurance out of pocket, or have no insurance; and women who give birth through cesarean delivery. They’re also more likely to enter pregnancy with health problems like obesity, diabetes, high blood pressure and smoking habits.” In the US, close to a third of births occur through Cesarean section, with the added risks of infection and hemorrhaging that accompany such surgical procedures. The World Health Organization recommends limiting Cesarean sections to 10%-15% of births, beyond which the benefits decrease. It was 32% in 2015 in the US. Much like the data on maternal mortality, the data on cesarean sections is not rigorously collected and published. The prevalence of its use may be more determined by the region in which a woman is giving birth or even which hospital. In a number of cases, simply alerting doctors to the number of cesarean sections they perform that are low risk pregnancies lowers the number. There are factors that seem to make cesarean deliveries a reactive choice in some situations where it’s not a medical necessity. Louise Roth and Megan M. Henley noted in their study of cesarean research, Unequal Motherhood: Racial-Ethnic and Socioeconomic Disparities in Cesarean Sections in the United States, “lower-SES women are more likely to have primary cesarean deliveries than higher-SES women with similar risks and complications… non-Hispanic Blacks, Latinas, and Native Americans are more likely to have primary cesareans than non-Hispanic white women.” It might be tempting to think that simply bringing our cesarean rates into line with the WHO standard will dramatically decrease pregnancy related deaths and impact the racial disparity. It would have positive results as part of a larger strategy for lowering maternal mortality, as it has in California and Arkansas, but that alone is not enough to address the problem. While there is correlation between the increase in cesarean deliveries and the increase in maternal mortality, Greece makes it clear that it is not causation. Greece has nearly twice the US cesarean rate and less than half of its maternal mortality rate.
The official cesarean rate in Greece is 50%, yet several sources place that number closer to 70%. According to reports most births in Greece occur between 7am and 3pm, which suggests that women are having labor induced on a time table connected to either the personal choice of the mother or the physician, or related to an institutional imperative. One study of 3 Greek hospitals noted that the rate dropped dramatically over the weekend in public hospitals and on Sunday in private hospitals and suggested that may be further evidence that doctor convenience plays a larger part than medical need. Further, the cesarean section rate in private hospitals and clinics are significantly higher than in public facilities. This matches the findings of a study of cesarean rates around Europe, which noted that the one private obstetric unit in the United Kingdom reporting had twice the national average. It also found that even within the National Health Services, where maternity units follow common guidelines, there were wide differences between maternity units even after accounting for medical need. The fact that private obstetric units have much higher cesarean rates is especially relevant to our own largely private healthcare system. Despite several studies suggesting that women of higher socioeconomic status choose the procedure, Roth and Henley found that, “women with racial and socioeconomic advantages use them to avoid medically unnecessary cesarean deliveries rather than request them.” Black women and women of a lower socioeconomic status are more likely to have medically unnecessary cesareans as well as be more likely to have chronic health conditions like diabetes, hypertension, and obesity, which contribute to the growing number of deaths from cardiovascular conditions, the second largest cause of pregnancy related deaths.
In his essay, “The Strange Disappearance of History From Racial Health Disparities Research” Merlin Chowkwanyun says, “What is missing, however, is a deeper understanding of how and why these social determinants of social health disparities matter so much, the long term process through which they came into being…the major shortcoming in racial health disparities research is an absence of historical perspective that would enable exploration of historically rooted “fundamental causes.” Although Harris gets closer than Warren, in the end they both fail to account for history in their assessments of the cause for the racial disparity; the history of individual Black women and generally of Black women in our healthcare system. In attempting to challenge the disparity by focusing on the bias of health care providers, they essentially place Black women in a vacuum separate from a context in which 14% of Black women remain uninsured, many more remain underinsured, and each pregnancy is outside the context of the woman’s medical history. The chronic health conditions that increasingly endanger pregnant women don’t begin with the pregnancy. The idea that disparities exist despite the woman’s current income or educational level has built into it the assumption that current status is reflective of a woman’s history despite the greater likelihood that Black women have experienced a discontinuity of care during their entire lifetimes. When Harris says “that racism and racial discrimination faced by Black women throughout their lifetimes” contributes to the problem, she is correct but misunderstands what that means with regard to the fundamental causes and long term processes through which the disparities came to be. In the case of healthcare, the manifestation of systemic racism is the deprivation of medical services that disproportionately impacts Black women. Six of the ten states with the highest maternal mortality rates, and many of the Southern states with the highest percentage of Black women have yet to expand Medicaid coverage and many have sought to limit coverage. Additionally, many of the same states limit access to contraception as well as reproductive health services resulting in unplanned pregnancies. To the degree that confronting the implicit bias of individual health care providers is important, it matters less than the systemic discrimination of poor women, who are disproportionately Black, from health services. It’s telling that neither plan for confronting the racial disparity in maternal mortality addresses the deficit in medical access for a medical problem, instead choosing to focus on the perceived manifestation of a social problem. It helps to portray the issue as one that might end in equal results with no regard to the unequal access to care. This is what they’re referring to when Chokwanyun and Adolph Reed Jr say. “[t]aking racial disparity as a starting point can subtly coerce a univariate view that precludes attention to many overarching class dynamics…[t]he discourse of racial disparity is, when all is said and done, a class discourse,” in their essay “Race, Class, Crisis: The Discourse of Racial Disparity and its Analytical Discontents.”
Obviously, an important factor in lowering the racial disparity in maternal mortality is to assure Black women a consistent continuity of healthcare responsive to their needs. It should go without saying that this includes reproductive health, including the ability to make informed decisions about birth control and pregnancy. Any plan that purports to tackle the disparity without acknowledging and challenging the ability of states to limit access to healthcare in the states where most Black women live is not intended to succeed. In the absence of a universal healthcare system, policy makers could start by investing in rigorously collecting accurate data on where women are dying and why, and regularly publishing the data.