A woman is more likely to die during or after childbirth in the United States than in any other developed nation.
In fact, as the maternal mortality rate has progressively fallen worldwide, it has risen sharply in the U.S. From 1987 to 2017, pregnancy-related deaths increased from 7.2 to 17.3 deaths per 100,000 live births, according to the Centers for Disease Control and Prevention’s (CDC’s) Pregnancy Mortality Surveillance System.
That the U.S.’ maternal mortality rate is nearly twice that of other high-income nations is alarming; what’s worse is that it is far from the whole story. In 2018, the maternal mortality rate for non-Hispanic Black women was 37.1 per 100,000, according to the National Center for Health Statistics — two and a half times the rate of non-Hispanic White women and more than three times that of Hispanic women. Worse still — of the approximately 700 pregnancy-related deaths in the U.S. each year, the majority are considered preventable.
Why Are American Mothers Dying?
More specifically, why, in the 21st century, in one of the most developed nations in the world, are women dying from a largely avoidable cause? And why are Black women dying at vastly disproportionate rates?
The short answer is, we don’t know. However, the role of systemic racism cannot be ignored. Research has repeatedly shown that racial and ethnic disparities persist in today’s healthcare system, and that these disparities are associated with poorer care and outcomes across various facets of health. With regard to maternal mortality, the systemic nature of the issue may also have a profound influence on outcomes. As Dr. Rachel Hardeman, Assistant Professor of the University of Minnesota’s Division of Health Policy and Management, told The New York Times:
“People of color experience the cumulative effects of disadvantages throughout their lives … The constant stress of racism may lead to premature biological aging and poor health outcomes for African Americans. This means they might enter into pregnancy less healthy.”
There are many other intersecting factors underlying the U.S.’ maternal health crisis and fueling the racial divide.
On a global scale, the U.S. has a shortage of maternity care providers compared to other high-income nations, according to an analysis from the Commonwealth Fund, which may have a disproportionate effect on medically underserved populations, including Black communities. The study pointed to a lack of sufficient postpartum care, despite the fact that the majority of the country’s pregnancy-related deaths occur after delivery. Postpartum home visits were covered by national insurance in all 10 of the countries analyzed; in the U.S., coverage varies by state Medicaid program and health plan.
This disparity in postpartum care speaks to a larger issue in America — access to and continuity of care for underserved populations. While federal law requires states to provide Medicaid coverage to low-income pregnant women, they must only do so up to 60 days postpartum, leaving many new mothers uninsured during a period when more than half of maternal deaths occur. As KFF notes, this issue is especially pronounced in states that did not expand Medicaid coverage under the Affordable Care Act (ACA). Research from Georgetown University links Medicaid expansion to improved health and outcomes across all stages of pregnancy, resulting in reduced maternal mortality rates.
Geography also plays a vital role. A 2020 March of Dimes report found that more than 2.2 million women of childbearing age live in a maternity care desert — a county in which there are “no hospitals providing obstetric care, no birth centers, no OB/GYN and no certified nurse midwives.” In 2017, Texas, the state with the highest uninsured rate, also had the highest maternal mortality rate, according to the BBC.
An Urgent Call for Progress
Maternal mortality is one of the World Health Organization’s 100 indicators of population health, and reducing it is a global priority. It’s the primary target of the United Nation’s Sustainable Development Goal number three, a campaign promise of President Joe Biden and a cause long championed by Vice President Kamala Harris.
On his campaign website, Biden outlined his commitment to reducing the U.S.’ “unacceptably high maternal mortality rate” — a problem he stressed is “especially prevalent among Black women.” To deliver on this promise, Biden pointed to California, whose Maternal Quality Care Collaborative (CMQCC) was successful in reducing the state’s maternal mortality rate by 55%. According to its website, CMQCC provides quality improvement toolkits to improve health outcomes for mothers and their infants. As president, Biden said, he would take California’s strategy nationwide.
But while California was successful in reducing its overall maternal mortality rate, the racial disparity in pregnancy-related deaths in the state remains wide. In response, CMQCC has launched its Birth Equity Collaborative, a pilot program to support the development of quality improvement tools that integrate clinical and sociocultural interventions. If California is to serve as a national compass, it is imperative to acknowledge the state’s shortcomings in reducing the racial maternal mortality gap, as well as understand and address the many determinants — clinical and non-clinical — that lie at the root of the crisis. Let’s root for California’s efforts to correct healthcare disparities to be a success, and also support similar efforts across the nation.
Read more from HMS about the cost of racial inequity in healthcare.
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