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The Tragic Connection Between Race, Birth and Death

Despite the fact that giving birth is one of the most natural experiences a woman can have, it’s also somehow one of the most terrifying. So much can go wrong. You don’t know what to expect. You’re going to have to squeeze something the size of a watermelon out of a hole the size of a lemon. It’s a scary experience, no denying that. Clearly there are risks associated with giving birth — risks to the baby of course, but also risks to the mother. But a recent report from the Centers for Disease Control and Prevention shows that these risks are not equal for all mothers-to-be and all women in labor. In reality, African-American, Native American and Alaska Native women are about three times more likely to die from causes related to pregnancy, compared to white women in the United States. 

And perhaps most shocking and disappointing is that in many of these tragic cases the deaths could have been prevented. While some pregnancy-related deaths are not preventable and are nothing more than terrible tragedies, in many cases — 60 percent to be exact — pregnancy-related deaths are due to poor access to health care and insufficient medical care and support.   

Shame on us.

These findings, while inexcusable and infuriating are sadly not new. The issue of equal access to healthcare and the undeniable racial disparities regarding deaths linked to pregnancy have been a cause for concern and outrage for years. But even more frustrating and devastating is that now, after years of calls to improve medical care for women of color, this racial disparity has not only persisted, but also grown. 

This recent CDC report used data from both the 2011–2015 national CDC Pregnancy Mortality Surveillance System (PMSS) as well as from 13 state maternal mortality review committees (MMRCs) during 2013–2017. The research was conducted in an effort to better understand the significant racial/ethnic disparities in pregnancy-related mortality and to assess the rates of these pregnancy-related deaths. The ultimate goal is to, of course, prevent future deaths, but also to address contributing factors to pregnancy-related deaths and raise awareness for the various risks faced by pregnant women of different ethnicities. 

The Stats Behind Pregnancy-Related Death and Race

There are several key takeaways from the CDC report. But the most important finding is that there is an undeniable link between ethnicity and maternal deaths in this country. To be clear, we are talking about deaths from pregnancy-related complications in the United States, and how those rates differ among ethnic minorities in the country. And it is very clear from the findings that there is a significant difference, especially for Non-Hispanic black (black) women and American Indian/Alaska Native women.

The agency found that black women were 3.3 times more likely than white women to suffer a pregnancy-related death; Native American and Alaska Native women were 2.5 times more likely to die than white women. 

While maternal deaths are still considered rare — there are about 3.8 million births each year, with only 700 deaths related to pregnancy occurring on average — but they still do occur, and are far more common among those minority groups. 

For every 100,000 live, healthy births, 13 white women die. That number goes up drastically for black women and Native American women. For every 100,000 live births, 42.8 African-American women die, and 32.5 Native American/Alaska Native women. In addition, the numbers increase with age; mothers aged 40 and over have a pregnancy-related death rate of 76.5 per 100,000 live births.

What are the Most Common Causes of Pregnancy-Related Death?

As any woman who has ever been pregnant or given birth knows, there is a whole lot of risk involved with birthing a human. There’s a lot that can go wrong, a lot of tests you need to undergo and a crap-load of monitoring every month/week of your gestation. And as annoying as some of those appointments may seem, remember that you get to endure those tests and checkups and blood tests and ultrasounds and follow-up appointments if you are lucky enough to have access to such thorough, preventative medical care. Not everyone has that luxury.

And sadly, many cases of death related to pregnancy and childbirth could have been prevented with proper prenatal and postnatal healthcare. 

According to the CDC report, the most common causes of death were obstetric emergencies involving complications like severe bleeding caused most of the deaths at delivery. Most of the deaths that occurred after delivery during the first week postpartum were related to high blood pressure and cardiovascular disease, conditions not commonly associated with young pregnant women. Strokes were the most common cause of death during the first 42 days after the delivery.

In some cases cardiac disease, one of the leading causes of pregnancy-related death, may be present in a woman prior to pregnancy or childbirth. In other situations it is a medical condition that presents itself during pregnancy. And in either scenario, if that heart disease goes undetected and untreated it can lead to death during childbirth or after the baby is born. As The New York Times reports, according to Dr. Lisa Hollier, immediate past president of the American College of Obstetricians and Gynecologists, “when we look at the proportion of pregnancy related deaths by cause, the proportion due to cardiomyopathy has been increasing.” 

Risk to a New Mother Doesn’t End with Childbirth

It’s important to note that the risks associated with pregnancy-related deaths do not go away the moment a baby is born. If only it were as simple as that. If a woman was only at risk when she was actually squeezing a human being out of her body, then perhaps it would be easier to identify and treat any conditions or complications that might lead to death. Presumably that woman is already in a hospital, under medical care, with the necessary tools, medications and physician attention she needs to make it out of childbirth alive. But truth be told, a woman is at risk for pregnancy-related death for several weeks, even months, after her baby is born. But once she leaves the hospital, many mothers’ health is ignored, and they are quite frankly forgotten.

According to the CDC, a death is determined to be pregnancy-related if the death was caused by a pregnancy complication, a chain of events initiated by the pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Despite what some may believe or mistakenly assume, pregnancy-related deaths and the risk of pregnancy complications do not end with childbirth. 

One of the biggest shocks to come from the recent CDC report is the prevalence of deaths occurring after childbirth. More than half of pregnancy-related deaths occurred after the day of the delivery, and the experts found that mothers were at an elevated risk for up to a year after birth. While the majority of pregnancy-related deaths do occur during delivery, they can, and often do, occur in the weeks and months that follow.

Among pregnancy-related deaths for which timing was known, 31.3% deaths occurred during pregnancy, 16.9% on the day of delivery, 18.6% on days 1–6 postpartum, 21.4% on days 7–42 postpartum, and 11.7% on days 43–365 postpartum. Which means that more than a third of all pregnancy-related deaths occur more than a week after delivery and during that entire first year postpartum.

African American Women are Also at an Increased Risk of Heart Disease

While heart disease can affect women of any and all ethnicities, it is definitely more prevalent among black women. 

According to the American Heart Association, heart disease disproportionately affects black women, but African-American women are less likely than Caucasian women to be aware that heart disease is the leading cause of death, and that they are at risk. 49 percent of African-American women over the age of 20 have heart disease, but only 52 percent of African-American women are aware of the signs and symptoms of a heart attack that they need to look for. Black women are at a higher risk of developing heart disease — which is one of the leading causes of pregnancy-related death — and they are often unaware just how at risk they may be.

As far as why African American women are at such an elevated risk, there are several potential explanations. First of all, the African-American population also tends to have higher rates of obesity and diabetes, both of which put an individual at a greater risk of developing cardiovascular disease. In addition, African Americans may be genetically predisposed to developing high blood pressure, but they are unaware of their risk and unaware of the symptoms to look for. It’s a recipe for disaster, especially for African American pregnant women. 

The Undeniable Connection Between Race and Maternal Death

Another reason for this increased risk and ultimately, higher death pregnancy-related death rate among African Americans — black women do not receive the same level of health care as white women. “Basically, black women are undervalued,” says Dr. Ana Langer, director of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health in Boston. “They are not monitored as carefully as white women are. When they do present with symptoms, they are often dismissed.” She continues to suggest, “both implicit bias and structural racism affect how women are cared for in the healthcare system.” 

And this inexcusable reality is not exclusive to African Americans, but rather common among several racial minorities. The CDC report found that racial bias within the healthcare system is not only prevalent, but it is largely to blame for the disproportionate number of pregnancy-related deaths among minority women. 

This is not a new phenomenon; in fact it’s been going on for decades. In a 2002 report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” published by a division of the National Academy of Sciences, researchers found that bias and stereotyping based on race can impact the level of health care a person receives, and that ethnic minorities are likely to receive a lower quality of health services. 

The CDC’s recent findings prove what many women already knew: not much has changed in terms of equal treatment in the healthcare arena, especially for minority pregnant women.

And the American College of Obstetricians and Gynecologists agrees with the CDC’s findings (though they were not involved in their report). They also acknowledged that racial bias within the healthcare system is contributing to the disproportionate number of pregnancy-related deaths among minority women. For black women in particular, there are many pregnancy-related deaths that could have been prevented if proper care had been given. “We are missing opportunities to identify risk factors prior to pregnancy, and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women,” Dr. Lisa Hollier said in a statement. Those missed opportunities include, but aren’t limited to, lack of access to health care, missed or delayed diagnoses, and failures by doctors or nurses to recognize the warning signs.

The Good News: Change is on the Horizon

While we still have a long way to go in terms of implementing change and ensuring that all women, regardless of race, receive the same medical care and attention before, during and after childbirth, there has been some progress leading in the right direction.

For starters, several states and local communities across the country have instituted programs to help prevent pregnancy-related deaths, in an effort to hopefully serve as a model for the rest of the nation. 

In addition, a new federal law, the Preventing Maternal Deaths Act, provides grants to states and review committees that investigate, analyze, and report specified data relating to pregnancy-associated deaths (i.e., deaths from any cause during, or within one year of, pregnancy) and pregnancy-related deaths (i.e., deaths from any cause during, or within one year of pregnancy that are related to pregnancy or its management, excluding accidental or incidental causes). 

The American College of Obstetricians and Gynecologists also recently released new guidelines for treating heart disease during pregnancy. They also revised their recommendation on how to optimize postpartum care. While generally speaking most women have a postpartum visit with their OB-GYN about six weeks after delivery, experts are now suggesting that recovery and monitoring should be an ongoing process with services, checkups and support offered as needed based on a woman’s individual needs. Which is why it is so important that women know what signs to look for if something is wrong before, during or after childbirth, and they should be able to raise those concerns to their physician and actually be heard and receive the care they need. The new recommendation is that women should have some contact with a care provider within the first three weeks postpartum, and then should have a follow-up comprehensive visit no later than 12 weeks after birth. 

postpartum follow up care belatina
Mercy Sister Karen Schneider, who is a pediatrician, talks with the mother of a child in the emergency room at Johns Hopkins Hospital in Baltimore.

You can expect to hear a lot more about the topic of racial disparities in pregnancy-related deaths, and more generally about equal access to healthcare for women of minorities in the upcoming 2020 election. It’s already an issue getting a lot of airtime among the democratic candidates. 

Senator Kamala Harris, Democrat of California, and Senator Elizabeth Warren, Democrat of Massachusetts, have both been discussing this issue on their campaign trail. “Everyone should be outraged this is happening in America,” Ms. Harris recently said on Twitter. She blamed the deaths on racial bias in the health system. Senator Cory Booker, Democrat of New Jersey, wants to sponsor a bill that would expand Medicaid coverage for pregnant women. A bill proposed by Senator Kirsten Gillibrand, Democrat of New York, co-sponsored by Senator Kamala Harris, Democrat of California, and Booker would call on states to submit an annual report to the Department of Health and Human Services and allocate funding to hospitals to improve their training procedures to prevent racial disparities and implicit bias in healthcare. 

While it seems like we might be on the right track in terms of protecting the health and longevity of pregnant women of all races, especially minorities, we still need to do more. We’re at a crossroads now where women’s reproductive rights are under attack and so, it seems, are their rights to receive thorough, safe and effective healthcare if and when they do reproduce.  

“The bottom line is that too many women are dying largely preventable deaths associated with their pregnancy,” said Dr. Anne Schuchat, principal deputy director of the C.D.C. “We have the means to identify and close gaps in the care they receive,” she said, and we should be doing everything we can to bring down maternal mortality rates and put an end to preventable pregnancy-related deaths.

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