Black Maternal Mortality: The Hard Truth

All pregnancies are not equal and neither are their outcomes. It might seem odd to say, but unfortunately it’s the truth. This is especially true for Black women in the United States. According to the CDC, each year, around 700 people die during pregnancy or in the year after. Black women are three times more likely to die from a pregnancy-related cause than White women. There are several factors that drive these disparities, including variations in the quality of healthcare, underlying chronic conditions, structural racism and implicit bias. Let’s explore some of these a little further.

Social determinants of health

In order to fully understand the complex factors that drive disparities in maternal mortality trends in the US, a deeper understanding of social determinants of health is needed.

What are social determinants of health or SDOH? The World Health Organization defines social determinants of health as ‘the conditions in which people are born, grow, live, work, and age – significant drivers of disease risk and susceptibility within clinical care and public health systems.’ It may sound like a mouthful, but the essential idea of social determinants of health is that factors outside of medicine, and rather your social wellbeing and state, can significantly affect your physical and mental health. These can include: access to healthcare, affordable housing, economic opportunity; just to name a few.

Taking into account social factors is essential to improving prevention and treatment of illnesses because social contexts do affect the delivery and outcomes of healthcare.

Access to quality care

One significant determinant of health, access to healthcare, has long been considered critical to improving maternal health outcomes for women of color. During pregnancy, a person’s need for access to maternal health services increases. Access to care is critical during pregnancy because it allows ‘providers to identify, treat, and stabilize chronic conditions; address behavioral needs; and plan for a healthy and intentional pregnancy.’1

Research has shown that women from racial and ethnic minority groups give birth in lower quality hospitals and in hospitals with higher rates of severe maternal morbidity. Using a simulation model, the same researchers found that if non-Hispanic Black women gave birth at the same hospitals as non-Hispanic White women, the non-Hispanic Black maternal morbidity rate would decrease by 47.7%, from 4.2% to 2.9%, clearly highlighting the huge inequities of quality care between Black and White women. Further research has also shown that many non-Hispanic Black women giving birth in underperforming hospitals experience poor communication with their providers and difficulties in obtaining appropriate prenatal and postpartum care.

Access to quality care is just one of the many determinants of health that play a role in the maternal mortality and morbidity rates we see in the U.S. today.

Structural racism: the underlying cause

While white women die from pregnancy-related causes at a rate of 13.4%, Black women die at a rate of 41.7%.2 These differences are striking, and while social determinants of health play a role, such as access to quality care discussed earlier, it’s so much more than that. Racism, classism, and gender oppression are at the root of these unequal health outcomes. These are what fuel the inequities seen in social determinants of health. However, it’s not enough to just consider the individual forms of racism and discrimination against Black people. We have to look further and acknowledge these bigger, structural and institutional systems in place to explain these disparities.

Black women’s higher maternal mortality and morbidity rates are rooted in structural racism. What is structural racism? Structural racism is defined as a ‘system in which public policies, institutional practices, and cultural representations work to perpetuate racial inequity.’3 Structural racism can manifest itself in several forms. A few ways include4:

High concentration of people of color in communities that lack quality healthcare facilities and providers
Harsh environmental factors and toxins in predominantly Black neighborhoods
Inequalities in the workplace
Highly concentrated food insecurity and food deserts within communities of color
Negative policy changes to healthcare programs (ex. Medicaid) that primarily serves people of color

Given the history of our country, some of this shouldn’t be surprising. Black people in the country have endured hundreds of years of racism in this country, within the various systems and institutions that are part of American society, with the US healthcare system being just one of them. Long-term and ongoing exposure to negative experiences, such as racism on both individual and systemic levels, can lead to toxic stress, raising the risk of conditions linked to higher rates of maternal and newborn mortality. It’s not just racism on an interpersonal level in everyday life, but racism in systems and structures, racism within the walls of hospitals on the part of healthcare providers, namely through forces such as implicit bias.

Implicit bias

Implicit bias is among many factors that contribute to disparities in health and healthcare. Implicit biases are ‘attitudes and beliefs about race, ethnicity, age, ability, gender, or other characteristics that operate outside our conscious awareness’5 Implicit bias can influence judgment and unintentionally lead to discriminatory behavior. Because implicit bias is an unconscious process, it’s hard to measure, and thus consequences resulting from it are difficult to recognize and control.

Discrimination and implicit bias in the healthcare delivery system are often expressed in the dismissal of Black women’s concerns and symptoms, leading to poor communication between the patient and their provider. A survey of women in California showed that Black women were ten times more likely to say they were treated unfairly than white women.6 This observation could be a result of poor patient-provider communication.

Implicit bias can affect how providers communicate with patients. Studies have found that people of color are more likely to report lower satisfaction with healthcare provider interactions.7 Implicit racial biases can manifest itself in the use of a condescending tone when speaking to patients, reducing the likelihood that they will feel heard and valued by their providers, or through the suggestion of a different course of treatment for patients based on presumptions about their ability to adhere to treatment or presumptive medical conditions. Further research has shown that healthcare providers who exhibit higher implicit bias demonstrate higher verbal dominance in their communication styles and less interpersonal interactions.8 As a result of this, patients of these providers report lower satisfaction ratings and a greater difficulty understanding or following recommendations by their providers, which can further reproduce biases by the provider. It’s a vicious cycle.

Moving forward

This blog just highlights a small portion of a bigger issue. It’s by no means an exhaustive review of the causes of Black maternal mortality in the U.S. Instead, it’s a brief overview written with the intentions of raising awareness on an issue that’s disproportionately impacting Black mothers. As a company that’s dedicated to improving maternal health and pregnancy outcomes through nutrition and lifestyle recommendations, it’s important to also recognize that there are bigger factors and systems at play.

References

“Improving Access to Maternal Health Care in Rural Communities.” Cms.gov, https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf. Accessed 30 Nov. 2022.
NHLBI, and NIH. “Systemic Racism, a Key Risk Factor for Maternal Death and Illness.” NHLBI, NIH, 26 Apr. 2021, https://www.nhlbi.nih.gov/news/2021/systemic-racism-key-risk-factor-maternal-death-and-illness.
“Closing the Coverage Gap Would Improve Black Maternal Health.” Cbpp.org, https://www.cbpp.org/research/health/closing-the-coverage-gap-would-improve-black-maternal-health. Accessed 30 Nov. 2022.
Taylor, Jamila, et al. “Eliminating Racial Disparities in Maternal and Infant Mortality A Comprehensive Policy Blueprint.” Americanprogress.org, 2019, https://cdn.americanprogress.org/content/uploads/2019/04/30133000/Maternal-Infant-Mortality-report.pdf?_ga=2.58426478.534167243.1625237322-612833220.1620046882.
Sabin, Janice A. “Tackling Implicit Bias in Health Care.” The New England Journal of Medicine, vol. 387, no. 2, 2022, pp. 105–107, doi:10.1056/NEJMp2201180.
National Partnership for Women & Families. “Listening to Black Mothers in California.” Nationalpartnership.org, https://www.nationalpartnership.org/our-work/resources/health-care/maternity/listening-to-black-mothers-in-california.pdf. Accessed 30 Nov. 2022.
Hall, William J., et al. “Implicit Racial/Ethnic Bias among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” American Journal of Public Health, vol. 105, no. 12, 2015, pp. e60-76, doi:10.2105/AJPH.2015.302903.
Johnson, Tiffani J. “Racial Bias and Its Impact on Children and Adolescents.” Pediatric Clinics of North America, vol. 67, no. 2, 2020, pp. 425–436, doi:10.1016/j.pcl.2019.12.011.
“Working Together to Reduce Black Maternal Mortality.” Cdc.gov, 10 May 2022, https://www.cdc.gov/healthequity/features/maternal-mortality/index.html.
“Social Determinants of Health.” Who.int, https://www.who.int/health-topics/social-determinants-of-health. Accessed 30 Nov. 2022.
Howell, Elizabeth A., et al. “Race and Ethnicity, Medical Insurance, and within-Hospital Severe Maternal Morbidity Disparities.” Obstetrics and Gynecology, vol. 135, no. 2, 2020, pp. 285–293, doi:10.1097/AOG.0000000000003667.