By Meghan Jusczak, Jane Crow Project Writer
August 10, 2017
Maps of African American maternal and infant mortality rates now provide significant insight into where life-savings strategies could be focused and most effective. In the United States, African American mothers die three to four times more often than white mothers, but that ratio varies dramatically from state to state, city to city and rural region to region.
For example, an African American mother in New Jersey is more than 14 times more likely to die due to pregnancy and childbirth-related complications than an average mother of any race in Massachusetts, a state that provides medical insurance for as little as $9 a month to all of its residents. Massachusetts’ overall maternal mortality ratio (5.6) is also significantly lower than the U.S. average for 2015 (26.4).
This data has become available President Trump and the U.S. Congress remain committed to cutting Medicaid’s budget. The federal health insurance plan pays for 69 percent of African American births.
The maternal mortality comparative data, based on the maternal mortality ratios from an October 2016 research study are represented above through maps created by the Preeclampsia Foundation to illustrate dramatic disparities in U.S. maternal mortality rates by race and from state-to-state.
These disparities carry over into infant mortality as well. A map from the National Birth Equity Collaborative’s Campaign for Black Babies reveals that major cities with the highest losses of African American pregnant women and new mothers — Washington, D.C., New York City, Detroit, Atlanta, Dallas and Houston — are among the 18 cities in the United States with the highest rates of black infant mortality.
“When it comes to these racial disparities, or even state-by-state disparity, it is a series of contributing factors, none of these has one single reason--if they did, we would probably be applying one single solution,” said Eleni Tsigas, the executive director of the Preeclampsia Foundation. “They’re deeply complex issues.”
Dr. Joia Crear-Perry, the founder and president of the National Birth Equity Collaborative, has detailed not only the root causes for the high rates of African American maternal and infant mortality in the United States (institutional racism, class oppression and gender discrimination and exploitation) but also how these root causes play out as social determinants of health, such as safe affordable housing, transportation and job security. Dr. Crear-Perry, based in New Orleans, presented her findings in July as part of the Council on Patient Safety in Women’s Health Care’s Safety Action Series.
These factors then can contribute to psychosocial stress and potential unhealthy behaviors, she reported.
Joining Dr. Crear-Perry in the presentation, Chanel L. Porchia, the founder and executive director of Brooklyn’s Ancient Doula Song Services, elaborated on black women’s “psychosocial stress.”
Intergenerational trauma among African American families (many now believe DNA can be modified due to recurring traumatic events) and the chronic stress of unequal treatment that, over the course of a lifetime, causes anxiety and releases stress hormones. These biological processes not only create “wear and tear on the body’s organs and systems, but can trigger premature labor,” Porchia said, quoting Dr. Michael Lu’s research. He is head of Maternal and Child Health Bureau of the federal Health and Human Services agency.
Alexis Dunn is another investigator into fatal health disparities. Dunn, a doctoral student in nursing at Atlanta’s Emory University, focuses her research on potential biological factors that explain why African American women are at the highest risk for preterm births (which is one of the leading causes of infant mortality). Emory is the preeminent university among the Historically Black Colleges and Universities.
“So much of what we do in this field is reactionary,” Dunn said. The larger research project she is a part of aims to be more preventative and create screenings that can reveal which women are at the highest risk for preterm births.
Outside of her research, Dunn said another way to address maternal and infant mortality from a more preventative approach is to address the shortage of U.S. maternity care providers. Georgia has one of the greatest number of births per year (more than 130,000 in 2015), some of the highest maternal mortality rates and a severe shortage of maternity care providers.
“Obstetric deserts” in Georgia
According to a 2014 study from Georgia’s House of Representatives, 52 percent of the counties outside of the Atlanta metropolitan area have overburdened obstetric providers or none whatsoever.
By 2020, the report estimates, 75 percent of these counties will lack adequate obstetric services.
“With one OB and a midwife, we did 550 deliveries last year,” said a representative from the only obstetrical practice in Moultrie, Ga., the third largest city in the state’s Southwest area. “Sometimes we see 60 women in a day; 75 to 80 percent of our patients are on Medicaid. It’s difficult to recruit physicians of any kind to this area.”
Despite the rising need, obstetric units throughout the state are closing--two units closed in October 2014, the month the report was published.
One solution to these “obstetric deserts” Dunn mentioned is an increased reliance on midwives. More stringent rules for midwifery in Georgia exist than in states with much better maternal outcomes, such as Oregon. Midwives must engage in “collaborative practice agreements” in Georgia, where at least four midwives must work with one physician. This makes it difficult for nurse-midwives to use the holistic approach in which they specialize, she said.
According to maps above, Oregon, with a ratio of 8.8 deaths per 100,000 live births, has the best outcomes for black mothers in the nation. Georgia, at 49.9 per 100,000, is among the worst.
“For the obstetric deserts, if there were fewer regulations, we could put some midwives in those areas,” Dunn said. “There are no doctors in that area, and we could at least put a midwife in that area. So we’re making a big push in our state right now, because it also costs significantly less to train a midwife. Plus we have the data to back it up that shows that nurse-midwives provide great maternity care.”
Congressional bills to address maternal mortality
In addition to pushing back against federal threats to Medicaid and public health infrastructure, Tsigas mentioned that the Preeclampsia Foundation is leading some of the advocacy efforts to pass two Congressional bills to decrease maternal mortality rates across the United States.
The House bill, the Preventing Maternal Deaths Act of 2017, was introduced in March and has more momentum, with one sponsor and 59 cosponsors signed on. The Senate’s Maternal Health Accountability Act introduced in May will build on many of the same objectives.
The bills focus on what Tsigas calls “maternal safety bundles” that address different factors leading to maternal mortality (and often infant mortality), such as obstetric hemorrhage, inadequate postpartum care, maternal depression and anxiety and better care for mothers with hypertension (A list of all the bundles, with more information on each, can be found here).
“The reason we’re so adamantly behind this bill is that it’s not just theoretical solutions,” Tsigas said. “Some parts of the bill are already being implemented and there are concrete effects.”
In California specifically, some elements of the bill, such as prescribing emergency hemorrhage care, are in place and as a result, over the last few years, overall maternal mortality has declined in the state.
“Honestly, it just comes down to the fact that women in every state should have hospitals that are using best practices,” Tsigas said. “And then they experience the better outcomes that come from those best practices.”