Black maternal mortality in the US: An example of racial bias

Systemic racism does not just show itself in wealth, education, and policing. Our healthcare system plays a role as well, and quality and outcomes for Black women’s health compare poorly to other ethnicities when observed at a systemic level.

One glaring example of this is pregnancy: Black women are 3 to 4 times more likely to die from pregnancy-related complications than white women in the US (1). We will be diving into this issue today. Read on to learn:

• How does maternal mortality compare in the US compared to other nations?
• How is maternal mortality an example of systemic racism in Black women’s health?
• How does maternal mortality compare for Black women vs. non-Black people of color and white communities?
• Why do Black women die from pregnancy-related causes at a higher rate than white women? What pre-existing conditions are Black women at risk for and how do socioeconomic factors play a role?
• What evidence is there to suggest that implicit racial bias is causing poor outcomes for Black pregnancies?
• What can I do as a women’s health specialist to bring equity and equality to Black women’s health? What can I do as an individual?

Black maternal mortality rates: A national problem

At over 17 deaths per 100,000 maternal births (2), the United States is known for its abysmal maternal morality rate compared to other developed nations. However, splitting out Black and white communities shows an even more shocking dynamic: while there are 13 deaths per 100,000 live births for white women, Black pregnancies see a mortality ratio of 41 (3,4):

This mortality rate - which indisputably compares poorly when US development and wealth is considered - is not equal across all ethnicities. As shown in Table 2 below, Black women are at higher risk compared to all other ethnicities (5):

Note that across the board, Hispanic women actually tend to have healthier pregnancies than white women, and Asian women see relatively similar outcomes with a 10% higher mortality rate. Native American and Black women, however, face a different reality: they see over 2x and over 3x deaths compared to white pregnancies respectively.

This data indicates that there are indeed racial disparities in healthcare outcomes between Black and non-Black women.

Socioeconomic factors behind maternal mortality

Racial disparities behind pregnancy-related mortality in the US is indisputable, particularly for Black and Native American communities. This can be attributed to several core factors: higher rates of co-morbidities seen in Black women and lack of access to higher quality hospitals and healthcare resources.

HIGHER RATES OF CO-MORBIDITIES

Certain pre-existing health conditions can make a woman more likely to have an at-risk pregnancy. According to the NIH these conditions include but are not limited to obesity, diabetes, hypertension (high blood pressure), PCOS, and other conditions relating to our autoimmune, thyroid, and overall health (6,7).

Due largely to lifestyle factors, Black women are at an increased risk for obesity, diabetes, hypertension, and general hormone imbalance in addition to other less common conditions. Consider the following:

• Black women have the highest obesity rates of any other ethnic group in the US, with 4 in 5 being overweight (20% more than white women) (8)
• Almost 15% of Black women have diabetes compared to 8% of white women - a 1.7x disparity rate (9)
• Black communities are 40% more likely to have higher blood pressure compared to white adults, but less likely to have their blood pressure under control (10)
• While limited reports indicate Black women are at an increased risk for PCOS, most studies show that there is no strong correlation (11). However, there is widespread knowledge that the Black community’s use of endocrine disrupting products - oftentimes which corporations specifically target them with - can result in estrogen-dominant issues that lead to pregnancy complications such as fibroids.

Obesity, diabetes, and hypertension are chronic conditions worth discussing in relation to systemic change because they are largely born out of lifestyle factors, not pre-existing propensity. Inactivity and poor diet can not only cause but snowball these conditions, and lack of education about preventative wellness coupled with insecure financial situations has been shown to worsen this dynamic for Black communities specifically (12).

LACK OF ACCESS TO QUALITY HEALTHCARE RESOURCES

Research indicates that when compared to mostly white and Hispanic-serving hospitals, those that serve primarily Black communities perform statistically worse when it comes to delivery and obstetric care (13).

Another data point is a study published by Am J Public Health that assessed outcomes for white and Black women with five of the same pregnancy complications (preeclampsia, eclampsia,  abruptio placentae, placenta previa, and postpartum hemorrhage). They found that fatality rates for Black women were 2.5x - 3.9x higher than their white counterparts overall, with only one-third of samples being somewhat attributable to a higher prevalence among the Black study participants (14).

Data points like this point to a slightly more direct example of systemic issues than prevalence of pre-existing conditions: on a broad level Black communities, and in particular Black mothers, do not have access to the same quality of healthcare as white people.

Implicit racial bias in the healthcare system

There are a host of external factors at play that cause a disparity in pregnancy-related mortality rates in Black women. Thinking about systemic change can be overwhelming, especially with an issue as massive as racial bias in America, and it can be easy to shift the blame to socioeconomic factors that are difficult to untangle and manage at the healthcare delivery level.

And as discussed in this article, there are countless social determinants of health that feed into Black women’s healthcare outcomes. Pre-existing conditions alone are heavily influenced by education, wealth, living conditions, overall security, and more. Discerning the true “root” of the problem when it comes to pregnancy mortality rate disparity amongst Black women is overwhelming, and it is difficult to pinpoint where to start (much like a hormonal imbalance, if that is a helpful comparison!).

One surprising trend seen in Table 2 is the way in which Black women’s disparity ratio increases with each higher education bracket. For example, Black women with a high school degree see about 2x pregnancy-related mortality compared to white pregnancies versus 5x for Black women who are a college graduate. If women with college degrees tend to have higher paying jobs than women without, why does this category of Black women see the highest disparity ratio of all other ethnicities in this data?

In general, higher levels of education are positively correlated to greater wealth and increased health. Given that, if Black women in the highest education bracket are still seeing over a 500% PRMR compared to white women, this indicates there is racial bias occurring at the health system and point of care level, as opposed to broader socioeconomic factors that leave Black communities predisposed to worse health outcomes.

Numerous other studies show this dynamic as well: even when controlling for education, socioeconomic factors, pre-existing conditions, and access to proper prenatal care, Black women see higher pregnancy mortality ratios than non-Hispanic white women (16, 17, 18).  

When controlling for external factors like socioeconomic status, education, and pre-existing risk factors, it is easier to see how implicit racial bias is showing up in the health system. From interactions between patient and physician, treatment strategies, health outcomes, and more, the evidence shows that race plays a role in quality of care (5, 19).

Recognizing that there are tangible systemic injustices within women’s health is a step to making a more equitable healthcare system for Black communities. The next step is for us to change it.

Working for change

Being aware of injustice within the systems we all use and act within is the step that needs to happen before action. In light of the recent killings of George Floyd, Breonna Taylor, Ahmaud Arbery, and other Black men and women whose lives have been unfairly taken by the police, we are at a pivotal moment where change seems more possible.

For many, police brutality is an overt action to label as unjust, devastating, and racist. But the real issue begins at a much more deep-seated level that is harder to recognize, admit, and confront as white and non-Black people of color. It is similar to unpacking the root cause of a hormonal imbalance as opposed to treating individual symptoms with medication. It is harder, and takes longer, but to truly heal we must do the work.

As mentioned, we believe healthcare injustice sits at an interesting point between being a very defined problem (e.g., police brutality), and systemic issue that is overwhelming to even begin comprehend changing (e.g., an incarceration system that has eroded the family unit, and subsequently security of the Black community, over time).

And as a women’s hormonal health company, we have a responsibility to do our part in addressing both the root cause and symptoms of racial bias within the healthcare system.

Below are some tangible steps for our community to contribute to this issue whether you are a member or provider. We will continue adding to this list as time goes on, and we encourage you to send ideas and feedback to hello@pollie.co.

PROVIDERS: QUESTIONS TO ASK

• Am I educated about the racial disparities within the US healthcare system? If so, how am I leveraging this knowledge to improve care for my patients through addressing factors that may be impacting them or directing them to more resources? How can I better improve my awareness and education?
• Is my decision-making process different when working with Black women and other people of color? If so, is this to create an enhanced and personalized care experience for my clients (e.g., more education on wellness for women who may be lacking this), or due to pre-existing assumptions, or implicit bias?
• Am I working within a practice that enables racial bias? What points can I surface with my colleagues to turn this into a discussion? Is this a practice I want to continue working at, or is the bias too ingrained and should I consider switching to a team that enables a more equitable system to flourish?
• How can I use my unique knowledge and strengths to tackle this at a systemic level with my work, or even outside of my organization? In what way will my time and energy be used most effectively to combat this problem?

MEMBERS: QUESTIONS TO ASK

• Am I educated about the racial disparities within the US healthcare system? If so, are my friends and family as well? How can I build awareness about this issue in a proactive way? If this is new information to me, how can I educate myself further?
• Have I experienced racial bias, either positive or negative, from a healthcare provider? Am I comfortable with bringing this up with my healthcare provider(s)? If I am white or have not experienced racial bias, how can I use this privilege to drive change in the way my providers may interact with Black and non-Black people of color?
• How can I support healthcare-related institutions that support a more equitable system vs. those that have allowed inequality to pervade?
• How can I leverage my strengths to make an impact on racial bias within the healthcare and wellness spaces if this is a system issue I feel strongly about and want to devote myself to?

EDUCATE YOURSELF

• BOOKS
• Seeing Patients: Unconscious Bias in Healthcare (Augustus A. White III, MD)
• Just Medicine: A Cure for Racial Inequality in American Healthcare (Dayna Bowen Matthew)
• Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine (Damon Tweedy, MD)
• ARTICLES
• Doctors and Racial Bias: Still a Long Way to Go (New York Times)
• Race and Medicine: The Harm that Comes from Mistrust (New York Times)
• The US finally has better mortality data. Black mothers still fare the worst (NBC)
• What’s killing America’s new mothers? (Quartz)
• For research, check out the references at the bottom of this article
• DOCUMENTARIES
• The Naked Truth: Death by Delivery (Fusion)

ORGANIZATIONS: GET INVOLVED, DONATE

• NBEC (National Birth Equity Collaborative)
• NBEC works toward creating solutions that optimize Black maternal and infant health through training, policy advocacy, research, and community collaboration. You can donate to them here.
• BMMA (Black Mamas Matter Alliance)
• BMMA was born out of the Center for Reproductive Rights (CRR) and SisterSong Women of Color Reproductive Justice Collective (SisterSong) that began in 2013. Their mission is to to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice. You can donate to BMMA here.
• Shades of Blue Project
• Shades of Blue Project’s Kay Matthews founded this organization after giving birth to a stillborn daughter. Her mission is to teach Black women how to advocate for themselves both before and after childbirth, particularly when it comes to maternal mental health. They organize support groups that you can sign up for on their website, and their next one will be starting on June 30th, 2020.

If you have feedback on this article or would like to see a specific future topic, please email your comments and ideas to hello@pollie.co.

References

1. Tsigas, Eleni Z, et al. “Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States.” CDC, Centers for Disease Control and Prevention Public Health Grand Rounds , 14 Nov. 2017, www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html.
2. Hoyert DL, Miniño AM. Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020.
3. “Maternal Mortality Ratio (per 100,000 Live Births) 2017.” World Health Organization, World Health Organization, 2017, gamapserver.who.int/gho/interactive_charts/mdg5_mm/atlas.html.
4. “GDP per Capita, PPP (Constant 2017 International $).” Data, data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD?end=2018&start=2018&view=map.
5. Peterson, Emily E, et al. “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016.” CDC, US Department of Health and Human Services/Centers for Disease Control and Prevention, 6 Sept. 2018, www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6835a3-H.pdf.
6. “What Are Some Factors That Make a Pregnancy High Risk?” Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, www.nichd.nih.gov/health/topics/high-risk/conditioninfo/factors.
7. Engmann, Lawrence, et al. “Racial and Ethnic Differences in the Polycystic Ovary Syndrome Metabolic Phenotype.” American Journal of Obstetrics and Gynecology, U.S. National Library of Medicine, May 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5420474/.
8. “Office of Minority Health.” Obesity and African Americans - The Office of Minority Health, minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=25.
9. “Office of Minority Health.” Diabetes and African Americans - The Office of Minority Health, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18.
10. “Office of Minority Health.” Heart Disease and African Americans - The Office of Minority Health, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19.
11. Wolf, Wendy M et al. “Geographical Prevalence of Polycystic Ovary Syndrome as Determined by Region and Race/Ethnicity.” International journal of environmental research and public health vol. 15,11 2589. 20 Nov. 2018, doi:10.3390/ijerph15112589
12. Scott AJ, Wilson RF. Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration. Rural Remote Health. 2011;11(1):1634.
13. Creanga AA, Bateman BT, Mhyre JM, Kuklina E, Shilkrut A, Callaghan WM. Performance of racial and ethnic minority-serving hospitals on delivery-related indicators. Am J Obstet Gynecol 2014;211:647.e1–16. https://doi.org/10.1016/j.ajog.2014.06.006
14. Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007;97:247–51. https://doi.org/10.2105/AJPH.2005.072975
15. Braveman, Paula, and Laura Gottlieb. “The social determinants of health: it's time to consider the causes of the causes.” Public health reports (Washington, D.C. : 1974) vol. 129 Suppl 2,Suppl 2 (2014): 19-31. doi:10.1177/00333549141291S206
16. Novoa, Cristina, and Jamila Taylor. “Exploring African Americans' High Maternal and Infant Death Rates.” Center for American Progress, Center for American Progress, 1 Feb. 2018, www.americanprogress.org/issues/early-childhood/reports/2018/02/01/445576/exploring-african-americans-high-maternal-infant-death-rates/.
17. Margaret A. Harper and others, “Racial disparity in pregnancy-related mortality following a live birth outcome,” Annals of Epidemiology 14 (4) (2004): 274–279, http://www.annalsofepidemiology.org/article/S1047-2797(03)00128-5/abstract
18. Joyce A. Martins and others, “Births: Final Data for 2006” (Atlanta: Centers for Disease Control and Prevention, 2009). https://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf
19. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105:e60–76. https://doi. org/10.2105/AJPH.2015.302903

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