Pregnancy is a milestone millions of women dream of. Each year, around 3.7 million women in the U.S. give birth, and while it’s a time of great joy for many women, it’s downright dangerous for others. Alarmingly, after decades of dropping, the maternal mortality rate in the U.S. is actually increasing — at a time when it’s going down everywhere else that's a high-income country.
But even as the national conversation about maternal health has shifted to focus on the shocking, unacceptable growth in the maternal mortality rate here in the U.S., it's important to discuss one crucial aspect: That moms of color have the highest risk of dying. According to the Centers for Disease Control and Prevention (CDC), Black moms are roughly three-and-a-half times more likely to die in childbirth or of pregnancy-related complications than white moms, while American Indian and Alaska Native women are about two-and-a-half times more likely — and we need to understand why, and work to change that.
Why are moms of color more at risk?
The reasons why are complicated. The leading causes of maternal deaths in the U.S. include hemorrhage, cardiovascular and coronary conditions, cardiomyopathy — disease of the heart muscle — infection and embolism. All of these pregnancy and postpartum complications are generally preventable. But all of them are also greatly exacerbated by three key factors: poverty, lack of access to care and the impact of institutionalized racism on quality health care — all of which disproportionately affect women of color.
Take Texas, which has the highest maternal mortality rate in the U.S. The numbers are worrisome: The Texas Maternal Mortality and Morbidity Task Force, which is part of the Texas Department of State Health Services, found that between 2011 and 2012, there were 189 maternal deaths. The task force also found that Black women had the greatest risk of dying. Although they made up only 11 percent of births in 2012, they made up 29 percent of deaths, mostly dying from heart disease, drug overdoses and high blood pressure, according to the Texas Tribune.
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Texas is also known as the “uninsured capital of the United States,” with 18 percent of Texas residents uninsured (low-income women, women of color and immigrant women are all more likely to be uninsured).
But even moms who are insured can still be at risk. In 2017, tennis superstar Serena Williams gave birth to her first child, Olympia, by emergency C-section after the baby’s heart rate plunged to dangerously low levels during contractions. The surgery went smoothly — but was followed by a six-day ordeal that could have killed Williams if not for her diligent team of doctors and nurses. Williams had a pulmonary embolism, followed by a popped C-section wound and large hematoma in her abdomen. "When I finally made it home to my family, I had to spend the first six weeks of motherhood in bed," she said in an op-ed for CNN in 2018.
Alarmingly, a new research study of 32 million U.S. births released in June found that climate change, including high levels of pollution and elevated temperatures, disproportionately affected pregnant Black women, including higher rates of preterm and underweight babies, as well as more stillborn births. The researchers said that “social determinants” of health, including living in urban areas with higher exposure to air pollutants, and long-term high levels of stress, contributed to “adverse obstetrical outcomes.” High temperatures increased the risk of premature birth up to 21 percent, and an increase of 1 degree Celsius (May through September), correlated with a 6 percent increased chance of stillbirth. Black mothers are also 2.4 times more likely to have low birth weight babies.
Although COVID-19 is too new for epidemiogists and researchers to have thoroughly understood and analyzed how the coronavirus affects pregnant women and their babies, the Centers for Disease Control and Prevention (CDC) says that systemic health and social inequities have put some, particularly American Indian/Alaska Native, Latinx and Black people, at a higher risk of getting COVID-19 and experiencing severe illness, including hospitalization rates. (Black people and American Indian/Alaska Native are approximately five times more likely to be hospitalized than white people.)
The CDC analyzed data on over 91,000 women of reproductive age who had COVID-19, with 9 percent being pregnant. Pregnant women had a 1.5 times higher risk of being hospitalized. (But, the researchers didn’t analyze by race, nor could they determine if the women were hospitalized for labor and delivery, or the coronavirus.) And pregnant women who develop COVID-19 pneumonia may be at an increased risk for preterm and cesarean delivery.
Low-income moms are especially at risk
Texas mom Alicia Woods was expecting her second child in 2017. Like a lot of other moms-to-be, she experienced the excitement of seeing that first positive pregnancy test, debated whether to find out her baby’s sex and delighted in watching her baby grow each week. But her experience illustrates just how hard it can be for millions of low-income women to juggle precarious financial situations with getting the care they need.
When she got pregnant the first time, Woods couldn’t afford health insurance because she had recently graduated college and her job didn’t offer it. It wasn’t until she was pregnant that she became eligible for Medicaid, which paid for her prenatal care and delivery. But she was booted off the program 60 days postpartum.
For context: Before the Affordable Care Act (ACA), low-income women without insurance had to be pregnant to get Medicaid coverage — childless adults weren’t eligible for the program at all — and 60 days postpartum, they’d lose their coverage and find themselves without insurance once again. The ACA changed that for women who lived in states that took the Medicaid expansion, meaning that women in those states now have increased access to screenings for postpartum depression, for example.
Unfortunately, Texas wasn’t one of them, which means that Texas moms on Medicaid are still kicked off the program 60 days postpartum — but the vast majority of maternal deaths occur in the days and weeks postpartum, making this a crucial time to catch and treat health complications. The Texas task force found that 60 percent of the state’s maternal deaths occurred between 42 days and a year after delivery, suggesting that many of those moms fell into a coverage gap and weren’t getting health care after giving birth.
After her first pregnancy, the lack of insurance meant that Woods couldn’t afford health resources — like birth control — after the first six weeks. “So I was stuck, with no care, no way to afford birth control and was paid too little to afford it out of pocket,” she continued.
For her second pregnancy, Woods was in another tricky situation. Although she took a job that did offer insurance, she hadn't worked there long enough to be eligible for it. Without any kind of job security, Woods planned to be back at work a week after giving birth. “In order for me to secure my position, I would have to be back at work post delivery within three days or be terminated as a ‘no show, no call,’” she said. According to one study, 25 percent of women return to work less than two weeks after giving birth.
Lack of job security impacts new moms’ ability to see doctors. For Woods, one clinic in particular was exceptionally difficult to schedule an appointment at. As a result, if Woods wanted care, she would have had to drive to the clinic during their limited times of service. “By the time I would get off work they would be closing and, of course, they are closed on weekends. That made it really difficult to make an appointment,” she explained.
A 2018 Kaiser Family Foundation report found that 19 percent of low-income women report that they can’t take time off work to see a doctor. It’s a luxury low-income women don’t have.
Prenatal and postpartum care are crucial for both mom and baby. They allow doctors to screen moms for complications during pregnancy (such as gestational diabetes, which increases the risk of preeclampsia) and afterward (e.g. postpartum depression). Doctors also monitor new babies’ health during well-baby visits. But because women of color are more likely to be uninsured than their white counterparts, they’re less likely to get the care they need.
In fact, according to Rachel Ward, the national director of research at Amnesty International, who co-authored Deadly Delivery: The Maternal Health Care Crisis in the USA, a 2010 report that discusses maternal issues in the U.S., Latina and Black women are two-and-a-half times more likely than white women to delay prenatal care — something that the CDC says puts moms at a much higher risk for dying of pregnancy-related causes than women who do get care.
Jessica Shepherd, M.D., assistant professor obstetrics and gynecology at the University of Illinois College of Medicine in Chicago, also points out that Black women have higher rates of hypertension and diabetes, which can increase the risk of preeclampsia and other pregnancy-related complications — which, again, highlights just how important regular access to prenatal and postpartum care are.
Racism in maternal health care
Another, potentially more insidious culprit in the disproportionately high rate of maternal mortality for moms of color: racism. Or, as Elizabeth Dawes Gay, a co-director of the Atlanta-based alliance Black Mamas Matter Alliance, put it in a Fusion piece, “It’s because of the experience of blackness.”
A 2011 Amnesty International report listed “discrimination and inappropriate treatment” from medical professionals as one of the key contributors to higher rates of death for Black moms. Other research bears that out. For example, several studies have shown that Black patients are less likely to be treated for pain than white patients. A 2016 study from the University of Virginia found that it may explained in part because doctors still hold outdated, untrue beliefs about race, such as that Black patients feel less pain or that their skin holds fewer nerve endings than whites. None of these ideas is true, but the studies suggest that the ramifications of them are very real. It may be why Black moms-to-be tend to receive different, and worse, medical and prenatal care than white moms do, no matter their socioeconomic status, as a 2009 study from Harvard found.
“Assumptions are made about you when you walk through the door, based on how you walk, how you dress, whether you sound educated or not,” Chanel Porchia-Albert, founder and executive director of Brooklyn-based Ancient Song Doula Services told Newsweek in a 2016 article. “That can affect the care you get.”
Fighting for change
Some organizations are fighting back against the dangerous effects of institutionalized discrimination and lack of access to care. One is Cleveland-based nonprofit Birthing Beautiful Communities (BBC), which was founded in 2014 by birth worker Christin Farmer-Kane, after she realized there were no organizations in Cleveland specifically serving Black moms. Farmer-Kane sees a lack of cultural competency as a huge problem in the health care system, so she trains women in low-income neighborhoods to be doulas. Because these women know their communities inside and out, the idea is that they can help moms get the resources they need to make sure they and their babies stay healthy.
After a comprehensive training, those birth workers get to work with moms in their community by providing help with a model that Farmer-Kane developed called holistic birth equity — preconception, pregnancy, postpartum, maternal mental health, the workforce, education, entrepreneurship/business, legal help and housing. “We take into account everything that can impact the mother's health,” Farmer-Kane says. “If you don’t have access to housing, adequate education or adequate pay to take care of your family, then your stress levels will be high.” To that end, BBC workers may help moms find housing, connect them with resources to help them get their GEDs or provide nutrition seminars, breastfeeding classes, workshops on how to bond with baby and tips on how to relieve stress.
BBC also make home visits during and after pregnancy to help moms in the early days of parenthood, answer questions and make sure that both mom and baby’s needs are being met. (Some research shows that home visits may lower the infant mortality rate.)
Farmer-Kane and BBC are making a difference in their community, but the fact is, it’s unacceptable that moms in the U.S. are still dying in childbirth in 2020. The U.S. frequently touts itself as a leader in the developed world, but if we want to be taken seriously, we need to address this issue. Moms' — especially American Indian, Alaska Native and Black moms — lives depend on it.
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