How do we prevent our mothers from dying before, during, and after childbirth? The United States has the worst maternal mortality rate among high-income nations — and it’s getting worse. According to the Centers for Disease Control and Prevention’s latest data, the maternal mortality rate is on the rise and racial disparities have widened. The maternal mortality rate, defined as the ratio of deaths to 100,000 live births, rose in the United States from 17.4 in 2018 to 23.8 in 2020.
This ratio is drastically different when broken down into racial categories. While non-hispanic white women face a maternal mortality rate of around 19.1 deaths(still two times higher than the next comparable country), Black women experience triple that rate at 55.3 deaths per 100,000 births. Disparities in outcomes do not disappear when controlling for education or socioeconomic status, and the CDC estimates that 60% of these deaths are preventable. With so many lives on the line, what are the solutions?
At this year’s Black Maternal Health Conference, hosted by Black Mamas Matter Alliance chapter at Tufts University in Boston, participants focused on the impact of policy on Black maternal health. Throughout the course of the conference, panelists discussed a variety of solutions to address this crisis, ranging from expanding paid maternity leave to strengthening our national midwifery workforce. Here are some of our key takeaways.
From prenatal to postnatal, we are failing our Black mothers
Pregnancy-related complications can occur before, during, and after birth, with about a third of deaths falling into each category. Prenatal health care is dependent on the individual’s home state and socioeconomic status, as many states have chosen not to expand Medicaid. Massachusetts State Representative Liz Miranda emphasized how life expectancy in the city of Boston can be predicted by zip codes, noting that the top 10 poorest zip codes also had the highest rates of poor maternal outcomes.
“Massachusetts is the most expensive state to give birth in the United States…and maternal mortality is on the rise. How are we letting this happen?”
-Massachusetts State Representative Liz Miranda
This makes it difficult for uninsured women to access prenatal care, leading to worse health outcomes. The leading causes of death during delivery are hemorrhage and other cardiovascular conditions, though for Black women the leading causes of death are preeclampsia, eclampsia, and embolism. The very fact that different racial groups have different leading causes of death with vastly different maternal mortality rates is an indicator that racism is at play. In fact, reports show that when Black individuals are treated by Black physicians, they have better outcomes.
But there’s still a lot we don’t know about the roots of racial disparities in maternal health.
“Key open questions include the following: 1) whether physician race proxies for differences in physician practice behavior, 2) if so, which practices, and 3) what actions can be taken by policymakers, administrators, and physicians to ensure that all newborns receive optimal care,” said Rachel Hardeman, Associate Professor at the University of Minnesota School of Public Health.
Improving maternal outcomes
The care team in charge during a pregnancy and birth can make a massive impact on the individual’s health outcomes. One study from the Commonwealth Fund indicates that there is a significant shortage of maternity care providers, especially midwives. Whereas most other countries have a larger ratio of midwives to OBGYNs, here in the United States, OBGYNs are proportionally overrepresented. Another consideration for care teams is the inclusion of a doula, a non-clinical member of the team who provides guidance and support during labor. While studies examining the benefits of a doula are limited, a 2017 Cochrane Review found that continuous support of a pregnant person improves outcomes without any identified adverse effects.
Policymakers have a few options when it comes to reducing maternal mortality rates via legislation. First and foremost is securing insurance for pregnant people, as uninsured individuals have poorer health outcomes than those privately insured or on Medicaid. Midwives should be utilized; we need to simultaneously ramp up our training of this vital health care workforce as well as allowing midwives to fully work within their scope of practice. Doulas could be subsidized as well, reducing the financial barriers for low-income families. Postpartum care needs to be a top priority as the United States currently has a dearth of postpartum supports such as provider home visits or paid parental leave.
It’s clear that the United States needs to address its maternal mortality crisis, especially for Black women. Just last year, the Black Maternal Health Caucus introduced the Momnibus Act of 2021. This comprehensive set of twelve bills aimed at tackling the maternal mortality crisis is promising, but passing these bills is easier said than done. A study from 2021 examining maternal health policies proposed from 2010-2020 found that only two policies were actually signed into law. As more research comes out from organizations dedicated to this cause such as MOTHER Lab and the National Birth Equity Collective, more pathways forward may become clear.
“Even as Black women were doing this work, they weren’t always centered in this movement. It deprioritized them as worthy populations…how can we make our own space, pull up at our own table?”
– Dr. Jallicia Jolly, Professor at Amherst College
Ending these preventable deaths requires not just changing current systems but focusing instead on how to create new ones that value Black lives.