Deaths during childbirth have declined sharply in most parts of the world — but not in the United States. Maternal mortality doubled in this country between 2000 and 2014, and it disproportionately affects African-American women, placing them at three to four times greater risk.
A panel at the Harvard T.H. Chan School on Monday offered some alarming statistics, but also a number of solutions, ranging from improving hospital facilities to addressing systemic racism. The panel, “Deaths from Pregnancy and Childbirth: Why Are More U.S. Mothers Dying and What Can Be Done,” was moderated by WGBH news anchor Tina Martin, and streamed live on YouTube and Facebook.
An introductory video produced by ProPublica and NPR stated that between 700 and 900 women died from pregnancy-related causes in the U.S. in 2016, and up to 60 percent of those deaths were preventable. There has been no improvement in the three years since, said Wanda Barfield, a rear admiral in the U.S. Public Health Service and the director of reproductive health for the Centers for Disease Control and Prevention.
“This really is a cause for concern,” she said, “and another major one is the evident racial disparities that we’re seeing. For more than 30 years we’ve seen a disproportionate burden of death in African-American women. … This is really an unconscionable issue.”
Because so many of these deaths were preventable, she said there is “a lot of room for opportunities for intervention.” While structural racism and unconscious bias are underlying conditions, another is the variations in hospital quality in different communities. Barfield recommended developing standardized care for mothers, both during childbirth and in the months afterward.
“These deaths don’t happen randomly,” concurred Ana Langer, director of the Women and Health Initiative at the Chan School. She cited a number of studies by human-rights groups, including a 2011 investigation by Amnesty International that showed the inequality of health risks. “The drivers include lack of access, poorer quality [health care], and the basic societal undervaluing of women of color.”
Speaking via closed-circuit video, Karen Scott, project director the California Birth Equity Collaborative, cited specific evidence of institutionalized racism, including the lesser personal attention and health counseling that black women receive as patients. “What in the system allows variation in the responsiveness to a black mother who is reporting symptoms that are dismissed and discounted? These women are coming to the hospital, they are educated, they have health insurance. All of these factors that are normally shown to protect are not doing that.”
Women in rural communities are also likely to face less-efficient hospital care than city dwellers. As Susan Mann, a Brookline obstetrician affiliated with Beth Israel Deaconess Medical Center, put it, “If I sneeze here, there are four people to hand me a Kleenex. In a rural community you may have to wait for the truck to deliver it.”
Mann proposed more standardized health care, focusing on the three most preventable causes of maternal death: hypertension, postpartum hemorrhaging, and blood clots. She also suggested that doctors take a tip from pilots by doing emergency simulations to better prepare for the real thing.
Haywood Brown, past president of the American Society of Obstetricians and Gynecologists, agreed that maternity care is fragmented in the U.S., and that “health deserts” exist in many rural areas. Fifty percent of all counties in the U.S. lack a practicing OB-GYN or a midwife, he noted. Access to insurance likewise varies by area, making some women less likely to find timely prenatal care. “The financial barriers are still there in a country as rich as ours.”
The panel agreed that improvements need to happen on two fronts: equalizing access to hospital care in different areas of the country, and equalizing the amount of respect women receive within those facilities.
“Clinical care is obviously essential,” Langer said, “but the way women experience their childbirth is also critical. When women are poorly treated, they will distrust the medical system and they may not come back.”