Maternal Mortality among African American Women in the US

Winner of the college’s NEW (Nurses Empowering Women) Club essay contest, Izzy is a sixth-semester nursing student from Mercer Island, Washington.

By Isabella Allgaier
Black women in the United States are more likely to experience preventable death than white women, a problem that has been recognized for many years (National Partnership, 2018). Though causes of preventable death include smoking, high blood pressure, and obesity, another major cause of preventable death is inadequate maternal healthcare. Black women in the United States are more likely to die from pregnancy or childbirth than women in any other racial group. They are up to five times more likely, according to the Centers for Disease Control and Prevention (CDC) (Petersen et al., 2019). If the various reports are accurate, then the US is ranked 55th in the world for maternal mortality. What could be causing these patient outcomes? Unfortunately, many intertwining medical and socioeconomic factors contribute to the problem. This essay will attempt to discuss these issues.

Physical Factors
A few of the leading direct causes of maternal death in the United States are hemorrhage, blood clots, preeclampsia, and stroke. Statistics show that Black women are at higher risk of experiencing these complications. For example, postpartum bleeding can be caused by fibroids, which are benign tumors that grow in the uterus and interfere with the uterus’s ability to contract after birth. Black women are three times more likely to develop fibroids than white women, which grow more quickly and at younger ages than white women (National Partnership, 2018). Another example is preeclampsia. Preeclampsia causes high blood pressure in pregnancy, and if left untreated, can cause seizures and ultimately harm to mother and child. With early intervention, these conditions can be controlled, and further complications such as cardiac arrest, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, congestive heart failure, and mechanical ventilation are prevented (National Partnership, 2018). However, access to treatment tends to be more difficult to obtain for African American women, leading to higher incidences of these complications (Shahul et al., 2015).

Healthcare-related Factors
A factor contributing to the lack of access is that many African American women fall in the “coverage gap” in which their income is too high to receive Medicaid, but not enough to purchase private health insurance (Black Mamas Matter Alliance, 2016). Without access to healthcare, African American women report they are less likely to have frequent prenatal check-ups. Prenatal care visits ensure that women receive education to promote maternal and fetal well-being (Mazul, Ward, & Ngui, 2017). For example, education concerning essential vitamins for fetal development and identifying teratogenic substances to prevent fetal defects is vital. Furthermore, medical conditions can be recognized and controlled in prenatal check-ups. Without sufficient access to reproductive healthcare, Black women are unlikely to receive necessary interventions given in prenatal visits.

Another unfortunate source of low-quality care is the behavior of healthcare professionals themselves. Stereotypes and implicit bias among healthcare professionals interfere with their ability to give compassionate and timely care to Black patients. Studies show that “Black patients are treated differently than white patients with the same symptoms, receiving fewer diagnostic and therapeutic interventions, and even less pain medication” (Black Mamas Matter Alliance, 2016). These experiences can quickly dissolve trust in patient-provider relationships and lead to the dismissal of severe patient concerns. Racism in healthcare is one of the many factors that can result in preventable poor maternal outcomes.

Financial Factors
Higher poverty rates correlate with higher rates of maternal mortality for all women, and African American women are more than twice as likely to live in poverty as white women are. A 2011 report explains that states with high poverty rates had maternal mortality rates that were more than 77 percent higher than states with relatively low poverty rates (Black Mamas Matter Alliance, 2016). This is likely because low-income families often must prioritize basic needs like food and housing costs, rather than seeking early medical care. Pregnancy discrimination in the workforce also contributes to their lower income. African American women are less likely to be able to keep their jobs after giving birth than white women (National Partnership, 2018). Without a consistent income after birth, follow-up care is often delayed. This can lead to worsening of general medical conditions like hypertension as well as preventable complications in future pregnancies. These significant financial factors indirectly related to maternal mortality rates in women due to delayed and decreased access to healthcare.

Current Strategies to Decrease Mortality Rates
There have been many initiatives to decrease maternal mortality rates in Black women. The Black Mamas Matter Alliance, formed in 2013, has raised public awareness of the issue and has advocated for policy changes to ensure Black women’s rights, respect, and resources. The inadequate responses to maternal mortality rates led to the 2018 Preventing Maternal Deaths Act, passed by Congress to collect more research on maternal death.

Hospitals have also increased protocols to improve patient outcomes. For example, the “Reduction of Peripartum Disparities Bundle” was created for health care providers to achieve safe and equitable healthcare for all childbearing women (Howell et al., 2018). It has four sections: Readiness, Recognition, Response, and Reporting & Systems Learning. The Readiness section ensures that systems are in place to educate staff on health disparities and to communicate with patients effectively. The Recognition section raises awareness of staff implicit biases and establishing respect. The Response section addresses the need to provide appropriate discharge instructions and facilitate follow-up care. Lastly, the Reporting and Systems Learning section of the bundle ensures that accurate measurement of patient outcomes is completed. This bundle is one of many patient safety bundles distributed by the Council on Patient Safety in Women’s healthcare, which was founded by the American College of Obstetrics and Gynecology in 2011.

Reflection
Looking into the statistics, I have been horrified at how alarmingly obvious the differences in patient outcomes are between white and nonwhite women. I was also frustrated at the various factors that are not easy to quickly “fix” like low income and location of care. However, discrimination, neglect, and failure to ensure patient understanding are factors within my control, and as a nurse, I can advocate for change in these areas. After graduation this December, I hope to work as a labor and delivery nurse in Baltimore, Maryland, where there is a significantly higher African American population than where I currently live. This research has solidified my desire to do all in my power to ensure that each of my patients, regardless of their race, receive the high-quality care that they deserve.

References
Black Mamas Matter Alliance. (2016). Research Overview of Maternal Mortality and Morbidity in the United States. https://www.reproductiverights.org/sites/crr.civicactions.net/ files/documents/USPA_MH _TO_ResearchBrief_Final_5.16.pdf

Council on Patient Safety in Women’s Healthcare. (2020). Alliance for Innovation on Maternal Health Program. https://safehealthcareforeverywoman.org/aim-program/

Howell, E. A., Brown, H., Brumley, J., Bryant, A. S., Caughey, A. B., Cornell, A. M., … & Mhyre, J. M. (2018). Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 275-289. doi:10.1097/AOG.0000000000002475

Mazul, M. C., Ward, T. C. S., & Ngui, E. M. (2017). Anatomy of good prenatal care: Perspectives of low-income African-American women on barriers and facilitators to prenatal care. Journal of Racial and Ethnic Health Disparities, 4(1), 79-86. doi:10.1007/s40615-015-0204-x

National Partnership for Women and Families. (2018). Black women’s maternal health: A multifaceted approach to addressing persistent and dire health disparities. Retrieved from https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html.

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., … & Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. Morbidity and Mortality Weekly Report, 68(35), 762. doi:10.15585/mmwr.mm6835a3

Shahul, S., Tung, A., Minhaj, M., Nizamuddin, J., Wenger, J., Mahmood, E., … & Talmor, D. (2015). Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia. Hypertension in Pregnancy, 34(4), 506–515. doi:10.3109/10641955.2015.1090581

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