Disparities in Maternal Morality in the U.S.

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700 women die annually in the United States due to conditions caused by or related to pregnancy.  For another 500,000 women, severe morbidities or ‘near misses’ complicate their pregnancies, deliveries, or first postpartum year.  Women in the US are more likely to die during and within a year after pregnancy than women in 48 other developed countries.

The leading causes of pregnancy related maternal mortality (MM) include hemorrhage, cardiomyopathy and other cardiac conditions, infection, embolism, cardiovascular accidents, and hypertensive disorders.  Two thirds of pregnancy related deaths are believed to be preventable and are often related to ‘failure to rescue’. The majority of deaths occur after the day of delivery, and a third occur a week or more later.

While global MM rates have dropped 38% in the last decade, the US continues to see large increases in maternal deaths.  Black and American Indian/Alaska Native (AI/AN) communities disproportionately bear the burden of MM, dying at rates 3-4 times that of white women. These disparities are unrelated to wealth and education.  Location does play a role, with higher MM rates occurring in southern and rural areas and states.  Recent state-level restriction on abortion and family planning access may also affect MM.  MM is increased for all races in predominantly Black-serving hospitals, but racial disparities are apparent in both Black- and white-serving hospitals.

Reasons for racial disparities in MM are multi-layered and complex but are traceable to the impact of systemic racism, colonialism and slavery on health, pregnancy comorbidities, and the availability and quality of health care for Black and AI/AN women. Theories explaining the role of racism and trauma women’s health shed light on the physiological basis of these effects, some of which may be transmitted to subsequent generations. 

While actual numbers of pregnancy associated MM, or deaths not caused by the pregnancy or conditions related to the pregnancy, are not entirely clear, they appear to be more common that pregnancy related deaths. The most frequent causes of pregnancy-associated MM are homicide, suicide, overdose and unintentional injuries.  Homicide and suicide related to intimate partner violence may be an important cause of maternal deaths and racial inequities in MM for Black & Indigenous women.  In some states, rates of overall and/or pregnancy-associated MM are highest among AI/AN women when compared to Black and other races.

Globally, midwives have played an essential role in MM reduction. Midwifery-led care, widespread adoption of health bundles and other evidence-based protocols to address pregnancy complications, and improved access to quality health care before and during pregnancy are among health care improvements that hold potential to reduce MM in the US.

Other recommendations to decrease MM include:

  • Routine screening for intimate partner violence, depression, and suicide risk
  • Addressing inherent bias and systemic racism in health care education and practice
  • Providing culturally aware/specific, patient-centered and trauma-informed care

The US Department of Health and Human Services has recently put forth goals to make the US one of the safest nations to give birth, and to decrease MM by 25% in five years. The session Disparities in Maternal Mortality in the US will be presented at the 66th Annual ACNM Meeting to be held virtually May 23-25, 2021.  Research and surveillance data related to this topic will be presented as well as additional policy and practice recommendations aimed at decreasing MM in the US.  National initiatives to address MM and racial disparities will also be reviewed.

Authors:

Dr. Bohn has spent 35 years addressing violence against woman, children and elders as advocate, educator, researcher, author, forensic nurse, clinician, program evaluator and program director.  Much of her clinical practice and research have been in Indian Country. She recently retired from clinical practice as a CNM at Cass Lake IHS where she founded and directed their Sexual Assault and Domestic Violence Prevention Initiative, and where she convened and facilitated the CLIHS Trauma Informed Care Workgroup. 

Emily J. Jones, PhD, RNC-OB, FAHA, FPCNA is an Associate Professor of Nursing and PhD Program Director in the Fran and Earl Ziegler College of Nursing at the University of Oklahoma Health Sciences Center. She completed a PhD in Nursing from the University of Alabama at Birmingham in 2010 and a Bachelor of Science in Nursing from Oklahoma Baptist University in 2005. With a broad background in women’s obstetrical health and health promotion, Dr. Jones has specific training and expertise in translational health disparities research and in the epidemiology and prevention of cardiovascular disease. Her research focuses on translating type 2 diabetes and cardiovascular disease prevention in partnership with regionally diverse American Indian/Indigenous communities by adapting and testing interventions for women diagnosed with gestational diabetes.

Dr. Jennifer Heck, PhD, RNC-NIC, CNE is a clinical assistant professor and interim ABSN program coordinator for the OKC campus at the Fran and Earl Ziegler College of Nursing at The University of Oklahoma Health Sciences Center.  She earned her PhD, MS as a Clinical Nurse Specialist with certification as a critical care CNS, neonatal, and BSN degrees from OU. Dr. Heck earned NICU certification in 2002 and certified nurse educator in 2012. She is the recipient of the Outstanding Graduate Research Award in 2018.