Majority of the maternal death-rate is based on race, but we can fix it

It is no secret that the Trump administration and the president seemingly have problems with two key constituencies: women and people of color. Attacking head on the heartbreaking tragedy of maternal mortality among African American women could mitigate, at least a bit, the administration’s reputation for misogyny and racism.

Politics aside, it is the right thing to do.

{mosads}The data on American mothers dying from pregnancy-related and pregnancy-associated causes are at once shameful and heartbreaking. Across the board, no developed nation has the rate of maternal deaths that we in the United States suffer. American women are three times more likely to die during pregnancy, delivery, or within one year of giving birth than women in Canada.

During the 20th century the maternal death rate in the United States consistently fell. In recent years, however, throughout the United States, the maternal mortality rate has been increasing steadily — it increased nearly 27 percent from 2000 to 2014, only partly the result of improved data collection.

A large part of this death rate is race-based. The overall U.S. maternal mortality rate is 18 per 100,000 births, itself shockingly high. But those 18 deaths become 40 deaths when analyzing the maternal mortality rate for African American women.

A similar racial disparity exists for babies. The death rate, officially the “infant mortality rate,” for African American children is more than double that for non-Hispanic white infants.

Yes, it is about race: pervasive racial gaps in income, education and opportunity still scar our nation. Yet the usual indicators of persisting discrimination in the United States do not fully explain African American maternal mortality.

Even after controlling for income, gestational age, maternal age and health status, the odds of dying from pregnancy or delivery complications are almost three times higher for African American women than for non-Hispanic white women. Institutional bias, both express and implicit, means that African-American women are likely to receive different and not better, prenatal and postnatal care than their white counterparts.

It does not have to be like this. Expert groups over the past decade keep calling for more research, more data collection and more study committees. Enough already. It is time to stop talking and start doing.

The Preventing Maternal Deaths Act, a bipartisan bill signed into law by President Trump in December, is a step forward but really only promises more of the same. Rather than directing the modest funds ($12 million a year) to hands on action to stem the tide of maternal deaths, the legislation authorizes state maternal mortality review committees. The job of the committees will be to review maternal deaths and come up with recommendations. The bill funds these committees for five years. 

The number of maternal deaths in the United States is small enough to be fixable. In a given year, about 700 American women die due to complications arising from pregnancy and childbirth. According to analysis from nine maternal mortality review committees, over 60 percent of pregnancy-related deaths were preventable.

The maternal mortality rate is for the most part at its highest in states with weak health care systems (and a resistance to Medicaid expansion). These include Georgia, Texas, Louisiana and Indiana. But other mortality hot spots are in New Jersey and Washington, DC.

Identifying areas of especially high maternal mortality and then bringing evidence based supports to those communities, can turn the tide and quickly. The goal, on the most fundamental level, is to save the lives of mothers and their babies. Broadly, we should at least be capable of bringing United States maternal death rates to a level consistent with the rest of the developed world.

Clinical experts in maternal health know what helps. They include many simple interventions: basic detection and management of pre-existing conditions such as diabetes and hypertension (e.g. low-dose aspirin to prevent preeclampsia, a hypertensive disorder of pregnancy that typically starts after the 20th week of pregnancy). The rate of preeclampsia in the U.S. has increased 25 percent in the last two decades and is a leading cause of maternal and infant death. Risk factors for preeclampsia include race, low socioeconomic status and obesity.

Perhaps the best, pinpointed intervention to save high risk mothers and their babies is the modern day doula. Doulas are basic and hands-on: they are trained to help women prepare for birth, aid in the birthing process and provide support once the baby is born.

Doula care is not cookie cutter care. The doula meets the expectant mother where she is, creating what is needed for a healthy birth. A doula is part advocate, confidant, educator, patient navigator and aide. Research suggests that mothers supported by doulas have better birth and postpartum outcomes (e.g. less babies born with low birth weight; less likely to experience a birth complication; and more likely to initiate breastfeeding.) Yet, only 6 percent of births are attended by doulas.

Governmental and private studies, data collections and pilot programs are all good and remain necessary. At the same time, we know how to pinpoint need, we know what works to reduce the risk of maternal death and we need not wait to tackle that.

There should be no political division here. Protecting maternal life — whether in high risk red states, among African American women, in cities or in rural America — is at once bi-partisan and doable.

Do not wait.

Robert M. Hayes is the president of Community Healthcare Network, a non-profit providing integrated healthcare to underserved New Yorkers at 14 community health centers and a fleet of mobile units. He is a founder of the National Coalition for the Homeless and the attorney who established the right to shelter in New York for homeless men, women and children.