Population Care

Inequities in maternal mortality must be attacked head-on

The U.S. is one of only three countries where maternal mortality rates are rising and the health inequities experienced by black, Native American and Alaska Native women cannot be explained away by insurance status and income, Patrice A. Harris, MD, President-elect of the AMA, told members of Congress.

Dr. Harris spoke during a May 16 hearing of the House Ways and Means Committee on racial disparities and social determinants of health in the “maternal mortality crisis.”

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“Birth inequities arise at the intersection of discrimination by race and gender for black and Native American women,” Dr. Harris, an Atlanta psychiatrist, said in a written statement submitted before the hearing. “At the provider and institutional levels, there is a growing body of evidence demonstrating that implicit and explicit biases exist that negatively impact the quality of health care equity and patient safety and drive these inequities.”

At the hearing, Dr. Harris highlighted the following factors as contributing to the rising maternal mortality rate:

  • Lack of insurance or inadequate coverage prior to, during, and after pregnancy.
  • Increased closures of maternity units in rural and urban communities.
  • Lack of inter-professional teams trained in best practices.
  • Structural determinants of health, such as public policies, laws and racism that produce inequities in the social determinants of health, such as education, employment, housing and transportation.
  • Stress exacerbated by discrimination that can result in hypertension, heart disease and gestational diabetes during pregnancy.
  • Clinicians not listening to black women, resulting in missed warning signs and delayed diagnosis.

To decrease maternal mortality rates, AMA policy encourages state and county health departments to develop a maternal mortality surveillance system, as well as research on identifying barriers and developing strategies toward the implementation of evidence-based practices to reduce poor obstetric outcomes and maternal morbidity and mortality in racial and ethnic minorities.

The AMA also has policy that supports establishing government-funded maternal mortality review committees (MMRCs).

“MMRCs are a critical first step in efforts to make pregnancy safer,” Dr. Harris said in both oral and written testimony, adding that the AMA supported the Preventing Maternal Deaths Act that was enacted last year and appreciated the $50 million Congress appropriated in 2019 to support such prevention efforts.

Dr. Harris also told of the AMA’s support of the Mothers and Offspring Mortality and Morbidity Awareness Act bills that have been introduced in both the House and Senate this year. The measures call for improving data collection, disseminating information on effective interventions, and expanding access to health care and social services for postpartum women.

Roadmap to health equity

This advocacy is part of the AMA’s multipronged, multiyear mission to improve health equity and to address inequities driven by race and the social determinants of health (SDOH), Dr. Harris told the panel. This strategy includes the hiring of Aletha Maybank, MD, a pediatrician who was with the New York City Public Health Department, to serve as the AMA’s first chief health equity officer.

“The AMA defines health equity as ‘optimal health for all’ and recognizes the importance and urgency of advancing health equity and addressing SDOH to ensure that all people and communities reach their full health potential,” she said in her written testimony. “Inequities are produced. They do not just happen. The people who are negatively impacted by experiencing the injustice are not to blame. And there is something that we can actually do to close the gap.”

Black women are three to four times more likely to die from a pregnancy-related cause. Native American and Alaska Native mothers were 2.5 times more likely, Dr. Harris said, citing statistics from the Centers for Disease Control and Prevention (CDC).

“Perhaps the most significant and troubling finding in the new study is that the CDC estimates that 60% of all maternal deaths are preventable,” she said.

The U.S. maternal mortality rate has jumped from 7.2 per 100,000 live births in 1987 to 18 in in 2014, according to the CDC. The U.S., Afghanistan and Sudan are the only nations experiencing this upward trend. The CDC reported that, between 2011 and 2014, the death rate was 12.4 deaths per 100,000 live births for white women compared to 40 deaths for black women.

Rep. John Larson, D-Calif., made note of these statistics during the hearing and mentioned how women in his district have much higher mortality rates than women in the United Kingdom, Canada, China and Saudi Arabia.

“If this isn’t a call to arms, I don’t know what is,” Larson said.

Dr. Harris pledged to follow up and provide Larson with a set of recommended immediate actions.

“It will certainly take all of us working in partnership to address this issue—and the AMA is committed to doing so,” Dr. Harris said. “We are committed to building and continuing on a path forward to more holistically and effectively improve maternal health and advance health equity.”