658 women died from pregnancy-related causes in 2018. Most of them were Black

Every year in the United States, nearly 700 women die of pregnancy-related complications. For every one of those deaths, approximately 100 more almost die. Maternal mortality—death during pregnancy or within 42 days after delivery—is the sixth most common cause of death among American women ages 25 years to 34 years old.

Within those disturbing statistics lies even worse ones. Black women are 2.5 times more likely to die from pregnancy-related issues than white women, according to the Center for Disease Control and Prevention’s (CDC) newly-released 2020 maternal mortality report, which found maternal mortality rates of 37.1 vs. 14.7 deaths per 100,000 live births in Black vs. white women in 2018 (the most recent data available). That means that of the 658 women who died of pregnancy-related causes in 2018, most of them were Black women.

This report is not the first time that the CDC has noted alarmingly high rates of pregnancy-related death among black women. A 2019 CDC report analyzing data from 2007 to 2016 found Black and American Indian/Alaska Native women had significantly more pregnancy-related deaths than any other racial group. “Disparities persisted over time and across age groups, and were present even in states with the lowest pregnancy-related mortality ratios and among groups with higher levels of education,” says David Goodman, MD, team lead of the Maternal Mortality Prevention Team at the CDC.

Up until 2020, however, rates were estimated, because some states had no way to officially report if a death was linked to pregnancy. The 2020 report was the first to fully capture maternal deaths, as all states finally added a check box to death certificates that allowed them to report whether a death was pregnancy-related—a process that began way back in 2003.

Identifying and evaluating accurate information is critical, experts say, to pinpoint problems and find interventions for preventable deaths. “It gives us a clearer picture of what’s actually happening and understand which populations are disproportionately affected and proactively come up with solutions,” says Dawn Godbolt, PhD, a health policy analyst with the National Partnership for Women & Families (NPWF).

The many factors contributing to high Black maternal mortality rates

So what’s behind this crisis? “There is not one reason with an easy solution,” says Dr. Goodman.

“These issues span education and income and insurance access for Black women,” adds Dr. Godbolt. “You [also] have women saying, ‘I’m not feeling well; something is wrong,’ and their concerns are dismissed.”

One of the biggest challenges is income and wealth disparity. African-American women are about twice as likely as white women to live in poverty, with about one in four living below the poverty level. Poor women are less likely to have less access to healthy food, safe housing, healthcare, and reliable transportation, says Dr. Godbolt. These “social determinants of health” are shown to impact health outcomes like maternal mortality. Indeed, a 2017 report in the New England Journal of Medicine noted that low-income women of all races are more likely to die during pregnancy.

Social determinants of health impact women’s pregnancies in more than one way. “Chronic diseases such as cardiovascular diseases are more prevalent in Black women, and these chronic conditions are associated with increased risk of pregnancy-related mortality,” says Dr. Goodman. Poorly-controlled high blood pressure before and during pregnancy, for example, increases the risk of preeclampsia, placental, gestational diabetes, and preterm delivery, he says. Poor women are also five times as likely to have unintended pregnancies than women who earn at least 200 percent of the poverty level, and unintended pregnancies are linked to an increased risk of potentially deadly complications.

The income inequality thus makes accessing healthcare inherently harder for many Black women. Research has found that women who get no prenatal care are three to four times more likely to have a pregnancy-related death—and the CDC estimates that one in three Black women don’t attend the recommended number of prenatal visits. Why? Studies have found that Black women are about twice as likely as white women to be uninsured. It doesn’t help that 14 states, such as Alabama and Georgia, have rejected Medicaid expansion, a program intended to fill in the health insurance gap for poor adults who earn too much to qualify for Medicaid but not enough to purchase private health insurance despite tax subsidies. Black women are more than twice as likely than white women to fall into this gap. Dr. Godbolt says that although Medicaid benefits kick in for an uninsured woman once she becomes pregnant, the care she receives before and after pregnancy is equally critical for her health.

“Providers are people, with biases and stereotypes, which affects the provider-client relationship, communication, pain management, and treatment course.” —Dawn Godbolt, PhD

In addition, the U.S. is the only developed country in the world without guaranteed paid leave for the birth of a child. That means it’s up to employers to give women time off for prenatal appointments and post-birth recovery. And Black women and women of color are more likely to work in low-paying jobs where their employers don’t voluntarily offer this kind of paid leave, says Dr. Godbolt. “Even if you do have health insurance, your employer may not give you the time off to get the care you need, or your job may be in jeopardy if you announce you’re pregnant or don’t come back soon enough after birth,” she says.

Even with health insurance, systemic racism affects the kind of care that Black women receive—which in turn puts them at risk. “Several recent studies found that racial and ethnic minority women deliver in different and lower-quality hospitals than whites,” says Dr. Goodman. The U.S. legacy of segregation lives on in healthcare: Black people are more likely to live in an area with a shortage of healthcare providers or where hospitals have been closed. What’s more, hospitals that care for the greatest number of Black women have worse outcomes for both Black and white women at delivery, notes Dr. Goodman.

Indeed, research has shown that Black patients receive fewer medical treatments than white patients, including pain medication, due to persistent misbeliefs (such as that Black people experience less pain). This is a deeply-held racist notion that dates back as far as the 19th century, when the doctor James Marion Sims, known as the father of modern gynecology, perfected his technology by experimenting on enslaved women without offering pain management. Today, Dr. Goodman points out that Black women with a college degree are five times more likely to die due to pregnancy-related complication than white women with a college degree. Black women also report having longer wait times to see their healthcare providers. “A growing body of research documents the role of structural racism plays in generating these differences,” he says.

“Providers are people, with biases and stereotypes, which affects the provider-client relationship, communication, pain management, and treatment course,” says Dr. Godbolt. “Women of color report discrimination and lack of respect from their healthcare providers more often… They have already been disrespected or treated poorly, so they’re afraid to seek care. They’re dictated to rather than presented options.”

Discrimination, racism, and chronic stress all take a toll on Black women’s health. Experts point to “weathering,” a theory that lifelong stressors makes pregnancy riskier at an earlier age. “It leads to wear and tear on the body,” says Dr. Godbolt. “We see complications at earlier periods, they tend to be more severe, and women take a longer time to recover.”

What’s being done to address Black maternal mortality

There is, as Dr. Goodman said, no one simple solution for such a complex and systemic issue. For its part, the CDC is building maternal mortality review committees in every state and improving their data collection. The agency awarded 25 states last year with grants for their review committees. “Review committees have access to multiple sources of information that provide a deeper understanding of the circumstances surrounding each death,” says Dr. Goodman. This information helps policymakers and care providers better understand what drives deaths and near-deaths so they can create impactful solutions.

Doctor groups have started to tackle the lead causes for pregnancy complications and maternal death. In 2017, a nationwide coalition of health organizations including American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives launched the Alliance for Innovation on Maternal Health (AIM), which seeks to improve outcomes and address preventable maternal deaths by providing best practice “safety bundles” to state health departments, hospitals, and health care providers.

“We need to diversify the workforce, so there are more inclusive practices.” —Dr. Goldbolt

Dr. Godbolt says Black women-led organizations including Black Mamas Matter Alliance and Sistersong have laid the groundwork for policy recommendations and a comprehensive agenda to address maternal deaths. They’re working collaboratively with groups like the National Women’s Law Center, the Black Women’s Health Imperative, the Center for American Progress, and the National Birth Equity Collaborative. In addition to better data collection, Black Mamas Matter has called for numerous other actions, including expanded access to health insurance (especially Medicaid), contraception, and family planning; more state funding for health care; greater access to quality hospitals for Black women; and better coordination among care providers.

Dr. Godbolt adds that the government should also adopt paid medical and family leave as well as fund bias training and programs that hire workers of color, while insurers should reimburse nontraditional birth services like community health workers and doulas. “We need to diversify the workforce, so there are more inclusive practices,” she says.

To that end, there are a growing number of community birth workers—Dr. Godbolt points to the Commonsense Childbirth Institute—who look like the people they’re serving and build bridges to social services. The promising results, says Dr. Godbolt, include reducing the rate of C-sections and preterm and low-birthweight births among Black women. “When you have access to a midwife and doula who look like you and communicate in a way that’s not steeped in biases, these have direct impacts on improving maternal health outcomes,” she says.

Feeling inspired to act? Call your congressperson; groups like the NPWF are working to push numerous bills to address maternal mortality through Congress. “We need support and endorsement,” says Dr. Godbolt. She also recommends volunteering your time or money at a local community-based organization, which serve mostly low-income women of color and are often extremely under-resourced and understaffed (search community-based midwife/doula/birth support and your city).

“Three in five maternal deaths are preventable, which tells me we can fix this,” says Dr. Goldbolt.

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