Maternity outcomes among African-American and other minority women and strategies to improve it
The United States is one of only 13 countries in the world where the rate of maternal mortality — the death of a woman related to pregnancy or childbirth up to a year after the end of pregnancy — is now worse than it was 25 years ago. Each year, an estimated 700 to 900 maternal deaths occur in the United States. Black women are three to four times as likely to die from pregnancy-related causes as their white counterparts, according to the Center for Disease Control and Prevention. In addition, black infants in America are more than twice as likely to die as white infants — 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data.
Researchers and health care professionals have been looking for answers to the maternity outcomes disparities for decades. Multiple studies have been conducted and variety of reasons and action plans have been proposed. In my Culminating Experience work I want to illustrate the discussed explanations of inequalities in maternity outcomes and to summarize the most promising strategies for reduction of these gaps.
The reasons for the black-white divide in both infant and maternal mortality have been debated by researchers and doctors for more than two decades. But recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: for black women in America, an atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.
Predictive factors (risk and protective) – pathophysiology
High blood pressure and cardiovascular disease are two of the leading causes of maternal death, according to the Centers for Disease Control and Prevention, and hypertensive disorders in pregnancy, including pre-eclampsia, have been on the rise over the past two decades, increasing 72 percent from 1993 to 2014. A Department of Health and Human Services report last year found that pre-eclampsia and eclampsia (seizures that develop after pre-eclampsia) are 60 percent more common in African-American women and more severe.
Women with preexisting hypertension (high blood pressure before pregnancy or within the first 20 weeks of gestation) and gestational hypertension (onset of high blood pressure after 20 weeks of gestation) are at increased risk for preeclampsia/
eclampsia, although many women who develop preeclampsia/ eclampsia have no history of high blood pressure. Other risk factors for preeclampsia/ eclampsia include preexisting diabetes, renal disease, obesity, falling in the youngest or oldest
categories of maternal age, multiple gestations, women giving birth for the first time, and race. Black women are more likely to develop preeclampsia and to experience poorer outcomes associated with the condition, including progression to eclampsia and in rare cases, death.,
* Center for Disease Control and Prevention, Pregnancy Mortality Surveillance System
Figure 1. Maternal death rate
In 2001-2005, their risk of death was seven times higher for black mothers compared to the risk for white mothers. Today, in New York City black mothers are twelve times more likely to die than white mothers. It is believed that widening gap reflects a dramatic improvement for white women but not for blacks. New York City offers a startling example: A 2016 analysis of five years of data found that black, college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school. The data illustrates the complexity of the problem and points that there is no single connection, e.g. socio-economic factors, to maternal disparities.
Black women are more likely to be uninsured outside of pregnancy, when Medicaid kicks in, and thus more likely to start prenatal care later and to lose coverage in the postpartum period. They are more likely to have chronic conditions such as obesity, diabetes and hypertension that make having a baby more dangerous. The hospitals where they give birth are often the products of historical segregation, lower in quality than those where white mothers deliver, with significantly higher rates of life-threatening complications.
Understanding why racial disparities in maternal outcomes exist is the first step in eliminating them. Most of the research on racial/ethnic disparities in obstetrics has attributed differences in outcomes to social and biological/genetic factors, and has not accounted for the systems within which obstetric care is delivered and how differences in quality of care may contribute to disparities. Howell et. al. found that both black and white patients who delivered in black-serving hospitals had a higher risk of severe maternal morbidity after accounting for patient characteristics. Their findings suggest that quality of care at hospitals that disproportionately serve blacks is lower than quality at low black-serving hospitals.
Dr. Howell ranks hospitals by their proportion of black deliveries among all deliveries. The top 5% of hospitals are defined as high black-serving hospitals, the next 20% as medium black-serving hospitals, and the remaining 75% of hospitals as low black-serving hospitals. Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs. 11.8 per 1000 deliveries, p
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