HEA 3050 Module 2 Maternal Mortality Paper: Racial Disparities in Pregnancy-Related Deaths Example

Three Times as Likely: Race, Pregnancy and the Deaths That Could Have Been Prevented

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B.S. in Health Studies, Thomas Edison State University

HEA-3050: Women's Health

Mentor Name

Month Day, Year

Three Times as Likely: Race, Pregnancy and the Deaths That Could Have Been Prevented

Introduction

Among high-income countries, the United States records the most maternal deaths per birth, and the burden falls unevenly. Black women, along with American Indian and Alaska Native women, lose their lives to pregnancy-related causes at much higher rates than white, Hispanic or Asian women. This paper describes the size of the gap, examines explanations at several levels and evaluates strategies to close it. It argues that the gap cannot be explained by individual characteristics such as income or education, and that the quality of care women receive must be part of the answer.

Definitions

The CDC counts a death as pregnancy-related when a woman dies while pregnant or in the year after the pregnancy ends and the cause traces to the pregnancy or to how it was managed. The pregnancy-related mortality ratio is the number of such deaths per 100,000 live births. The CDC's Pregnancy Mortality Surveillance System collects these deaths from all states.

The Size of the Gap

For 2011 to 2013, Creanga et al. (2017) reported 17.0 pregnancy-related deaths for every 100,000 live births. The ratio for Black women was 43.5, more than three times the ratio for white women, 12.7. Cardiovascular conditions and other chronic medical conditions had become the leading causes of death, overtaking hemorrhage and hypertensive disorders, which had led in earlier decades.

Petersen et al. (2019) extended the analysis to 2007 through 2016. Black women's ratio was 40.8, and Native American and Alaska Native mothers stood at 29.7, compared with 12.7 for white women. The gap held across age groups and was largest among women over 30. Most striking, the gap persisted among women with degrees: Black college graduates died at about five times the ratio of white college graduates.

Explanations at Several Levels

Howell (2018) organized the causes of disparities in severe maternal morbidity and mortality into patient, community, provider and health system factors. At the patient level, chronic hypertension, diabetes and obesity before pregnancy are more common among Black women, and each raises risk. But these differences do not explain the full gap, as the persistence among educated women shows.

At the community level, neighborhood poverty, distance to care, housing and exposure to chronic stress shape health before and during pregnancy. Some researchers argue that years of stress from racism wear down the body and bring chronic disease earlier, a process sometimes called weathering.

At the provider level, Howell described evidence of implicit bias and poor communication, including symptoms that are dismissed or not acted on. Women's accounts of being disbelieved when they reported pain, swelling or breathlessness appear often in maternal mortality reviews.

At the system level, Howell noted that Black women are more likely to deliver in a relatively small number of hospitals where severe complications are more common for every patient, whatever her race. Differences in hospital quality, not only differences among patients, contribute to the gap.

The Year After Birth

Many pregnancy-related deaths happen after the woman has gone home, some weeks or months after delivery, from cardiomyopathy, blood clots, infection or mental health conditions. Until recently, Medicaid coverage for pregnancy ended about sixty days after birth in many states, leaving women uninsured during a high-risk period. Most states have since extended postpartum Medicaid coverage to twelve months, a change aimed directly at this gap.

Strategies

Several strategies address the levels Howell described. Hospital safety bundles for hemorrhage and severe hypertension standardize the response to the two most preventable emergencies, so that every woman gets the same timely care regardless of who is on duty. State perinatal quality collaboratives share data among hospitals to find and fix differences in outcomes. Maternal mortality review committees, now active in most states, examine each death and recommend changes. Training in bias and respectful care, doula support and community health workers address communication and trust. Extended postpartum coverage addresses the year after birth.

Evaluation

None of these strategies alone will close the gap. Bundles reduce deaths from specific causes, but cardiovascular and mental health deaths require care across the year after delivery. Bias training is popular, but evidence that it changes outcomes is limited. That the gap survives a college degree suggests that structural change in hospitals and health systems, not only individual behavior or income, must lead.

New Jersey's Response

New Jersey offers an example of a state acting on several levels at once. In 2019 the governor's office launched Nurture NJ, a statewide plan to reduce maternal and infant deaths and narrow racial gaps, which set goals for hospitals, community programs and data. The state extended postpartum Medicaid to a full year in 2021, earlier than most states, and moved to cover doula services under Medicaid. Whether these changes close the gap will take years of surveillance to judge, but they match the levels Howell described.

Limits of the Data

Surveillance figures have weaknesses that a careful reader should name. The pregnancy checkbox on death certificates arrived in different states in different years, which changed how many deaths were counted and makes comparisons across years difficult. Race and ethnicity may be recorded by a funeral director rather than reported by family. Small numbers make rates for American Indian and Alaska Native women and for some states unstable from year to year. None of these weaknesses explains away a gap that has persisted for decades, but they caution against reading small changes as trends.

Conclusion

In the United States, Black women and Native American women die of pregnancy-related causes at two to three times the white ratio, and state review committees judge many of these deaths preventable. CDC surveillance shows that the gap holds even among women with college degrees. Howell's framework shows causes at every level, from chronic disease to the hospitals where women deliver. Closing the gap will require better care in hospitals that serve Black women, attention through the full year after birth and listening when women say something is wrong.

References

Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-related mortality in the United States, 2011-2013. Obstetrics & Gynecology, 130(2), 366-373. https://doi.org/10.1097/AOG.0000000000002114

Howell, E. A. (2018). Reducing disparities in severe maternal morbidity and mortality. Clinical Obstetrics and Gynecology, 61(2), 387-399. https://doi.org/10.1097/GRF.0000000000000349

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths: United States, 2007-2016. Morbidity and Mortality Weekly Report, 68(35), 762-765. https://doi.org/10.15585/mmwr.mm6835a3