Because 60% of the deaths linked to pregnancy are preventable, it is important to understand why women of color face greater risks, what care gaps exist along the maternity care continuum, and how specific health interventions can reduce the loss of life.  The maternal mortality disparity is partly due to social determinants of health, such as poverty and lack of access to care, which impact communities of color more substantially than White communities. Moreover, various clinical risk factors across the stages of pregnancy and birth are more prevalent among women of color and are further exacerbated by those social determinant of health factors. To reduce pregnancy-related deaths, shared decision-making (SDM), standardized protocols, and other strategies must be used as tools to create a comprehensive approach to providing equitable maternity care to women of color.

Background

Maternal mortality is a high-profile global health indicator defined as death occurring during pregnancy, childbirth, or up to 42 days after birth due to pregnancy-related health problems. A recent Commonwealth Fund study found American women aged 15–39 experienced 14 deaths per 100,000 live births, a rate higher than Canada, Australia, New Zealand, and 7 Western European nations. Sweden reported the lowest rate in the group, with 4 maternal deaths per 100,000 births; Norway and Switzerland each reported 5.

In 2018, the Centers for Disease Control (CDC) calculated the US maternal mortality rate at 17.4 deaths per 100,000 live births. The agency had not previously published the indicator since 2007 due to efforts aimed at ensuring consistent death certificate pregnancy reporting at the state level. According to the CDC, 658 women died of maternity-related causes in 2018, with American Indian, Alaskan Native, and African-American populations among those most frequently impacted. Native groups collectively experienced a mortality rate of 43.6 deaths per 100,000 live births in 2019, while African-Americans suffered 37.1 deaths per 100,000 in 2018.

The rate for African-Americans was 2.5 times that of White women (14.8), and 3.1 times that of Hispanic women (11.8). Over the past 60 years, the risk of maternal mortality among Black women has consistently remained about 3–4 times higher than the equivalent risk for White women. For women of all races, the risk of maternal death predictably increases with age. This risk is further highlighted by the average age of women during first birth also steadily increasing from 1990 to 2012.Women 35–39 are about twice as likely to suffer maternal mortality than those age 20–24, while women over 40 face an even higher risk of dying.

Underlying Population Health Challenges

Social determinants of health are major factors underlying higher incidence of maternal mortality among women of color. Women living in middle- to high-poverty areas face a 60% and 100% greater risk of maternal-related death than women living in low-poverty areas. Among Black and Hispanic populations, the proportion of those living below the poverty rate is more than twice that of Whites (22% and 19%, respectively, compared to 9% for Whites); among Natives, the percentage living in poverty (26%) is nearly 3 times that of Whites.

Poverty contributes to a lack of health insurance and reduced access to high-quality healthcare services, including information on reproductive health. In 2017, the uninsured rate was 24.4% for Hispanic new mothers, 12.1% for Black new mothers, and 7% for White new mothers. Women who receive no prenatal care are 3–4 times more likely to have a pregnancy-related death than women who do.

Barriers to appropriate care, including lack of insurance, also contribute to higher rates of comorbidities among pregnant women of color, who rank substantially lower than White women on a range of key health indicators, including diabetes, obesity, heart disease, and hypertension. Overall, cardiovascular disease is the leading cause of postpartum death among American women.

Research further suggests that the cumulative stress associated with systemic racism and early childhood trauma can contribute to poor perinatal outcomes. The term “weathering” has been developed to describe the early health deterioration Blacks experience due to long-term social and economic adversity and accompanying political marginalization. The phenomenon is believed to contribute to high maternal mortality rates, making pregnancy riskier at an earlier age.

Contributing Risk Factors Across the Maternity Care Continuum

According to the CDC, maternal mortality events occur in nearly equal proportion across the childbearing continuum, with 31% of deaths taking place during the 40-week prenatal period, 36% during delivery or within a week after birth, and 33% between 1 week and 1 year postpartum (Figure 1).

Created from data from CDC Vital Signs, May 2019

Understanding the predominant risks present for women of color during each stage of pregnancy is essential for developing comprehensive, integrated population health programs and interventions to reduce maternal mortality.

Source: VeryWellFamily, Maternal Mortality Rate, Causes, and Prevention, June 5, 2019

Key Recommendations for Reducing Maternal Mortality Among Women of Color

Closer patient monitoring and engagement across the maternity care continuum, improved patient education, standardized emergency protocols, quality measures supported by value-based reimbursement, and the extension of care in the postpartum period represent some of the tools available to reduce US maternal mortality rates. Payers, providers, and other healthcare stakeholders looking to improve maternal outcomes should consider developing or implementing various strategies such as:

• Preconception health counseling helps women better understand their pre-existing health conditions and the potential risk factors that could negatively impact a pregnancy. These visits give clinicians the opportunity to discuss family history, medical conditions, lifestyle decisions, and medication use with women who are considering getting pregnant. Important clinical recommendations can be made to help ensure that women are aware of what to do before and between pregnancies to increase the chances of having a healthy delivery and baby. In 2019, the American College of Obstetricians and Gynecologists (ACOG) released new guidance after concluding physicians were missing opportunities to identify risk factors prior to pregnancy. The ACOG also determined that delays often occurred in recognizing symptoms during pregnancy and postpartum, particularly for Black patients. According to the 2019 guidance, patients should see a cardiologist prior to pregnancy and receive pre-pregnancy counseling. If they are determined to be at moderate or high risk, cardiovascular disease should be managed during pregnancy, delivery, and postpartum in a medical center capable of providing a high level of care. A follow-up visit with a primary care clinician or cardiologist should occur within 7–10 days of delivery for all women with hypertensive disorders and 7–14 days for all women with heart disease or cardiovascular disorders.
• SDM is a process that enables clinicians and women to make decisions and plan care together based on a balance between clinical evidence, patient risk, and patient preferences. During the course of a pregnancy, SDM discussions may help doctors and patients make care and delivery decisions that could reduce the chance of complications and death. To address site-of-delivery hazards, the ACOG recommends SDM discussions with expectant women that include information about the risks associated with home birth for both mother and baby, as well as absolute contraindications for home birthing, including fetal malpresentation, multiple gestation, or prior cesarean delivery. Payers may want to consider leveraging provider networks, clinical care teams, and care navigators to support and influence patient decisions around maternal care.
• Quality measurement can improve healthcare quality, increase provider accountability, and identify the misuse of health services. While some quality measures have been endorsed and implemented for perinatal and reproductive health, the development of more accurate and appropriate measures related to pregnancy and delivery is needed. Once created, widespread use of maternal mortality quality measures will be necessary to increase awareness of various potential complications. Eventually tying physician performance on the measures to reimbursement will be another step to help ensure quality improvement for birthing mothers. Payers can enable greater prenatal and postpartum outreach from quality management and performance improvement teams focused on closing gaps in care, with particular focus on Healthcare Effectiveness Data and Information Set measures tied to better maternal outcomes such as the Prenatal and Postpartum Care measures.
• Postpartum assessments for all women within the first 3 weeks following birth can help address issues related to poor postpartum outcomes. Ongoing care should be provided as necessary, along with a final, comprehensive postpartum visit occurring no later than 12 weeks after birth. One way to ensure more women receive these assessments is to extend Medicaid coverage in the postpartum period beyond the currently required 60 days. Home health visits for postpartum mothers would similarly increase access to postpartum care and reduce the likelihood of postpartum complications, especially for women that may struggle with issues of social support, transportation, and maternity leave. Some payers have developed incentive or intervention programs focused on improving the rates of postpartum follow-up visits to enhance maternal and child health outcomes. These strategies include distribution of postpartum care education brochures and community resources, as well as the use of obstetrics care managers monitoring high-risk women with individualized care plans.
• Standardized obstetric emergency protocols based on evidence-based guidelines could reduce potentially dangerous variances in care. Insofar as over half of pregnancy-related deaths are preventable, better systems are needed to prevent or reduce the severity of emergencies that arise during delivery. The ACOG encourages clinicians to assess potential emergencies, establish early warning systems, designate specialized first responders, conduct emergency drills, and debrief staff after actual events to identify strengths and opportunities for improvement. These protocols are typically developed by individual facilities, but it may be more beneficial for minimum standards to be mandated at the state or national level.

Maternal Mortality Illuminates a Wider Problem

While it’s true the absolute number of US mothers lost annually due to maternity-related causes is relatively small, the repercussions of these deaths for surviving loved ones, particularly children, are enormous and ongoing. Moreover, maternal mortality statistics are merely the most visible indicator of a much deeper public health problem: For every maternal death, more than 100 women experience severe maternal morbidity, a life-threatening diagnosis, or a life-saving procedure during delivery hospitalization.

A comprehensive approach to reducing maternal mortality that integrates patient education, clinical improvements, and care standardization across the maternity care continuum could have a substantial impact on the rate of birth-related deaths and the morbidities that contribute to them among women of color.

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