High Black Maternal Mortality: A Review of the Data and Suggestions for Further Research
Across the nation, maternal mortality rates are significantly higher for black mothers than for white mothers. As Graph 1 shows, black women are far more likely to die during pregnancy and childbirth. What’s the cause of this large disparity in death rates that is correlated with race? Many suggest that there is an implicit bias in medicine, meaning doctors are less likely to believe black patients when they report complications. If a doctor does not believe a patient’s concerns about their medical condition, that doctor is less likely to take the medical precautions to de-escalate the situation. Others postulate that black women are more likely to suffer from diseases which inherently complicate their pregnancies, leading to higher mortality rates. Using data from the Centers for Disease Control and Prevention (CDC), we can examine if higher diabetes, higher obesity and higher hypertension (high blood pressure) mortality rates of black women explain their increased likelihood to die during pregnancy and childbirth.
From the CDC Wonder web page, one can download data on the underlying causes of death in the United States. California, Florida, Georgia, Illinois, Louisiana, New York, North Carolina and Texas have the most complete data on deaths caused by diabetes, obesity, hypertension and maternal mortality over the last four years. These eight states reported on both white and black women every year for the last four years. The data shows that black women consistently suffer from higher maternal mortality than white women. Graphs 1–4 show that although black women die at somewhat higher rates from diabetes, obesity and hypertension than white women, the maternal mortality rates are significantly higher in all eight states for each of the four years, with the exception of Georgia and Texas in 2014 and California in 2016.
Graph 4 shows that in North Carolina in 2017, black women were 180% more likely to die from diabetes, 140% more likely to die from hypertension, 190% more likely to die from obesity, but 520% more likely to die from pregnancy or childbirth. This means that a black woman’s likelihood to suffer from diabetes, hypertension or being obese does not explain her increased risk to die from pregnancy or childbirth.
Graph 5 below shows the ratio of black to white maternal deaths in each of the eight states over the last 4 years, demonstrating that the inflated maternal mortality of black women is a consistent problem that is not getting better as technology and medicine advance.
A research study by Nelson, Moniz and Davis, “Population-level factors associated with maternal mortality in the United States, 1997–2012” published online by BMC Public health found that 31% of maternal deaths were due to obesity, 17% were due to diabetes, 5.1% were due to non completion of high school and 2% were due to being a member of the African American race. While 2% is a low number, it’s interesting that the researchers identified race as a factor that impacted maternal mortality. The researchers credited the 2% statistic to black mothers having poorer access to healthcare and being overall less educated than their white peers. However, maternal mortality of black women reaches across education levels and socioeconomic status. The New York City Department of Health and Mental Hygiene − Bureau of Maternal, Infant and Reproductive Health found that between 2008 and 2012, black women who graduated college were more likely to die from pregnancy or childbirth than white women who didn’t finish high school. This finding suggests that maternal mortality of African American women is not a problem of accessing or affording healthcare and further supports the possibility that it is an issue of doctors being less attentive to and less likely to believe black women when they report pain and complications associated with their pregnancy.
One theory as to why black mothers suffer from higher maternal mortality rates is that black mothers receive lower quality care in hospitals that are “products of historical segregation”. Another hypothesis is that black women suffer from lifelong stress due to racism in the United States; a phenomenon that Arline T. Geronimus calls the “Weathering Hypothesis” in her article “‘Weathering’ and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States” . Geronimus bases this hypothesis on the claim that people who are black experience “early health deterioration” due to the “cumulative impact of repeated experience with social or economic adversity and political marginalization”.
There seems to be a great deal of conflicting information in the research. If there is an implicit bias in science, how can that be measured and recorded? Racism is a hard variable to measure as it is a sensitive subject and, increasingly, subjective depending on who you talk to. After examining the existing opinions and research on maternal mortality based on race, and the data from the CDC, it’s clear that there is not a consensus on the root cause of inflated maternal mortality among black women. Further research on maternal mortality needs to be done and this research should take race, education level, and income into account.
State legislators are taking steps to identify why black women die more often during pregnancy and introduce policies that will decrease mortality rates for expecting mothers who are black. House Representative Shawn Thierry (D-Houston), a black woman, has filed House Bill 607 and House Bill 2703. H.B. 2703 aims to establish a maternal mortality and morbidity data registry. This data registry will be available online and include data from participating healthcare providers on: the most high risk conditions; infants who die within 12 months of birth and mothers who were pregnant 12 months preceding death; maternal and infant race and ethnicity distributions; incidence of diabetes, hypertension, and hemorrhaging among patients. This data registry would provide insight on maternal mortality in Texas alone, and the annual reports would identify causes of maternal mortality in Texas, providing lawmakers with relevant information to develop policies to address the problem. H.B. 607, if passed, would require general practice physicians, pediatricians, obstetricians and gynecologists to complete cultural competence and implicit bias training when renewing their registration to practice medicine. The purpose of the training will be to educate doctors on how to address health issues from patients of diverse backgrounds, and educate them on implicit biases, subconscious attitudes and stereotypes. Legislation such as this is aimed at combatting the notion that doctors find black patients less believable than white patients when reporting health issues.
Maternal mortality in the U.S. is obviously something that impacts black women more than it impacts white women but the reasons why race seems to be a dependent variable are still unclear. The research that does exist comes to inconsistent conclusions. More research dedicated to identifying the root cause of high maternal mortality for black women needs to be done, and legislation such as H.B. 2703 should be passed to further inform our decisions about health care and policy.