Black women in the United States are at a disproportionately higher risk of dying during - or as a result of - childbirth. What's to blame? And what must be done to end this troubling trend here in metro Detroit?
The number of black women dying as a result of pregnancy or childbirth is reaching alarming numbers. Today, black women are three to four times more likely to die from pregnancy or childbirth complications than white women.
Activist Erica Garner – the 27-year-old daughter of Eric Garner, who was killed by police, sparking national attention toward police brutality – died in December from a heart attack related to an enlarged heart that was aggravated from the birth of her son just fourth months before.
Garner's death shined a spotlight on the United States' maternal mortality problems – and racial disparities when it comes to pregnant and new moms.
Across the globe, the number of women who die as a result of complications from pregnancy or childbirth has steadily decreased over the years. From 1990 to 2015, UNICEF reports the global maternal mortality rate has dropped 44 percent. The numbers in the U.S., however, are steadily going in the opposite direction.
The American maternal mortality rate – defined as the death of a mother from pregnancy-related complications while she's carrying through 42 days after birth – has risen from 10 deaths per 100,000 live births in 1990 to over 17.3 deaths per 100,000 live births in 2013, according to the Centers for Disease Control and Prevention, which reports that about 700 women die each year as a result of pregnancy or childbirth. Our maternal death rate lands the United States at the bottom of the world's developed countries, and the CDC estimates that 60 percent of these deaths are preventable.
"The number one on the list is still postpartum hemorrhage," says Dr. Robert Welch, a fellow of The American Congress of Obstetricians and Gynecologists and director and chief of maternal fetal medicine at Detroit Medical Center and Wayne State University. "After the baby is born, and delivery of the placenta or even after the placenta is delivered, the tendency for the uterus to bleed and have massive hemorrhage is still a major problem."
Welch says the second most prominent complication women face during childbirth are pulmonary embolisms – which was recently highlighted by tennis player Serena Williams when she gave birth to her daughter last year.
"She had a post-pulmonary embolism. A venous thromboembolism is really a major cause of maternal mortality," Welch says. "This is where they develop blood clots in their legs or deep in their pelvis, and then these float off to their lungs, shut off blood supply to their lungs, and they die of a respiratory problem."
'SOCIAL DETERMINANTS OF HEALTH'
The World Health Organization uses the term "social determinants of health," or SDH, to describe "the conditions in which people are born, grow, live, work and age," which "are shaped by the distribution of money, power and resources and health." For the majority of black women, SDH don't work in favor of healthy pregnancies.
When assessing black women's SDH, many health professionals begin by looking at health conditions predisposed at birth. Over 45 percent of black women suffer from hypertension at some point in their lives, compared to just over 31 percent of white women, the CDC says. And, according to the American Diabetes Association, almost 19 percent of all African-Americans over age 20 have diagnosed or undiagnosed diabetes, compared to just over 7 percent of non-Hispanic white Americans.
Environment and living conditions also play a role. Over 21 percent of black women live in poverty, the National Women's Law Center notes. Living in communities with high poverty comes with its own set of struggles and stresses that can take a toll on a woman's health.
"Being afraid of the possible violence in the community, not being able to get out and walk in your neighborhood because of the violence in the community – a lot us that don't live in that situation take those things for granted, but it's something a lot of pregnant black women have to deal with," says Dr. Melva Craft-Blacksheare, a certified nurse midwife and assistant professor of nursing at University of Michigan-Flint.
General health also plays a role. In 2015, African-American women were 60 percent more likely to be obese than non-Hispanic white women, the U.S. Department of Health and Human Services Office of Minority Health reports.
Dr. Gregory Goyert, division head of maternal fetal medicine and women's health services at Henry Ford Health System in Detroit, says patients throughout the city don't have easy access to grocery stores for fresh and healthy foods.
"Many of our patients exist in food deserts, and then they come in extremely obese with BMIs (body mass indexes) that are two, three, four times normal with significantly higher rates of chronic high blood pressure (and) diabetes that is not well treated," Goyert says. "Patients bring into pregnancy all of these risk factors that significantly increase the risk for poor outcomes in general, and it significantly increases the risk for maternal mortality."
Craft-Blacksheare adds, "As black women, the majority of us are in that lower socioeconomic area. But even with the statistics of women that are college educated, that are middle income – they still have a higher maternal mortality rate than their white counterparts."
Goyert calls it a multifactorial issue.
"If you take those groups of African-American patients and compare them to extremely similar groups of age, maternal BMI, socioeconomic status, income, ZIP codes – so we've stripped away the differences – there is still a three-to-four-times increased risk for adverse obstetric outcomes and same increased risk for maternal mortality (among African-American patients)," Goyert says.
"We can't always talk about genetics. I don't want people to think black people just aren't strong. We need to look at something deeper than that," continues Craft-Blacksheare. "One of the things that's come up lately is about implicit bias as it relates to health care."
Bias, whether implicit or not, has bred distrust of medical professionals and the health care system among black Americans for generations. Historical instances date all the way back to slavery – one of the most notable being the Tuskegee syphilis experiment.
"It's one of the reasons that the Institute of Medicine and the Robert Wood Johnson Foundation are trying help diversify the health care system and health care professionals, because there have been many studies that show the biases," Craft-Blacksheare says. "We talk about the importance of health care providers to be culturally competent, and that's all great and good. But it's important for health care providers to learn about themselves and look into their own biases."
TACKLING THE PROBLEMS
While the overall maternal mortality rate has been increasing in the U.S. for about the past two decades, California has made progress reducing the number of maternal deaths in the state. The California Maternal Quality Care Collaborative is an organization led by Stanford University School of Medicine and the state of California. Through research, statewide outreach and its Maternal Data Center, the organization notes that California's maternal death rate has decreased by 55 percent since the organization's inception in 2006.
"We do have an initiative in place," Welch says, "but the California Maternal Quality Care Collaborative really kind of leads the nation."
In 2015, Michigan joined the national effort to reduce pregnancy-related complications and deaths by forming the Michigan Alliance for Innovation on Maternal Health, or MI-AIM – a partnership led by the Michigan Department of Health and Human Services, Michigan Health and Hospital Association and Wayne State University. MI-AIM focuses on provider education and procedures for specific maternal morbidity issues like postpartum hemorrhage and thromboembolic disease, in addition to maternal mortality.
But Craft-Blacksheare notes that the onus of saving our mothers can't fall entirely on the medical community. Improving the physical and mental health of women before and during pregnancy needs to start within the community.
"We have an obesity crisis, so we need to talk about safe places to exercise. Not everybody can put on their jogging shoes and go walking in their neighborhood. These things have to be addressed in the community where people gather – in the schools, the churches," Craft-Blacksheare says. "These are societal problems. The health care community alone cannot take care of this. It's a national issue."