The ongoing series on by ProPublica has shined light on the serious problem of US maternal mortality. Interestingly the series evolved over time, initially framing the problem with a story of a privileged white woman who was a victim of malpractice and ultimately recognizing that it is a problem of race and healthcare disparities.
Perhaps the most shocking fact about US maternal mortality is this:
…[A]lthough Washington, DC, has the highest maternal mortality ratio in the nation, non-Hispanic white patients in this district have the lowest mortality ratio in the United States. Excellent care is apparently available but is not reaching all the people.
New data presented in the forthcoming issue of Obstetrics and Gynecology confirms this assessment. The paper is Health Care Disparity and Pregnancy-Related Mortality in the United States, 2005–2014.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Excellent obstetric care is available but it is not reaching the women who need it most.[/pullquote]
The trend is displayed in the following graph: Trends in maternal mortality ratio (maternal deaths/100,000 live births) by ethnic group and race: United States, 2005–2014. Numbers in parentheses represent P values for the Jonckheere-Terpstra test.Moaddab.
The authors note:
The U.S. maternal mortality ratio continues to climb and reached a rate of 21–22 per 100,000 in 2013 and 2014. Many explanations for this trend have been offered. Although the United States has a higher rural population than many European nations … our data failed to identify a statistical correlation between state-specific maternal mortality and either rural status or poverty. Immigration has also been cited as a factor in this mortality trend. However, we found lower mortality for Hispanic women who make up the majority of recent immigrants.
So the cause is NOT rural status, immigration or poverty.
What about the C-section rate, the all purpose bogeyman constantly used by natural childbirth advocates to scare women about obstetric care?
The high U.S. cesarean rate has also been invoked as an explanation for increased mortality, yet our data demonstrate only a weak correlation of mortality with cesarean delivery. Furthermore, previous work has demonstrated that this correlation does not reflect causation; the overwhelming majority of maternal deaths associated with cesarean delivery is a consequence of the indication for the cesarean delivery, not the operation itself.
What accounts for the difference in statewide maternal mortality rates?
Our data suggest that much of the variation in statewide maternal mortality ratios in the United States is accounted for by social rather than medical or geographic factors: unintended pregnancy, unmarried mother, and non-Hispanic black race. These data provide evidence for a strong contribution of racial disparity to maternal mortality ratio in the United States. Particularly striking is the close correlation between ethnic background and maternal mortality. A factor derived from factor analysis, which primarily represented ethnic background, accounted for 26% of the differences in statewide mortality. Excellent care is apparently available, but is not reaching all the people.
How should we compare maternal mortality across states (or countries, though the authors do not address international differences)?
…[C]omparative health care statistics that do not adjust for these important demographic factors are of little significance in judging the intrinsic quality of available health care in an individual state or region. The potential relative contributions of factors such as racial disparities in health care availability and access or utilization by underserved populations are not addressed by our data, but are important issues faced by states seeking to decrease maternal mortality. Ethnic genetic differences may also be involved. In addition, the potential role of unconscious (implicit) bias in this significant racial disparity must be considered.
Indeed, the US, which has the highest maternal mortality of any industrialized nation has by far the highest proportion of women of African descent.
The British press has been bemoaning the high US maternal mortality rate. For example, a recent BBC interview with Serena Williams was described thus:
Serena Williams says it is “heartbreaking” black women in the United States are more likely than white women to die from complications in pregnancy or childbirth.
It IS heart breaking that black women in the US are 3X more likely to die from complications in pregnancy or childbirth. What the BBC and Serena Williams don’t seem to realize is that the disparity is even greater in the UK; black women in the UK are 4X more likely to die from complications in pregnancy or childbirth.
According to the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15:
The rates of maternal mortality varied by age, socioeconomic status and ethnic background of the women, which are known to be independently associated with an increased risk of maternal death in the UK. The rate of maternal mortality was higher amongst older women, those living in the most deprived areas and amongst women from particular ethnic minority groups… Comparable to the previous reports, the risk of maternal death in 2013–15 was signi cantly higher among women from Black ethnic minority backgrounds compared with White women (RR 4.28; 95% CI 2.65 to 6.69).
The overall UK statistics look better than the US because women of African descent represent a far smaller proportion of the population in the UK (3%) than in the US (12.85%). The sad truth is that lower rates of maternal mortality in other industrialized countries reflect the fact that those countries are whiter. The countries with the lowest maternal mortality rates in the world (including Iceland, Sweden, Finland and Japan) are the whitest countries in the world.
The authors conclude:
…The increased mortality ratios seen in the United States in recent years reflect significant social as well as medical challenges and are closely related to lack of access to health care in the non-Hispanic black population. Our results provide evidence for the strong contribution of racial disparity to the maternal mortality ratio in the United States and suggest that addressing issues related to health care disparity and access for this population will play an important role in national attempts to reverse this mortality trend.
The only question that remains is whether we have the will to tackle the problem.
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I think the problem with US Obstetrics is we have become too “fetocentric” in our care. The 39 week rule is a prime example of the nonsense foisted upon us by various regulatory agencies in the last ten years dubiously to protect undeveloped fetal growth but as I see it creating this mentality that 37 or 38 weeks is somehow harmful for delivery. By virtue our training now is too push women further in their pregnancies even with comorbidities such as diabetes and hypertension. Now we wait until a patient progresses from mild to severe preeclampsia if they are not “late term” and invariably winding up with a patient with low platelets, pulmonary edema, and a whole host of medical nightmares all of which could have been prevented. In my mind there is not a race bias per se but unfortunately African American women are more predisposed to these comorbidites and have fallen victim to the the 21 century US Obstetrical mindset. ACOG has become a joke. The most current labor recommendations might has well been written by a lay midwife. ACOG will not take a direct stand against homebirth and sadly in my state our legislature just legalized midwives to perform such procedures. And at ACOG’s Annual Meeting in 2016 Lockwood and Norwitz both argued for delivery BY 39 weeks yet obviously fell on deaf ears. Maternal mortality will not change in our country until ACOG quits listening to Leapfrog and March of DImes and promotes a mother first mentality.
Well, don’t tell anyone but our hospital staff simply revolted and we now deliver for any indication when we think it’s the right time for the mother. And the department chair OKs it. If you look at the new gestational hypertension guidelines you have a LOT of leeway. Use it. March of Dimes can go pound sand.
Well I have become a master at fudging indications! But what I have seen with younger Obstetricians and Maternal Fetal Medicine is this idea of pushing pregnancy to 39 weeks when in my training twenty plus years ago we would have looked at (and I still look at) in horror. Previous C section twins should go to 39 weeks? Previa should go to 39 weeks? I mean when will the insanity end.
A white (middle class) woman talking about inherit racism in America, how ridiculous.
Man mansplains. How unusual.
I think the computer ate your prefrontal cortex.
He’s an idiot who knows everything. Don’t waste your time with him.
If you’re white and you complain about racism, you should mind your own business, if you’re minority, you’re obviously just looking for a handout, unless you’re already wealthy, in which case you should shut up and be grateful.
Does that cover all the bases?
Are you a professor in disingenuous prolix?
This is incredibly damning. We need to do better for women of color in this country. 🙁
Or actually that we need to do better for black and Native women in this country. Latinas and Asian women have lower mortality rates than white women.
I have, unfortunately noticed a disturbing trend in my medical care and the medical care of my kids. It dawned on me when MrC accompanied me to my neurologist half a year ago. All of a sudden the complaints I’d have for years, that had been blown off, were taken extremely seriously. A problem that was completely blown off three months prior led to a discussion about admitting me to the hospital when MrC described it. I’ve noticed the same with the boys. All doctors, male and female alike, take MrC’s word far more seriously than mine, even though the kids aren’t even his. He’s stepdad and all, but still. I imagine this problem is magnified many times for women of color.
It happens in other areas too. I took a car for a test drive a few years back, and was very keen to buy. I asked the salesman about part exchange for the car I already had, and he said he would look into what it was worth and get back to me. He never bothered getting back in touch, so instead of going back to that dealership I went to another dealership, pointed at the model wanted and said ‘I’ll have one of those in black, please’. The salesman just sat there gawping-probably the easiest sale he’d ever made!
A while later, I had parked the car in the mortuary parking area and a funeral director was asking about it, and when he found out it was mine he told me my husband should have put his foot down and not let me buy a car like that (it was a bit of a sporty number). The fact that it was my car, paid for by me and chosen by me just didn’t seem to compute with him.
Oh lord yes. My husband gets a lot more attention and respect when it comes to buying cars than I do – even though I’m the one who makes more money, the loan comes from me, and I know cars.
When we were living in a tiny village in North Kent, one of my husband’s friends came round one day. I opened the door, and he asked to speak to my husband. When hubby appeared, the friend asked him if he could go with him, because he was having trouble with his car. The friends face was a picture when my husband immediately said “Oh, you need my wife for that.”
Several years ago I had a similar experience. My husband had just bought a car from this salesman a couple months before, so I contacted him about finding what I wanted to buy. I had several must-haves, and as I was telling him what they were, he asked if I had ok’d them with my husband. I explained that as the purchaser of the car, and an adult, I had no need of anyone’s ok but my own, and that I would be quite happy to call a different dealership if he felt accommodating me was beyond his capabilities. “Well, hon, I know, but you know, you don’t want to make a big decision without talking to your spouse, right?” I wondered why I hadn’t heard from him when my husband was considering his purchase, because, you know, married people and all that. Silence.
They’d be more likely to ask a man whether he had OKed the color with “the little woman”.
In yet another different topic, I renovated the master bathroom in my house in October. I decided I wanted to replace the light fixture, but there were some fussy details because the moron that built the house did some really stupid things in the construction. So we go looking for light fixtures, which had to have a specific type of mount within a very narrow size range, but also had to be something we both liked cosmetically. So we’re off shopping, and I asked to see the back side of a couple of the fixtures we were considering. The salesperson asked what we were looking, though he directed the question at MrC. I answered, but he ignored me and asked MrC the same question, he referred back to me. Then the salesperson proceeded to completely freeze me out. I walked away. I don’t know exactly what MrC said, but he found me a minute or two later.
The bottom line is that this was my project. MrC knows fuck all about construction. He can do electrical stuff and some basic plumbing, but for the most part, all household repairs and renovations are my domain, and it just so happened that I was paying for the light fixture because I was the one who could no longer deal with the old one. We wound up going to a different store and paying a little bit more for one of the light fixtures I’d asked to look at in the first store, but didn’t buy there because the sexist salesperson.
I am literally invisible to car salespeople. When I bought my car I had to bring my father with me to get anyone to acknowledge my presence (and even then, I was only greeted after my father pointed out my existence). I was 30 at the time.
Buying cars is one of the few areas where I am happy to be invisible. I hate the hard sell – so I’m happy for an accompanying male to get it while I quietly decide which car to buy.
And then there is the reverse. My husband and I are redecorating our house and at every appointment, the designer is focused on me, not my husband. As decorating is his thing and not mine, I just point to my husband and say “whatever he decides is what we’re going with.” The looks on people’s faces is priceless.
In my case, that’s understandable. Demodocus’ one request was a wing chair as soon as we could afford one. Not that we have a designer
Bah. The mechanic where I just got my car fixed was fixated on showing my husband what they were going to work on. Never mind that i mentioned he’s BLIND only 5 or 192 times. Grr. Might have been funny to see their reactions to -that-.
I did something similar when I was buying a minibus for my taxi business. Left the first dealership and the salesman who seemed entirely disinterested in selling to me, and went to a rival one, where they treated me with great respect (and I went on to have a good relationship with them). I took great pleasure in driving my new purchase to the sexist dealership, and asking the manager to thank the salesman for not allowing me to buy one of their vehicles, because I was very happy with the one I bought from their rival.
And then there was the moronic young salesman at the tech store where I bought my first mobile phone. This was in 1990, when they were rare and the size and weight of a concrete block. My husband was actually with me, although pretending to be interested in some Hi-Fi equipment a few feet away. The salesman was trying to persuade me that I actually wanted a two-way radio. I kept saying that I didn’t, I wanted a mobile phone so that I wouldn’t miss calls for business. Sounding frustrated, he said “But taxi drivers usually have a two-way radio and their wives take the calls on the house phone and pass them on!” I gave him my best Hard Stare and said “That’s my husband I came in with. Do I look as if I have a wife at home?” My husband cracked up.
I used to always take my husband along if I had any issues at my son’s (all boy) school. My husband is an extreme introvert, and very conflict averse, but he can sit and watch me go in to bat every day, with some pleasure.
It used to bug the hell out of me that I needed him there for them to take me seriously, especially since it was me that wanted the private schooling, and was working to cover the cost, not that they knew that.
Then I figured, it’s their weakness, not mine. I’m a very small, very feminine looking and sounding woman. Many men have (initially) underestimated me, to their cost.
“…to their cost.” Love it! That sent a chill through me. #yetshepersisted
Is there any sense of whether the exact same providers have different outcomes with patients of different races? Or is it a case of Black and Native American women using one set of providers and everyone else using a different set of doctors and hospitals?
I’m looking for references, but I think the answer is racism affects how particular health care professionals act. Health care professionals are more likely to dismiss the pain of black people, or women. I think the American opiate crisis really is disproportionately white, and I’ve seen it suggested that that is because doctors were under-prescribing those medicines to black people.
But sure, class plays a part too, in America at least, and being lower-class is counfounded with being non-white. But upper-class non-white people still have worse health care outcomes than upper-class whites.
Do you think it’s influenced by someone like Grantly Dick-Read saying that ‘primitive’ women don’t feel pain during childbirth? So are health care providers ignoring the pain of POC on the grounds its not ‘real’ pain?
I think the simpler explanation is that racism, sexism, whatever-ism predisposes people to think that ‘others’ don’t feel things like ‘real’ people do. Or that if some ‘other’ feels pain, it’s their fault, unlike ‘my’ people, who really deserve help when they need it.
In the States, also, the “war on drugs” pretty intentionally portrayed drug abuse and associated criminal behavior as common among black people, so that those who don’t know better are way more likely to perceive black people as drug-seekers than white people. White women more than white men, and POC more than any white person.
If my experience (described in a different comment) is any guide, then it’s a case of providers treating POC differently than white people, and women differently than men.
Exactly. I think this is becoming more and more well-documented. A good rule of thumb is that any pattern of discrimination that adversely affects white women will affect POC even more, with black women being most strongly adversely affected.
And people are shocked when even an 11-year-old black girl can see it clearly. I’m so impressed by Naomi Wadler, and I do hope she continues to do great things in her life.
She was absolutely amazing, wasn’t she? And then you have a complete tool like Santorum complaining that these children shouldn’t be asking for someone else to do something and instead learn CPR. Wanker.
I am flabbergasted that the NRA and even some repub politicians are flat out attacking these children. Really showing their true colors, aren’t they?
Both, I think. Black and Native Americans have less access. And doctors dismiss their symptoms as drug seeking.
With the NHS technically all women should have the same access to the same standard of care, so why should BME mothers have a higher risk in the UK? Its the same with mums who don’t have English as a first language-they technically should have access to the same standard of care but they also have a higher morbidity and mortality rate. Is it that BME mums have a higher rate of pre-existing medical disease? Are they taken less seriously if they have symptoms, and not investigated to the same extent that a non-BME mum might be? Are there cultural issues-are they more likely to acquiesce to medical staff and not kick up a fuss if they feel something is wrong? We have the MBRRACE-UK data going back years (with CESDI and CMACE before that going back to the 60s and before) so we have a comprehensive national overview, we just seem to be moving fairly slowly on it.
This is just a thought but from experience so much of the care you get if you show up in an NHS hospital depends upon your being able to convince the midwifery team to take you seriously enough to let you see a consultant or senior doctor I can easily see how racism amoung said team could have an disproportionate impact in the UK. All it would take would be for UK midwives to be statistically more likely to blow off a BME mother’s concerns than a European mother’s for a significant number of BME mothers in serious trouble to simply not get properly checked out at all before being sent home with reassurance. From what I can tell of the American system the medical caution and “intervention happy” culture would tend to mitigate this slightly as mothers in general are more likely to be referred to someone senior in the event of a doubt (hence the less bad statistics for the US on this) as the US system is more comfortable with the idea of giving women interventions generally.
I think being the sort of woman who’s most likely to be taken seriously means you’re more likely to be white.
You’d need to be fluent in English that isn’t strongly accented (and in that I include some very strong native regional accents as well as foreign ones). You’d need to sound educated and for the people you’re addressing to recognise that. You’d need to be confident speaking to professionals and making demands, and to not be assumed to be angry or stroppy or stupid or lying if you argued. You’d also not want to be a young mum, and iirc BME and non-native English speakers have younger average ages at first birth than the general population. There’s also stuff like black women being viewed as being more able to bear pain. And there are class issues, but bear in mind that black women are more likely to be perceived as underclass. It’s a toxic brew.
Totally agree – intersectionality: it’s a thing people!
Was James Titcombe’s wife a WoC, or am I misremembering?
Yes, she’s called Hoa. I think she’s Malaysian.
Also, one of the mothers who died in Barrow in Furness (along with her baby) was Nittaya Hendricksen-she was a WOC too.
There would be geographical factors to take into consideration, as BME women are concentrated in certain areas rather than evenly spread around the country. Same with women who don’t have English as a first language, or Welsh in a Welsh speaking area. So if eg there were a toxic culture at Homerton in Hackney, that would affect many more BME women than the same problem in the Highlands. This isn’t to say that in cases like eg Morecambe Bay where the women would’ve been less BME than the general population, an individual woman such as Hoa Titcombe not being white couldn’t possibly have made a difference.
That said, I don’t think it’s the case that care in urban areas where BME women are most likely to live is worse than care in more rural areas. Sometimes the opposite. The problems faced by both are different. I think units in urban areas are more likely to be closed temporarily, for example?
I found in having my baby in the U.K. that you need to be really proactive with the NHS and really advocate hard for yourself. This was easy for me as an older, educated, wealthy white woman. It isn’t as easy for others.
Completely. Look at Serena Williams-a hugely confident, intelligent and professional woman and she had to really push to get the help she needed, even with the very strong medical history she had (of clots). It’s worrying that even when a woman stands up and shouts, her voice is ignored or downplayed. I’m a large, gobby, white woman, very well used to talking in formal settings and business meetings etc, and I’m very aware of the privilege that gives me. I can imagine that someone less confident, less well spoken or more conflict-averse gets a different standard of attention, notice or action. The treatment you get shouldn’t depend on your fluency or level of education, but I’ve had a few friends of friends or extended family members tell me that things only happen when you start shouting or threaten to complain formally.
One of the solutions is to address disparity of health care providers; clearly we need more African American physicians.
Oooh! Dr. Lemagie! So nice to see you here. We met at a medical meeting a few years back.
Yes, you’re right. Couldn’t agree more.
And such low hanging fruit really, such a simple and easy solution. I cannot imagine it would be practically difficult to fund more training for black doctors, and it would pay for itself soon enough in better outcomes.
Yeah, but it’s more than that. Aside from systematic racism, it’s harder for POC and immigrants to forge medical or nursing careers, in part because the time commitment before you can start earning well is so huge. Many of the clinicians I’ve spoken to on this issue enter college and med/nursing school a bit later in life d/t financial concerns, so by the time they’re in residency, they’re also caregiving for young or elderly families, often without much support. But funding would help, certainly.
It is, but I have read that there are hundreds of black applicants each year who apply for medical school and aren’t offered a place. Well that there would suggest there’s a pool of people who, despite the difficulties they might face, are still able to get to the application stage and have the desire to do it. Assume some of them won’t be suitable for whatever reason and others will drop out for reasons that can’t be easily prevented. That would still appear to be a group of black people ready and willing to be doctors and ideal participants for some kind of programme looking to increase the numbers?
I’m not saying that there wouldn’t still be structural problems preventing many more black students than white from getting to this position in the first place, or that they’d all be starting from the same point in the blocks. Not at all. Just that even with all the issues you mention, there are still prospective black medical students who are basically an untapped resource. Tap that, more black doctors, improved outcomes for black patients even with lots of other problems of racism and structural inequality still there.
Sarah “It is, but I have read that there are hundreds of black applicants each
year who apply for medical school and aren’t offered a place.”
Do you remember where you read that? I am truly interested, because it does not go along with my own observations within my own community (see my other comment).
I can’t remember where I first read it so did some nosing for stats. Mostly the research seems to focus on percentages not exact numbers but I did find a couple of things.
https://www.aamc.org/download/321514/data/factstablea24-2.pdf
This one breaks down black applicants by institution, the total number is into the four figures for the 2017-18 year:
https://www.aamc.org/download/321446/data/factstablea2-1.pdf
Knowing what we do about admissions rates for black applicants, this would indicate there are hundreds who didn’t get in. It seems unlikely that all those refused were unsuitable, or even unsuitable in a way that targeted funding couldn’t fix, so with that in mind they seem to be very much an untapped resource. This, I think, is indefensible when we know that more black doctors benefit black patients.
It’s not a simple solution.
You have to fix the entire education system. You’re not going to increase the number of African American physicians until they can get into medical schools – which means they have to pass the pre-requisities. That means they have to *take* the prerequisites.
That improving the education of African Americans – all of them, not just a few who are already well off and in private school – at the elementary and middle school levels.
It’s not a simple solution to the problems in the education system, no. It’s identifying black people who despite all those problems still want to go to medical school and would have the ability, and then funding this to happen. Yes, this would still leave lots of black people unfairly disadvantaged. It wouldn’t solve all the problems of racism in healthcare, but we know that black doctors means better care for black patients.