Infant and Maternal Mortality in the United States

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Last week’s New York Times Magazine had an absolutely wonderful piece entitled “Why America’s Black Mother’s and Babies Are in a Life-or-Death Crisis” that I would like to highlight in this blog post.  This article was written by Linda Villarosa, a black female contributing reporter who has a long history of writing about racial justice issues in a way that highlights experiences of particular individuals as well as the facts surrounding these issues.  In 2017 she wrote a wonderful piece about the high HIV rate among black and gay men.  One of the astounding facts Villarosa brought to light was that “Last year, the Centers for Disease Control and Prevention, using the first comprehensive national estimates of lifetime risk of H.I.V. for several key populations, predicted that if current rates continue, one in two African-American gay and bisexual men will be infected with the virus. That compares with a lifetime risk of one in 99 for all Americans and one in 11 for white gay and bisexual men. To offer more perspective: Swaziland, a tiny African nation, has the world’s highest rate of H.I.V., at 28.8 percent of the population. If gay and bisexual African-American men made up a country, its rate would surpass that of this impoverished African nation — and all other nations.”  

Villarosa’s latest New York Times article was very similar in some ways to this previous piece on HIV, weaving facts through a wonderfully in-depth story of Simone Landrum.  In her account, Simone Landrum tragically lost a baby girl and several years later traumatically, but successfully, birthed a baby boy.  Unfortunately Landrum is far from the first individual to experience such injustices nor the first to be written about.  Villarosa also tells her own birth story that also may have been impacted by her experience as an African American woman.  Over the past year there have been many articles retelling similar stories, including several pieces written on the birth of Serena Williams’ baby girl and an NPR piece on Shalon Irving who died from complications of high blood pressure three weeks postpartum.  Indeed, just one week after Villarosa’s article, the Times published a follow-up article with 5 equally devastating personal accounts.  

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The Numbers

All of these individual stories have brought the astounding facts to life. Villarosa did an amazing job outlining these facts and the history of beliefs surrounding them.  In the following few sections, I wish to highlight some of these facts. But I strongly encourage you to go read Villarosa's article for the full picture. 

At present, the United States ranks 46th out of the 184 countries that collect this data.  In fact, it is one of only 13 countries in the world whose rate of maternal mortality in 2015 was worse than in 1990.  Also from 1993 to 2014 the number of hypertensive disorders in pregnancy, postpartum hemorrhage, pulmonary embolism, and number of potentially preventable near-deaths per year rose nearly 200% to 50,000 per year, according to the CDC.  In general, ratings of medical conditions in the United States tend to vary widely by race.  Black women are 22% more likely to die from heart disease than a white woman, 71% more likely to perish from cervical cancer but 243% more likely to die from pregnancy or childbirth-related causes.  One study analyzed in a 2002 report found that “cesarean sections were 40 percent more likely among black women compared with white women.”  Ten years later, The Listening to Mothers Survey III, “a national sampling of 2,400 women who gave birth in 2011 and 2012, found that more than a quarter of black women meet their birth attendants for the first time during childbirth, compared with 18 percent of white women.”

What about the rankings of infant mortality? 

The United States ranks 32 out of the 35 wealthiest nations in infant mortality (and 55th out of the 225 countries that collect this data).  If we look at this data by state California has the 5th lowest deaths per 1000 births of all the states at a rate of 4.2 deaths per 1000 (35 countries in the world have infant mortality rates lower than California).  When we look at the ratings by race, black infants are more than twice as likely to die as white infants at a rate of 11.3 / 1000 black babies compared to 5.1 / 1000 white babies.

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Why are these numbers so atrocious?

Lets look at different myths that were held starting from 1850, when the United States first gathered rankings on infant and maternal mortality, to closer to the present day.  The following are all myths on infant mortality rates for black women.  The facts are all from Villarosa's article.

Myth: These ratings are only true for women who are too young. 

Fact: Dr. Arline Geronimus, professor of health behavior and health education at the University of Michigan School of Public Health published an article in 1987 noting that “black women in their mid-20s had higher rates of infant death than teenage girls did - presumably because they were older and stress had more time to affect their bodies.  For white mothers, the opposite proved true.  Teenagers had the highest rank of infant mortality, and women in their mid-20s the lowest."

Myth: Only true for women who smoke and drink during pregnancy. 

Fact: In 1997, “a study of more than 1,000 women in New York and Chicago, published in The American Journal of Public Health in 1997, found that black women were less likely to drink and smoke during pregnancy, and that even when they had access to prenatal care, their babies were often born small.”

Myth: Only true because black people have different genes than white people.

Fact: In 2007, two Chicago neonatologists, Richard David and James Collins, published an examination of race and infant mortality "again dispelling the notion of some sort of gene that would predispose black women to preterm birth or low birth weight.

Myth: Only true because black women are poor and uneducated.

Fact: The infant mortality rate for black women with an advanced or professional degree is 6.1 / 1000 whereas the infant mortality rate for a white woman with less than an eighth grade education is 5.9 / 1000.

So, what’s the real reason for these discrepancies?

Racism.  Societal racism is expressed in a longstanding racial bias in health care.  A 2016 study "examined why African-American patients receive inadequate treatment for pain not only compared with white patients but also relative to World Health Organization guidelines. The study found that white medical students and residents often believed incorrect and sometimes “fantastical” biological fallacies about racial differences in patients. For example, many thought, falsely, that blacks have less-sensitive nerve endings than whites, that black people’s blood coagulates more quickly and that black skin is thicker than white. For these assumptions, researchers blamed not individual prejudice but deeply ingrained unconscious stereotypes about people of color, as well as physicians’ difficulty in empathizing with patients whose experiences differ from their own. In specific research regarding childbirth, the Listening to Mothers Survey III found that one in five black and Hispanic women reported poor treatment from hospital staff because of race, ethnicity, cultural background or language, compared with 8 percent of white mothers.”

What is being done about these discrepancies?

One of the things that Villarosa pointed out as a helping factor for Simone Landrum is her doula, Latona Giwa.  Villarosa noted a potential connection between doulas and granny midwives.  She also pointed to the fact that pregnant women with continuous support (ie a doula) are 39% less likely to have cesarean deliveries.  The largest systematic review of continuous support was published in 2011.  Aside from cesarean deliveries, doula-supported women were "31% less likely to use synthetic oxytocin, 9% less likely to use any pain medication, and 34% less likely to rate their childbirth experience negatively".  In February of 2017, ACOG (the American College of Obstetricians and Gynecologists) released a statement on the approaches to limit intervention during labor and birth that said “evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support [provided by support personnel, such as a doula] is associated with improved outcomes for women in labor.”  

Last year I had the extreme privilege of meeting Jennie Joseph whose "‘Easy Access’ Prenatal Care Clinics offer quality maternity care for all, regardless of their choice of delivery-site or ability to pay, and have successfully reduced both maternal and infant morbidity and mortality in Central Florida."  I also got a chance to hear a talk by Carolyn Sufrin, an anthropologist and ob-gyn, who spoke about the “experiences of incarcerated pregnant women, as well as on the practices of the jail guards and health providers who care for them.”  In recounting some of the experiences she personally witnessed, Sufrin spoke about how the context of poverty, addiction, violence, and racial poppression characterize women’s lives in jail.  She speaks more in depth about these issues in her book entitled Jailcare.  Other individuals have taken smaller approaches to bring attention to the racial injustices around birth and babies in general, including photo shoots to normalize breastfeeding in the black community among many other things.

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Individuals on the city and state level have taken notice of the impact that these doulas and Joseph has had on mortality rates.  In 2009, Baltimore started the program B’more for Healthy Babies.  One component of this program is to train individuals in the community to be doulas who assist expectant mothers during pregnancy, delivery and afterward.  When the city began this program, “a white newborn was more than three times as likely to survive infancy as a black baby.  By 2014, the gap had narrowed to about 2.5 times as likely.”  Governor Andrew Cuomo announced a doula pilot program for New York this past weekend.  “If the doula program is successful, New York would join Minnesota and Oregon as the only states that allow Medicaid reimbursements for doula services.”  New York is also “creating the Task Force on Maternal Mortality and Disparate Racial Outcomes, which will collaborate with the Maternal Mortality Review Board, a new entity composed of health professionals that will review each maternal death in the state.”  The Pew Trust article on Baltimore also noted that Chicago and Tampa have their own doula programs and San Francisco, Denver and San Antonio may be starting programs soon.  Hopefully, doulas will be able to reduce the rates of both infant and maternal mortality.

Resources I used while writing this article: