Racism, Filters, and Maternal and Fetal Mortality

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Image courtesy of the Seattle Municipal Archives.

 

NOTE: This post will pull from a previous post I wrote about maternal and fetal mortality in 2016.  I really encourage you to read it.  Most of this will come from the CDC data and graphics I cite in that post.

Maternal mortality is a public health issue.  American women die at a rate much higher than elsewhere in the developed world.  I’ve written about how this rate has actually been climbing in recent years.  Across the board, American women are at risk.

There are reasons for this .  A main killer of women is pre-eclampsia.  Pre-e is not only a risk during pregnancy and immediately following. We now know it can make women 8 times more likely to develop heart disease in their lifetime.  Obesity contributes to this and we can link obesity rates to the rate of risk for chronic conditions like heart disease.  Thus, we know that women with these risks are most likely to develop these issues.  Most importantly, we know that women who suffer from low socioeconomic status (SES) are most likely to go without medical care following pregnancy.  Their last postpartum visit is when medical care ends if they are on Medicaid.  And, in many cases, that is not enough to keep women on track health-wise.  This is what leads women of low SES status to be most at risk for pre-e and also most likely to have sufficient postpartum care and chronic condition monitoring over the rest of their lives.

One of main issues with maternal deaths is that they are much more likely to be in black women vs. white or Hispanic women.  Black women are, in fact, three times more likely to die in or immediately following childbirth.  If you are a black woman in the United States, you are much more likely to face poor health outcomes.

Infant death rates are another issue.   Likewise, while infant rates of death are declining on average, there are stark differences in the rates of death in white and Hispanic babies and those of African American descent.  Babies of African American descent are almost 2 times as likely to die as their white and Hispanic counterparts.

Why are black women and their babies at risk of much different health outcomes than their white counterparts?

Maternal Death Rates

Well, the CDC has released some reasons why they believe this unfortunate disparity exists in maternal rates:

1. Black women are more likely to have a lower socioeconomic status and this makes them pre-disposed to being doubted by health professionals and having lower-quality care.

 I have seen women complain about this.  While I was pregnant with R, I was in a group for moms suffering from hyperemesis gravidarum.  Black women in the group suffered in silence.  If they had to rely on Medicaid, they had care at a later date that those of us on private plans.  This meant that their providers may have not even been aware of HG or proper modes of treatment.  They were more likely to be “gingered” or denied life-saving meds like Zofran.  But even with that aside, the members of the group who were women of color reported that their providers did not take them seriously.  Several times, I read long-running posts of frustration from these women who had gotten a golden recommendation for a doctor from a white friend but the doctor was being dismissive in a way they had not anticipated.  I could definitely see this being even worse in a case of pregnancy hypertension.  While this was my anecdotal experience with my friends in this group, the CDC has identified this is a problem, too, so it has to be widespread.

2. Black women are more likely to receive inadequate and less frequent health care over the curse of their pregnancy.

When you add this in with Number 1, you’ve got a dynamite issue for black women.  The first, according to the Office of Minority Health, is that black women are much less likely to receive prompt and proper care or care that mothers determined was as early and effective as they would have liked.  They were also more likely to smoke, something that women would be helped with if they were able to obtain good care.  This may be related to the greater likelihood that low income black women are primarily relying on Medicaid, which may not kick in immediately and may make it more difficult for women to find a good provider as early as they would like.

3. Black women are more at-risk for certain health conditions which are correlated with poor maternal health outcomes.

We’ve already discussed this but black women are more at-risk of chronic conditions like heart disease and diabetes which make them more at risk of complications like pre-eclampsia or serious hypertension postpartum.

4. Black women have stress.  This stress is a side-effect of living in a culture of racism, most likely.

There are poor health outcomes even when we account for SES status.  Black women, across the board suffer from stress.  This stress can exacerbate chronic conditions and these are of particular concern during pregnancy.  Why do black women have stress?  Well, they make less money and they face social barriers white women do not.

The most poignant case study I could find was that of Shalon Irving.  If you read one article I cite, please read this one.  Shalon’s story is not unlike mine.  She was a researcher.  She had it together when she got pregnant.  She had her ducks in a row.  So, with her career in hand, she was happy to be a new mom!  But, there were issues.  She suffered the unfortunate consequences of racism, it seems – something I never dealt with.  You see, Shalon was black.  She died shortly after she gave birth from massive blood pressure issues which had not been treated properly.  Shalon did what she thought she needed to.  She called her doctor when she was concerned.  It didn’t help.  She was told to come in a day later – a day too late to save her life.  Her baby was only a few weeks old when she was died.  Postpartum hypertension, a pregnancy complication which is most definitely treatable, left her child without a mom.  A bright star was put out.

The world should weep for the Shalon’s of the world.  It should also be livid.  Her death was senseless but it is a perfect illustration of how implicit bias hurts women of color.

 

Infant Death Rates

The CDC suggests that racial disparities in infant death rates is attributable to a few things.

As we know, black women may receive less care and inadequate, dismissive care from providers.  This can put women at risk and their babies will suffer, too.

Likewise, we know that black women are more likely to suffer from chronic conditions like heart disease, hypertension, and diabetes.  Thus, the poorer health outcomes of black women during pregnancy can negatively impact their babies.  Maternal mortality and infant mortality are linked by this issue.

Recent research suggests that, as in the case of black mothers and their own mortality, black babies are unfortunate victims of racism.  Racism doesn’t just cause providers to doubt their patients know their bodies best.  It causes a burden of stress that is inexcusable, as shown above.  When mom is stressed and has a poor level of care due, in part, to descrimination or disadvantage, her baby suffers.  Stress was found to be a problem even when controlling for SES factors (Geronimus 2006).

What can we do?

We have options.  The first is most obvious.  We need to admit we have bias.  The medical community needs to do better.  White people like myself need to be aware of this and be very concerned.  It is hurting our sisters.  It is literally killing them and their babies!  That is a complicated mountain to climb but we need to do this.  That, however, could take years, decades even!

In the short term, we know there are things that can be done to address disparities via medical care.  An examination of a protocol taken up in North Carolina shows us this.  In NC, women who are deemed high-risk are given a “pregnancy care manager” who is a case manager that will guide women through the steps to better care for their health and seek treatment during their pregnancy.  It’s basically a chronic health risk concierge from what I can gather.  This person can even visit a woman in her home to address these issues.  Care managers can provide guidance on medical issues as well as nutritional ones and just be supportive.  North Carolina promotes these referrals for providers by providing financial incentives for the use of these services for Medicaid patients.   While maternal and fetal death rates are still on the rise in NC, the gap between women of color and white women has basically gone away. Thus, better outcomes are possible.  Programs like the Pregnancy Care Manager approach could be implemented elsewhere  – even in states without Medicaid expansion (as NC has not expanded Medicaid).

The bottom line… racism has serious implications for black women and their babies.  We can just wish this away.  We need to realize that racism has lasting effects on minority women and causes real, tangible scars.  The American public, academy, and women’s health practitioners must take note and do something.  A world in which my friends of color are most at risk of these outcomes simply due to the burden of racism is not a world I want to live in.  There are things we can do to help women, as the program in North Carolina, but in order to make a real difference, we will have to confront racism head on.

If you are a woman of color and you’ve experienced these issues, I would love to link to you or publish a guest blog.  I am always looking to incorporate new voices and can’t directly speak to these issues as a white lady.  However, I would like to spotlight you and your experiences because, as a white lady and an ally, I need to listen.  Still, I hope that I’ve done this topic some justice.  It is really, really dear to me.  It’s just so wrong.

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