Why are African American Mothers at Higher Risk for Maternal Death?

February is Black History Month — a time to reflect and highlight the experience of African American mothers.

Did you know that between three and six times as many African American mothers die during pregnancy, childbirth and the post partum period than Caucasian women? According to an article published in the January 2015 issue of ACOG’s journal, Obstetrics and Gynecology, the maternal mortality ratio for non-Hispanic black women is 38.9 per 100,000 live births. For white women, it’s 12.0. That leads us to this question:

Why African American Women?

Whether it is genetics, nutrition, lifestyle, social or health factors or the cumulative affects of generations of intense stress, the truth is, race matters. A high proportion of African American women live in poverty or with low socio-economic conditions that impact their nutrition, safety, healthcare access and wellbeing. African American women have higher rates of diabetes, hypertension and obesity, three conditions that contribute to increased maternal deaths. And for older African American mothers, the increase in maternal mortality due to age-related conditions becomes even more dramatic.

The Medical-Cultural Connection

Amanda Calhoun, MD, an Ob-Gyn with Kaiser Permanente in Richmond, California says the reasons why more African American women die is due to a complicated combination of factors. Calhoun says, “The biggest medical reasons why so many more African American mothers die are related to obesity, diabetes and heart diseases including hypertensive disorders of pregnancy. Some of that has to do with poor healthcare access. Some of it is related to the genetics of hypertension and diabetes, which are more common in African American women, and both of those are also related to obesity, which is far more common in African American women. But it’s more complicated than that. Eating is a way that a lot of people deal with chronic stressors. Obesity is associated with a history of childhood trauma. There’s just so much stuff here that’s culturally related that has to do with chronic stressors in society. But, I think the mediator of all that is obesity and hypertensive disorders, low socioeconomic status and poor access to prenatal care. Late entry into prenatal care and late diagnoses of complications during pregnancy are extremely common.”

What about access to healthcare?

For women with health insurance, finding a provider who is conveniently located and accepting new patients is challenging. For women without health insurance and even those with publicly funded insurance policies, it can be insurmountable. Doctors and midwives are hesitant to accept uninsured or under-insured patients because the rate of reimbursement for their services is low even though patient risk factors are high. Where county clinics and public healthcare resources are available, the services delivered often lack the personal attention, respect and atmosphere that make women want to return to month after month as needed for prenatal care. The paperwork and red tape often required to access even basic services is overwhelming, intimidating and time consuming.

The Stress Factor

Jennie Joseph, CPM midwife and founder of Commonsense Childbirth in Florida thinks that stress caused by the way healthcare is delivered to African American women is the biggest problem. Joseph says, “I don’t think it’s all genetic or socioeconomic. I’ve practiced in the U.S. for over 25 years, but I’ve practiced in Europe as well. The comparison of the two countries has led me to believe that it is in the delivery of health care and the translational reception of that care by the patient that creates disparities. Especially for African American women, stress is the end result of their treatment and healthcare experience.”

Why is healthcare so stressful for African American women? Joseph explains that stress related to the maternal healthcare experience is common for many women of color. Joseph says, “It might be caused by the personal interaction between provider and patient or on the institutional level, in the way hospital or clinic policies are put in place. Maybe it’s the staff being mandated or sanctioned to behave in certain ways. Whatever the reason the resultant stress of these interactions contributes to bad outcomes for African American mothers. I am absolutely convinced of this because when you provide the same patient populations with compassionate, humanistic, culturally safe, patient and family centered care, with humility and good listening skills in a calm environment, we get great outcomes. We’re midwives. We can’t claim our great outcomes come from fancy, highly technological techniques or massive clinics with the latest equipment. We aren’t providing extra medical or pharmaceutical interventions. Our outcomes come solely from the way we deliver care and every year, our statistics show that our African American mothers are healthy women who have full term, healthy babies. That’s it. The only thing different we have to offer is how we deliver care.”

In terms of Black History Month, one thing is clear — it’s time we find solutions to the tragedy of African American mothers dying during pregnancy, so that in years to come we’ll be sharing success stories and excellent outcomes instead of highlighting disparities, inequities, and poor outcomes.

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