Credit: cheriejoyful on Flickr, under Creative Commons (CC BY-NC-ND 2.0).
(WOMENSENEWS)--It's been called a conundrum. A mystery. A disgrace. A national crisis. But when you ask why black women in the United States die from complications of pregnancy and childbirth at three to four times the rate of other ethnic/racial groups, the answer is usually the same: "We simply don't know."
Why not? The short answer is – it's complicated. It gets even more complex with older black mothers.
For one thing, the way data is collected on maternal mortality depends on the state. Some states such as Florida and Maryland make analytical comparisons between the standard death certificate for the mother and the birth certificate of the infant – and some states do not. For example, according to the final 2009 National Vital Statistics Report from the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services, Maryland has reportedly seen an improvement in its data collection on maternal mortality due to collecting multiple data sources, including the use of a separate checkbox question to indicate the pregnancy status of the mother at the time of death.
In fact, as of 2009, 39 states and the District of Columbia use the checkbox question, which was introduced in the 2003 revision of the U.S. Standard Certificate of Death.
The harsh reality is there is no national standard or federal requirement on reporting maternal deaths and scant national data. The last national data was compiled in 2007 by the CDC's Pregnancy Mortality Surveillance System, which uses data from 52 U.S. reporting areas – 50 states, New York City and Washington, D.C.
The surveillance system indicated wide disparities in pregnancy-related mortality ratios in the U.S., with the pregnancy-related ratio for white women at 11 deaths per 100,000 live births and 34.8 deaths per 100,000 live births for black women. The ratio was 15.7 deaths per 100,000 live births for women of other races.
Gathering of States
In November, representatives of 14 states, including California, Florida, Maryland and New Jersey, and the city of Philadelphia convened in Atlanta for a day and a half-long meeting hosted by the CDC's Reproductive Health Branch Division. The meeting was prompted by the need to better understand and collate best practices for the identification and review of maternal deaths at the state level, said Dr. William Callaghan, the CDC's chief of Maternal and Infant Branch Division of Reproductive Health.
Callaghan, who has written extensively on this issue, said black maternal mortality was by far the "No. 1" topic of discussion.
"One of the key questions we asked during our recent meeting was: 'What are the barriers to doing this work?'" Callaghan said.
Eleanor Hinton Hoytt, president and CEO of the Washington-based Black Women's Health Imperative, has some ideas. Like Callaghan and other investigators, she says access to care and quality of care are both issues that must be considered in connection with the higher rates of maternal mortality among African American women.
"This issue has not been part of the public health narrative," said Hinton Hoytt. "Although the data tell one story, I would rather we focus on prevention rather than how we compare to white women and how bad the numbers are for black women."
Hinton Hoytt says the nation has failed to develop a framework that allows black women to be well. She points to unequal treatment and access in the health care system, as well as institutionalized racism, social determinants that can prevent black women from accessing new medicines and cures.
"We have to be more patient-centered and deal with women across their lifespan – not just when they get sick," said Hinton Hoytt. Of course, this requires resources, which Hinton Hoytt says remains a major problem for organizations like hers to adequately address these issues.
Reviewing Data Process
Callaghan says many states are now reviewing how they handle data about maternal mortality. "It's hard to get a handle on exactly where states are individually on the issue, but to the best of our knowledge, there are about 30 states doing some form of review on maternal mortality."
Some states, adds Callaghan, do not have the capability to make the record linkages between death and birth certificates to get good data, such as electronic data reporting.
California, considered a leader in the quest to get a handle on the real numbers, has collected new data for 2009, but its efforts have not produced good news for African American women. In fact, the maternal mortality ratio for African American women in California is in the 40s compared to other groups with ratios of 12 to 14.
"One out of every seven births in the U.S. each year occurs in California," said Dr. Elliott Main, chief of obstetrics and gynecology at California Pacific Medical Center and medical director of the California Maternal Quality Care Collaborative, which oversees the medical review for maternal deaths in the state. "African Americans account for 6 percent of the births in California, yet they represent 25 percent of the maternal deaths; a huge disparity."
Main says African American women are at higher risk due to core morbidity conditions, such as hypertension, diabetes and obesity, which can raise the risk for maternal death.
Diseases of the heart and blood vessels, which the CDC says is now the leading cause of maternal mortality in the U.S., affect women across all racial and ethnic groups.
"One problem is that the symptoms of heart disease and pregnancy are very similar, such as shortness of breath, which is very common in pregnancy," said Main. "If you are obese, you are likely to experience shortness of breath."
Older Mothers at Risk
Pregnancy-related mortality, meanwhile, increases with maternal age. Among African American women, the intersection between race and age plays out most intensely. This interaction could be the effect of pre-existing conditions and pregnancy complications, both more prominent among older than younger women, or of the lower access to and use of health care by black women, according to a 2012 report Callaghan co-authored.
Compared with women aged 25-29, women aged 35-39 are more than twice as likely to suffer a pregnancy-related death, and women aged 40 or over have a roughly five-fold increased risk of pregnancy-related mortality, according to the report.
For older African American women, Callaghan found maternal mortality rates similar to those of developing countries, where the ratio is 150 per 100,000 live births.
"Age is a major factor. As women age, they bring with them the changes that happen as you grow older. And for some women, that's chronic disease, such as hypertension," said Callaghan.
Meanwhile, Main says his group is collaborating with 80 hospitals across California to create greater awareness around pregnancy-related complications to prevent maternal deaths. In January, he says, they plan to roll out a new initiative on hypertension and pregnancy. He hopes the state's efforts will encourage others to follow suit.