Why are black Mamas dying in childbirth?

March 19th, 2010

Why are Black mamas dying at nearly 3 times the rate of their white couterparts during childbirth? This staggering statistic is only beginning to be addressed as the public health emergency that it is. Being an African American woman, it has not only alarmed me but saddened me to learn that African American women continue to die during childbirth and it seems to have nothing to do with age, education, job or career status or socioeconomic status. African American women are dying in childbirth now, today, in 2010. So what is causing this crisis?

Currently, The state of California is doing intensive research to identify why maternal mortality rates have nearly tripled from 1996 to 2006 and are now 4.5 times the benchmark set for Healthy People 2010. Part of their investigation is focusing on why African American women in that state  and nationwide are at a 2-3 times increased risk of pregnancy related death compared to white women for similar complications.

While there is limited data available to fully explain the disparity, there have been a few studies done to investigate this problem. In 2007, Myra Tucker et al. conducted a study which was published in the American Journal of Public Health*. Tucker and her colleagues found that while African American women did not have higher rates of 5 specific pregnancy related complications (preeclampsia, eclampsia, placental abruption, placenta previa, and postpartum hemorrhage), they died at 2-3 times the rate of white women. Further, this disparity was independent of how many children African American women had previously had, their level of education, age or socioeconomic status. So in short, African American women are not having these complications any more frequently, they are just more likely to die from them than their white counterparts. In 2004, Margaret Harper, MD and her associated concluded that,“there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.”**

So is being an African American Woman a risk factor for maternal mortality during childbirth? It would seem so. I spoke with Sharon Dormire, PhD, RN, an Associate Professor of Nursing in the Family, Public Health and Nursing Systems Division at the University of Texas at Austin about this disparity. Dr. Dormire is a certified Maternal-Fetal Nurse and also does research in Maternal-Fetal Health. Dr. Dormire and others have noted there is a difference in mortality for African American Women even when compared to women of African descent who come from other countries and have children in the US. Dr. Dormire relates that several researchers have noted, yet not fully studied and published data,  that an African woman who comes to the United States and becomes pregnant does not have the same rates of morbidity and mortality that African American women have during childbirth. However, if that same African woman has a daughter and that daughter is raised in the United States, when the daughter becomes pregnant, her morbidity and mortality mimic those of African American Women. Additionally, similar findings have been noted in women of African descent who come from other countries to the US and their daughters born and raised in the US. As a result of these findings, more research is being done to determine what, if anything, is occurring in the upbring, lifestyles and health maintenance of African American women to cause these disparities.

In 2007, Dr. Harper and her colleagues published another study in the Annals of Epidemiology*** which looked at why African American Women are at greater risk of pregnancy-related death. Their research yielded these findings:

African-American women had more severe hypertension, lower hemoglobin concentrations preceding hemorrhage (they were more often anemic), more antepartum hospital admissions, and a higher rate of obesity. The rate of surgical intervention for hemorrhage was lower among African-Americans, although the severity of hemorrhage did not differ between the two racial groups. More African-American women received eclampsia prophylaxis. After stratifying by severity of hypertension, we found that more African-Americans received antihypertensive therapy. The rate of enrollment for prenatal care was lower in the African-American group. Among women receiving prenatal care, African-American women enrolled significantly later in their pregnancies.”

Dr. Harper and her colleagues concluded that the differences in the severity of the diseases, associated co-morbidities such as obesity and the disparity in patient care all contribute to the disparity of maternal mortality between African American women and white women, yet, they are all MODIFIABLE, and as such could be modified in order to reduce maternal mortality amongst African American women.

I am convinced that not only these factors but others exist and are contributing to the higher rate of maternal mortality in African American women. We don’t have all the answers yet, but thankfully researchers are beginning to ask “Why” and are actively seeking answers. I’ll keep you posted.

*Myra J. Tucker, Cynthia J. Berg, William M. Callaghan, and Jason Hsia
The Black–White Disparity in Pregnancy-Related Mortality From 5 Conditions: Differences in Prevalence and Case-Fatality Rates
Am J Public Health, Feb 2007; 97: 247 – 251.

**Harper MA, Espeland MA, Dugan E, Meyer R, Lane K, Williams S.  Racial disparity in pregnancy-related mortality following a live birth outcome.  Ann Epidemiol 2004; 14: 274-9.

***Harper M, Dugan E, Espeland M, Martinez-Borges A, Mcquellon C. Why African-American women are at greater risk for pregnancy-related death. Ann Epidemiol 2007; 17: 180-5.

If you know of any research related to maternal mortality in African American women, please post it in the comments section. We all need to be aware of what’s going on.

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5 responses to “Why are black Mamas dying in childbirth?”

  1. kia says:

    When I interviewed home birth midwives one of my questions was how well they dealt with diverse cultural communication only because I only had the option of White midwives in my area. The midwife I chose is a regional representative for the Midwife Alliance of North America and she relayed how diversity in their professional membership was a subject they discuss because it is hard to get midwives of color to not only deal with basic cultural comfort for clients but also because of the statistically different outcomes between races. It was from her and our initial interview that I first heard of these differences. Thank you for this brief blog post and for posting the peer-reviewed sources you used. I really appreciate it. It will be nice to have enough data to do an ANOVA to begin to tease out some of the multitude of factors that contribute to these differences. Let’s hope this research leads to credible conclusions fast!

  2. Darline says:

    I really don’t thing anyone realized the gaping chasm until people started doing chart reviews and compiling data. The disparity between African American Women and women of other colors is so remarkable that it really takes one aback! But I am so thankful that researchers are looking into these disparities. Sometimes such
    things get “overlooked” so as not to “borrow trouble” or to seem racist. But this is a true public health issue and it must be addressed-even if the answers found are not nice and neat and possibly reveal bias. Thanks so much for your comment,

  3. Christine says:

    Medical chart reviews can only tell us so much. The charts contain medical and technical information that may allow a careful reviewer to note lapses in standard of care or timing of treatments or errors in diagnoses. But medical charts are not a good source of data for the social and cultural components of care in hospitals, such as how clinicians respond to patients, whether patients claims are disregarded or discounted, or the conscious or unconscious bias in clinician attitudes and actions toward certain types of patients. These disparities in outcomes are a travesty of our health care system, and until recently, medical and public health researchers were looking for primarily individual, biological causal explanations. Tuckers’ research is an important step in another direction, by looking at prenatal risk for hospital based complications and comparing this against outcomes. Researchers like James Collins at Northwestern and Tyan Parker Dominguez at USC are also looking beyond individual biomarkers and addressing harder questions about racism and health care in the US. Unfortunately most data available are collected on the individual/biological level. We need more data that connects hospital and provider characteristics to outcomes. We need more data on the processes of care, that can be gathered from women directly in the form of sensitive qualitative interviews or from direct observation of maternity care practices by trained ethnographers. Looking in the charts for answers to social/cultural and process questions is an exercise in futility.

  4. Darline says:

    Christine,
    I wholeheartedly agree with you and am thankful that people are at least beginning to look for reasons why the disparities exist. For so long these disparities in health care were just overlooked. I agree that chart reviews are inadequate, but the fact they showed what they did, as imperfect as they are, is an indicator that there are some definite flaws in our health care delivery system that need to be changed.

    The researchers that you mention, Collins and Dominguez, are on the right track and I think that other researchers are going to take up the reins as well to see what changes can be made to close this gap. But my point in the post is that finally, people are noticing what many of us have been stating for years-biases exist and patients are paying the price, sometimes with their lives and this has to stop.

    Thanks so much for your post.

  5. Christine says:

    Great to have this conversation – I’m working with the team in California on maternal mortality and as the sociologist in the room, i can appreciate how much information the clinicians can glean from the medical record with regard to processes of care. And you are right, it is a start. I wanted to make the point that you can only get out of the chart the data that is in there…and a lot is missing! The medical chart is as much a legal as a medical record, and there are many other factors which might be examined but cannot be, due to lack of data and/or lack of bio-medically oriented researchers asking the creative questions as Tucker, Collins, and Dominguez have begun to do. Tucker’s conclusions do point to possible processes of care but so far the research funders are still crafting their proposals around big epidemiological research studies that utilize administrative data and/or chart review. I agree with you that many folks have been saying biases exist — the challenge is to tease that out in the data that we have — and unless we are really creative, it’s very difficult. Collins has acknowledged the severe limits of administrative/chart data in addressing these issues. The challenge is one of scale – qualitative interviews or ethnographic research are time and labor intensive and require significant financial backing to be done right.

    The other aspect of this issue is that for a long time, researchers have focused on disparities in neonatal outcomes, not maternal outcomes. So the focus in this line of research has also led to factors pointing back to individual causes — ie., the mother. The factors that might be beyond that individual’s control, such as a toxic contaminant in the environment, or access only to a poor performing hospital or clinician (like schools, hospitals have disparate resources and varying levels of professional skills), are not included.

    I’m currently working with a colleague on a paper that examines this relative lack of attention to maternal outcomes vs neonatal, and would love your comments on it as we move it along…

    Check out our website: http://www.cmqcc.org and you will see the trend data for maternal mortality in California by race/ethnicity – it’s sobering and is very much a factor in why we are doing this work.

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