Where Government Fails, Community Prevails
Written by: Asia Ingram
Maternal Mortality: Where Government fails, Community prevails.
The decline in Maternal Mortality was previously a hallmark of medical superiority and social progress 1,2. Welcoming new life has always signified something more than fecundity. Nations cannot drive productivity without its citizens, so it’s no coincidence that birth rates are historically indicative of the wellbeing of a society. However, the decline of maternal health and increasing morbidities seems to no longer indicate the same societal failures. Especially when the majority of those deaths take the lives of Black women. For so long, maternal mortality was discussed with incredulity and attributed to intangibles, however, community based organization have remained a way to overcome the failures of legislation and medical oversight. Taking a brief review of maternal mortality within the context of the gruesome history of gynecology in the US allows for racism, classism and access to serve as a juggernaut for positive maternal outcomes.
The United States’ maternal mortality rate is exacerbated by structural failures such as inaccurate data collection, incongruent data assessment and a lack of legislative foresight. In 1915 the National Center for Health Statistics (NCHS) began documenting maternal outcomes and individual states began to create “Maternal Mortality Review Committees” (MMRC)2. State-led reporting created decentralized data collection methods with inconsistent end measurements and assessment tools contributing to limited data on maternal deaths. By 1968, 44 states and Washington, DC established MMRCs but by the late 80s many of the state-led committees disbanded due to the apparent decline in mortality rates and fear of litigation from medical organizations2,3. The Pregnancy Mortality Surveillance System (PMSS) was created in response to monitor maternal outcomes and prioritize collecting data1,2. In 2003, US Standard Death Certificates were to indicate recent pregnancy for more accurate assessment on maternal mortality but this was not fully implemented until 2017 by 46 states and Washington, DC2. The historical failures of the federal government to surveil nor standardize reporting create limited data and implicate a lack of priority of maternal outcomes.
Government agencies meant to address the growing issues of maternal mortality suggest that disparities in health care and access to care remain a primary way to address mortality. Recent social trends such as waiting longer for pregnancy and additional complications (morbidities) can be attributed to a rising overall maternal mortality in the US but the widening gap between Black and White patient outcomes has steadily increased since the 1930s1. The Maternal mortality rate for Black Americans is double that of white counterparts no matter the income and education level1,2. Interestingly, it was determined more than 60% of all maternal deaths were preventable with the most common cause associated with cardiovascular conditions, infection and hemorrhage1,2. Since 2000 the United States tops the charts for maternal mortality and in 2017 we saw more than a 50% increase in US maternal mortality while global trends continue to decrease1,2. In 2022, the Supreme Court overturned Roe V. Wade, the landmark decision that gave women access to abortion care solidifying an extreme lack of foresight on the 2008 presidency which campaigned with dreams to codify abortion access. Research shows that outlawing 3rd trimester abortion and limiting access to Family planning services is associated with increased maternal mortality4,5. These findings suggest that with additional limits to accessing quality care due to legislation like overturning Roe V. Wade, increases the risk of mortality for all women but especially Black women.
An overwhelming majority of research on Maternal mortality highlight these same legislative failures and structural limitations to accessing quality care for Black women but fail to highlight the qualitative factors that contribute to poor doctor-patient interactions. Lucinda Canty’s 2021 publication explores the concerns and experiences of Black women who have experienced “severe maternal morbidity”, or complications that can have fatal outcomes or leave women with consequences short or long term. Participants reflect on a “startling revelation” to the news of maternal complications, implicating either a lack of thorough discussion about the complication, a lack of time to discuss the complication because of the severity and potentially a huge oversight from previous providers6. Understanding the complication is the first level of care that providers fail to protect Black patients which can add stress and emotional turmoil once the uncertainty of the complication begins to weigh-in on patients6. Canty reports on explicit racial biases and the lack of bedside manner that translates to a lack of trust and poor doctor-patient relationships6. Lastly, the report asserts that Black women are often blamed for their outcomes, often attributing fatal consequences to socioeconomic and limited access but not implicating racism as a primary cause of these complications6.
Canty’s 2021 report explored the experiences of women who survived severe maternal complications leading to critical care for survival or long term health consequences and successfully identified key areas for changing maternal outcomes for Black women. Currently, the data assessing the use of doulas on Maternal mortality is overwhelmingly positive, specifically for socioeconomically vulnerable populations7,8. Since 2017, 47% of maternal deaths occurred during pregnancy and delivery and 40% occurred 42 days postpartum, suggesting the greatest need is delivery and postpartum care1. Doula support is associated with decreasing Cesarean delivery, uterine rupture and overall mortality by more than 30%7,8. A cost effectiveness analysis concluded that Doula care lowers overall costs and results in a higher quality of life7. In 2022, a bill against Maternal Death was signed into law to decrease maternal death by implementing an option for Medicaid postpartum coverage for up to 12 months, expanding rural care and expanding the perinatal workforce including Doulas9. The US Dept. of Health and Human Services released a report on evaluating the benefits of Doula support specifically citing the need for Black and indigenous populations and 26 states that have expanded Medicaid covered Doula services or reimbursement programs citing a need to explore community based organizations9. This report also indicated providing services for navigating health care, patient education, advocacy and emotional support directly identifying unique support for Black and Indigenous populations9.
Historically, evolving standards of data collection contribute to limited data and solutions for Maternal Mortality2. However, recent Federal support for Doula services and extending Medicaid reimbursement to support utilization of community based organizations is encouraging. The “Doula Care and Maternal Health: An Evidence Review” report identified needs that align specifically with themes that the Lucinda Canty’s 2021 report directly identified in Black women who experienced Severe Maternal Morbidities. The concept of advocacy must remain a primary service when supporting Black and indigenous populations. Within the historical context of strained doctor-patient relationships amongst Black and Indigenous communities, this means that we must consider the importance of advocacy and support systems remaining independent from hospitals and state-led programs, if any. Community based solutions provide protection to both birthing people and infants through an additional layer of advocacy and emotional support meditated through cultural context and human connection. It is imperative that we take advantage of this legislative momentum to support our communities and protect expectant mothers and children. This means continuing education for community-based doula organizations. Supporting organizations through advocacy and prioritization of these issues for financial consideration of Federal grants and private donations for the advancement of technology and resources to support all maternal outcomes.
Where government fails, community prevails.
Citations
[1]Douthard, R. A., Martin, I. K., Chapple-McGruder, T., Langer, A., & Chang, S. (2021). U.S. Maternal Mortality Within a Global Context: Historical Trends, Current State, and Future Directions. Journal of women's health (2002), 30(2), 168–177. https://doi.org/10.1089/jwh.2020.8863
[2] Weigel, R. (2019, March 19). Maternal Mortality in the United States: A Brief History, Overview, and Update. Public Health Review. Retrieved February 28, 2023, from https://pubs.lib.umn.edu/index.php/phr/index
[3]St Pierre, A., Zaharatos, J., Goodman, D., & Callaghan, W. M. (2018). Challenges and Opportunities in Identifying, Reviewing, and Preventing Maternal Deaths. Obstetrics and gynecology, 131(1), 138–142. https://doi.org/10.1097/AOG.0000000000002417
[4]Hawkins, S. S., Ghiani, M., Harper, S., Baum, C. F., & Kaufman, J. S. (2020). Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-Experimental Study. American journal of preventive medicine, 58(2), 165–174. https://doi.org/10.1016/j.amepre.2019.09.012
[5]Brown, B. P., Hebert, L. E., Gilliam, M., & Kaestner, R. (2020). Association of Highly Restrictive State Abortion Policies With Abortion Rates, 2000-2014. JAMA network open, 3(11), e2024610. https://doi.org/10.1001/jamanetworkopen.2020.24610
[6]Canty L. (2022). The lived experience of severe maternal morbidity among Black women. Nursing inquiry, 29(1), e12466. https://doi.org/10.1111/nin.12466
[7]Greiner, K. S., Hersh, A. R., Hersh, S. R., Remer, J. M., Gallagher, A. C., Caughey, A. B., & Tilden, E. L. (2019). The Cost-Effectiveness of Professional Doula Care for a Woman's First Two Births: A Decision Analysis Model. Journal of midwifery & women's health, 64(4), 410–420. https://doi.org/10.1111/jmwh.12972
[8]Falconi, A. M., Bromfield, S. G., Tang, T., Malloy, D., Blanco, D., Disciglio, R. S., & Chi, R. W. (2022). Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching. EClinicalMedicine, 50, 101531. https://doi.org/10.1016/j.eclinm.2022.101531
[9]Yocom, C. L. (2022, October 19). Maternal health: Outcomes worsened and disparities persisted during the pandemic. Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic | U.S. GAO. Retrieved February 28, 2023, from https://www.gao.gov/products/gao-23-105871