Black Maternal Health: Amplify the Conversation and Act

By Dr. Janine A. Clayton
 

First, I want to address the concerns that expectant mothers, including Black women, may have about the COVID-19 pandemic. According to the Centers for Disease Control and Prevention (CDC), “we do not currently know if pregnant women have a greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have serious illness as a result. Pregnant women experience changes in their bodies that may increase their risk of some infections. With viruses from the same family as COVID-19, and other viral respiratory infections, such as influenza, women have had a higher risk of developing severe illness. It is always important for pregnant women to protect themselves from illnesses. Pregnant women should do the same things as the general public to avoid infection.” See the box at the bottom for more information.

Black women die from pregnancy complications two to three times more than their White and Hispanic counterparts, according to a January 30, 2020, Centers for Disease Control and Prevention (CDC) report containing the first national data on maternal deaths in the United States since 2007. Black Maternal Health Week (April 11–17) helps keep this heartbreaking health disparity front and center, where it belongs. When our sisters, mothers, daughters, friends, and co-workers are in danger, we need to do more. We all need to elevate and amplify the national conversation to raise awareness, spur action, and take steps to address Black maternal health. We know that about 60% of pregnancy-related deaths are preventable, and these new data are an important tool to guide our efforts.

According to that January CDC report, 658 women died from pregnancy complications in 2018¹. There were an additional 277 deaths occurring more than 42 days but less than 1 year after delivery; these “late maternal deaths” represented 11.7% of maternal mortalities between 2011 and 2015, according to a previous CDC analysis. The new data reveal stark disparities related to race and ethnicity—with a 2018 maternal mortality rate for Black women of 37.1 per 100,000 live births, compared with 14.7 for White women and 11.8 for Hispanic women. Importantly, higher levels of education and income do not mitigate the risk for maternal deaths among Black women, according to prior analyses. 

For every woman who dies of pregnancy complications, at least 70 experience a near miss—that is, severe maternal morbidity (SMM) (50,000 annually), which includes an unintended outcome (or outcomes) of the process of labor and delivery that results in significant consequences for a woman’s health. Potential short-term consequences include bleeding requiring a transfusion, infection, cardiovascular disease, high blood pressure, and gestational diabetes. In essence, pregnancy is a stress test, meaning it reveals risk factors. Specifically, women who experience complications are at risk for developing chronic disease later in life, such as hypertension—some as early as 3 years after delivery. Addressing SMM will go a long way toward reducing maternal deaths and improving the health of women during pregnancy and throughout their lives. 

SMM also shows disparities related to race and ethnicity—as the incidence is 166% higher among Black women than White women. This disproportionate burden affects health beyond pregnancy and for years to come. For some women, pregnancy complications influence the risk for disease in later life. For example, women who experience gestational diabetes show a threefold greater risk for disorders of glucose metabolism 10 to 14 years postpartum.

The reasons for disparities in maternal health are multiple and complex, and addressing them requires more research in a variety of areas. NIH—along with our colleagues at other U.S. Department of Health and Human Services (HHS) agencies—makes substantial investments to improve maternal health in the United States and reduce disparities related to race and ethnicity in this area. 

In fiscal year (FY) 2019, NIH spent more than $300 million on maternal health research—a 20% increase from FY 2017. 

• The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) supports the majority of research on maternal health, such as the Human Placenta Project, which develops new tools to study how the organ develops and functions throughout pregnancy. NICHD also supports PregSource—a research project that aims to learn about the pregnancy experience directly from women—among other studies on maternal health. 
• The National Institute on Minority Health and Health Disparities (NIMHD) supports research on how health information technology (health IT) can be used to address racial and ethnic disparities—including in maternal morbidity and mortality (MMM)—and on the role of hospital quality in disparate maternal health outcomes. Just last week, NIMHD announced a funding opportunity (RFA-MD-20-008) for multidisciplinary research of racial and ethnic disparities in MMM, including projects to test prevention and treatment interventions to reduce these disparities. Applications are due by May 29, 2020. 
• The National Heart, Lung, and Blood Institute supports research on pregnancy-related hypertension disorders, such as the nuMoM2b Heart Health Study. It’s evaluating the potential effects preeclampsia and sleep have on future maternal cardiovascular health. 
• The National Institute of Diabetes and Digestive and Kidney Diseases addresses gestational diabetes mellitus (GDM). For example, the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study, which was co-funded by ORWH, suggests that elevated maternal glycemia, even below the diagnostic level, is associated with adverse pregnancy outcomes. The HAPO Follow-Up Study is determining whether hyperglycemia less severe than GDM is associated with obesity in children and diabetes in mothers. 

ORWH has supported pregnancy and maternal health research for many years, through co-funding and collaborations with multiple other NIH Institutes, Centers, and Offices (ICOs). ORWH’s U3 program—which focuses on understudied, underrepresented, and underreported populations of women—supports research on ways to prevent infection among obese women who have a cesarean delivery, on maternal outcomes among women with sickle cell disease, and on similar topics. 

I’m very excited about a recently announced maternal health research collaboration. ORWH, in partnership with the National Institute of General Medical Sciences and 12 other ICOs, issued a notice of special interest titled “Administrative Supplements for Research on Women’s Health in the IDeA States” (NOT-GM-20-017), which aims to expand women’s health research in States that historically have had low levels of NIH funding and are among those with the highest maternal and infant mortality rates. 

NIH’s approach and other Federal efforts related to MMM are briefly described in the ORWH publication titled “Maternal Morbidity and Mortality: What Do We Know? How Are We Addressing It?” 

During Black Maternal Health Week and every week of the year, I ask all of you to do your part in safeguarding the health and saving the lives of our mothers, sisters, friends, and colleagues. 

• Help us by amplifying and elevating the much-needed conversation about health disparities in maternal health. 
• Find out more from the Black Mamas Matter Alliance, and join in on social media by following and using the hashtags #BMHW20 and #BlackMaternalHealthWeek to show support. A social media toolkit is available. 
• Be aware of friends and family members, along with a wide range of professionals—such as social workers, community health professionals, midwives, and doulas—who can provide support during and after pregnancy. 
• Listen to pregnant and postpartum women when they say something is not quite right with their bodies, and help them get the necessary medical care. 
• Offer assistance to women who are engaged in prenatal care or ongoing visits during the “fourth trimester” (the 3 months after delivery). 
• Volunteer for a clinical trial—in consultation with your doctor, of course. Even healthy and pregnant women can participate! Check out details here.

For additional information, visit the ORWH MMM web portal; you can learn about steps toward a healthy pregnancy at that webpage and at the websites of NICHD and HHS’s Office on Women’s Health.

Of course, professionals play an important role in improving maternal health. To reduce MMM, health care providers can do the following: 

• Implement evidence-driven practices for maternity care (also called maternal safety bundles)—including “Reduction of Peripartum Racial/Ethnic Disparities”—in the hospitals where they practice.
• Join or support the work of their institutions’ maternal mortality review committees (also called MMRCs).
• Participate in the CDC’s National Network of Perinatal Quality Collaboratives.

The new CDC data highlight that we can do better. I know we can do better. If everyone raises awareness during Black Maternal Health Week and takes action within his or her sphere of influence, we can improve maternal health and save lives. We owe it to all the mothers and mothers-to-be in our lives.

¹  “Maternal death” includes the death of a woman while pregnant or within 42 days of termination of pregnancy, not including fatalities from causes such as drug overdose, suicide, and homicide.