May 12, 2019 Liz Borkowski, MPH 0Comment

Shortly before Mother’s Day, CDC released an analysis of 2011-2015 data from the agency’s Pregnancy Mortality Surveillance System, reporting national pregnancy-related mortality ratios (PRMRs; pregnancy-related deaths per 100,000 live births):

For 2011–2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1–6 days postpartum, 21.4% 7–42 days postpartum, and 11.7% 43–365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. … Approximately three in five pregnancy-related deaths were preventable.

Reporting and commentary on these statistics provided an opportunity for experts like Arrianna M. Planey to remind us that “it’s not that ‘being Black’ is a risk factor for birth outcomes. Rather, *being racialized as Black* & the attendant stressors & cumulative disadvantages that make pregnancy & birth riskier.” (For more, see Joia Crear-Perry’s classic “Race Isn’t a Risk Factor in Maternal Health. Racism Is.“)

Although the exact numbers were news, appalling racial disparities in maternal mortality are something advocates and researchers have been addressing for years; this toolkit from the Black Mamas Matter Alliance pulls together a range of recommendations. Reporting like that in ProPublica’s Lost Mothers series has helped draw public attention to the problem, and last year’s passage of the Preventing Maternal Deaths Act (which supports state and tribal maternal mortality review committees to examine maternal deaths) represented an acknowledgment of the problem and a small but important step toward solving it.

Shortly before CDC’s new analysis appeared, the Center for American Progress released Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint. Jamila Taylor, Cristina Novoa, Katie Hamm, and Shilpa Phadke write in the introduction:

Disparities in maternal and infant mortality are rooted in racism. Structural racism in health care and social service delivery means that African American women often receive poorer quality care than white women. It means the denial of care when African American women seek help when enduring pain or that health care and social service providers fail to treat them with dignity and respect. These stressors and the cumulative experience of racism and sexism, especially during sensitive developmental periods, trigger a chain of biological processes, known as weathering, that undermine African American women’s physical and mental health. The long-term psychological toll of racism puts African American women at higher risk for a range of medical conditions that threaten their lives and their infants’ lives, including preeclampsia (pregnancy-related high blood pressure), eclampsia (a complication of preeclampsia characterized by seizures), embolisms (blood vessel obstructions), and mental health conditions.

Although racism drives racial disparities in maternal and infant mortality, it bears mentioning that significant underinvestment in family support and health care programs contribute to the alarming trends in maternal and infant health. In the past decades, many programs that support families in need—such as Medicaid, Temporary Assistance for Needy Families (TANF), and nutrition assistance—have experienced a steady erosion of funding, if not outright budget cuts. The fact that these cuts have a harmful impact on families of color, who are overrepresented in these programs due to barriers to economic opportunity in this country, can be attributed to structural racism.

The blueprint offers recommendations that fall under five main headings: Improve access to critical services; Improve the quality of care provided to pregnant women; Address maternal and infant mental health; Enhance supports for families before and after birth; and Improve data collection and oversight.

One of the specific policy recommendations is for federal law to require that states offer full-benefit Medicaid coverage to those under the income limit for at least a full year after delivery, rather than requiring it only for 60 days postpartum. “Because women of color are more likely to be covered by Medicaid, which covers almost half of all births in the United States, the program is essential to addressing racial disparities in maternal and infant mortality,” Taylor and colleagues note.

Among several legislative proposals to address U.S. maternal mortality, two introduced shortly before Mother’s Day address Medicaid coverage. The Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act, introduced by Senator Cory Booker (D-NJ) and Representative Ayanna Pressley (D-MA) would extend full-benefit Medicaid coverage for a year after delivery; establish a Maternity Care Home demonstration project; increase payments to primary care providers serving Medicaid beneficiaries; and increase access to doula care. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act, introduced by Representative Robin Kelly (D-IL) and Senators Dick Durbin (D-IL) and Tammy Duckworth (D-IL), would extend Medicaid coverage for the full postpartum year; establish national obstetric emergency protocols; ensure dissemination of best practices; standardize data collection and reporting; and improve access to culturally competent care.

Both proposals would represent important progress, but additional work would still be necessary to address other policy shortcomings. At the March for Moms on the national mall the day before Mother’s Day, multiple speakers emphasized the need for living wages, affordable and high-quality healthcare and childcare, and paid medical and family leave. “When you don’t value women, particularly Black women, you create harmful policies that limit our ability to thrive,” Dr. Joia Crear-Perry told the crowd. Ensuring survival beyond childbirth is the bare minimum; we also need to work to ensure families can thrive.

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