U.S. Maternal Mortality is Much Higher for African-Americans Dr. Aaron Carroll: In the United States, too many moms are dying around the time of childbirth. Every year more than 700 mothers die from complications related to pregnancy and delivery, leaving behind grieving families, as well as urgent policy questions about how we, as a country, can do better. Between the 1980s and 2010, the maternal mortality rate doubled in the United States. Clearly, births should be safer for moms in the United States, all moms. But it's not. Some moms are at greater risk. That's the topic of this week's Healthcare Triage. [MUSIC PLAYING] Black women are more than three times as likely as white women to die around the time of childbirth. Data from the CDC showed that between 2011 and 2013, white women had a maternal mortality rate of 12.7 deaths per 100,000 live births, while black women had a rate of 43.5 deaths per 100,000 live births. These racial inequities are not explained by differences in education or income. For example, a 2016 study of data from New York City showed that college-educated black women had a higher risk of severe maternal morbidity than a white woman without a high school diploma. The causes of maternal mortality and racial disparities in maternal mortality are myriad and complex. They can be grouped based on timing and include one, maternal health before pregnancy, two, access to care and quality of care during pregnancy and childbirth, and three, recovery, support, and access to care after childbirth. Many research studies document that the risks for maternal mortality are greater for black women. For example, a 2007 study in the American Journal of Public Health looked at five of the most common and potentially fatal pregnancy-related complications, and found that black women were two to three times as likely to die as white women with the same diagnoses. Black women are also more than twice as likely as white women to initiate prenatal care late in pregnancy, which may derive from access barriers that relate to geography and health insurance. While public dialogue often blames black mothers for these disparities, many experts who are much more versed in this than me believed that the true cause is racism. Commonly defined as prejudice plus power, racism is discrimination against someone based on his or her race. Racism can be manifested through beliefs, attitudes, actions, and policies. Structural racism is the systematic allocation of resources and opportunity based on race. It refers to the ways that institutions and systems operate together to produce outcomes that differ based on race, even in the absence of racist intent. Indicators of structural racism include power inequalities, unequal access to opportunities, and differing policy outcomes by race. Because these effects are reinforced across multiple institutions, the root causes of structural racism are hard to isolate, but a good entry point to address structural racism is to tackle inequality in education, employment, imprisonment, and socioeconomic status. This link has been shown empirically. A 2017 study of all US states found that high levels of structural racism and unemployment were associated with a 5% increase in infant mortality among blacks versus whites, but low levels of structural racism in education were associated with a 10% reduction in the black infant mortality rate compared with whites. Here's the thing, though-- racism is man-made. The good news is that if it has been built, it can be dismantled. Dismantling structural racism in healthcare can seem like a Herculean task, but it starts with two things. First, we must understand our nation's history and recognize that race is a social construct and racism as an ideology was invented to differentiate white people from those with different skin colors, creating a racial hierarchy that continues to this day. Second, we must become comfortable with asking the question-- how is racism operating here? This simple question, when asked honestly and openly with curiosity and positive intent, can open the floodgates to change in any clinic, classroom, hospital, or home. In maternity care, a roadmap exists. From 2015 to 2017, the Alliance for Innovation on Maternal Health convened a national workgroup. The group reviewed reams of scientific evidence and developed what's known as a care bundle, or a set of practices to reduce maternal racial and ethnic disparities in perinatal health. That bundle was recently published and provides concrete action steps that clinicians and health systems can take during pregnancy to identify, measure, understand, and begin to make change in racial inequities that occur during pregnancy and childbirth care. The bundle may signal progress, but it's not a panacea. It will take more than the bundle to undo the effects of racism on birth outcomes, including expanding the work beyond health care delivery systems to address payment reform, workforce diversity, and most importantly, listening to all mothers. Everyone deserves to feel safe, respected, cared for, and empowered during pregnancy and childbirth. Birth is at the core of the human experience. It is the deepest form of human connection and the ultimate antidote to dehumanizing policy or rhetoric. Birth binds us together and ensuring safe births and strong families for all mothers starts with targeted efforts to lift up those who are most vulnerable. Too many black mothers die in childbirth. We can fix that. This episode was written in conjunction with Katy [INAUDIBLE] and Rachel Hardman, who are 2016 Robert Wood Johnson Foundation interdisciplinary Research Leaders Fellows. Interdisciplinary Research Leaders is a national program of the Robert Wood Johnson Foundation, led by the University of Minnesota. Hey, do you like the show? Always helps if you like or subscribe right down there. And another good way to support the show is the subscription service called patreon.com, which allows you, the viewer, to directly support Healthcare Triage through a donation as little as $1 a month, or more if you like. Anything else. We'd especially like to thank our research associates, Joe Sevits, Jonathan Dunn, and Crafty_Geek, and of course, our Surgeon Admiral Sam. If you'd like to help subscribe to the show through partreon.com, go to patreon.com/healthcaretriage. Also remember-- Healthcare Triage merch is available at hctmerch.com, and of course my book, The Bad Food Bible, still on sale in stores. [MUSIC PLAYING]