Reducing Perinatal Health Disparities

Reducing Perinatal Health Disparities

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Maternal Mortality | Infant Mortality | Cesarean Section

Of all the forms of inequality, injustice in health care is the most shocking and inhumane”

(Martin Luther King, Jr., 25 March 1966)

 

For too long America has failed to acknowledge the outrageous and seemingly intractable rates of poor maternal health and deaths of mothers in childbirth. The United States has the highest maternal mortality rate of any industrialized country in the world. More than two women die every day in the US from pregnancy-related causes. And while the vast majority of countries have reduced their maternal mortality ratios, for the past 25 years the numbers of women lost during pregnancy, birth or postpartum have increased dramatically in the U.S.

African-American women in the U.S. are at especially high risk; they are nearly 4 times more likely to die of pregnancy-related complications compared to European American women.

Women of color are less likely to go into pregnancy in good health because of a lack of access to primary health care services. They are also less likely to have access to adequate maternal health care services. Black women are by far the largest demographic to suffer these outcomes, it has been this way for decades and yet they are seldom able to make their voices heard.

Its time for change.

Through the documentary “the AMERICAN dream” the women tell their own stories: they know what is wrong, they share their hopes, they share their fears, and they share about their American dream, related to maternal health in the U.S.

Perhaps it is time to listen.

FACTS ON MATERNAL AND INFANT HEALTH

  • Black women have the highest rates of cesarean section followed by Hispanic women in the USA.
  • Between 1999 and 2004 in Los Angeles County, the Maternal Mortality rate of African-American women rose 157%, to 45.6 per 100,000 live births, more than double the rise among Caucasian women. Over the same period there was also an unexpected 765% surge in the maternal mortality rate of Asian/Pacific Islanders.(LABBN, 2009).
  • There has been a rising cesarean section rate in the USA in the past decade in part due to repeat cesareans and low rates of Vaginal Birth After Cesarean (VBAC). Vaginal birth after cesarean (VBAC) were relatively few and decreased from 3.75% in 1999 to 1.41% in 2005 (p<0.0001). This represents a significant 62% decrease in VBAC over the study period (Maternal Quality Indicators Project, 2011, p. 38 ).
  • In California in 2012-2014, Black women have the highest rates of cesarean section, as they do nationally. In California, the rate is 37.7% for Blacks compared to 32.4% for Whites, and 33.1% overall in the state. The US overall rate is 32.6%, and for Black women it is 35.5% and 32% for White women from 2012-2014. (National Center for Health Statistics, 2017).
  • The cesarean section rate by Los Angeles Service Planning Area (SPA) is 37% in SPA 7 compared to 34.8 in Metro LA (SPA 4), which is the lowest in the county and 38.3% in the San Fernando Valley, which is 2nd highest. The highest in the county is 39% in San Gabriel Valley(California Department of Public Health, Center for Health Statistics, OHIR Vital Statistics Section, 2003-2012).
  • Maternal Mortality is 4-5 times higher for African-American women than White women in the USA. This is the leading perinatal indicator between Blacks and Whites a disparity has not changed in 5 decades (APHA, 2010).
  • In 2006, African-American women in California were more than three times as likely to die from pregnancy-related causes as Caucasian women. Certain Los Angeles zip codes have 3-4 times higher rate of Maternal Mortality than others.
  • In Los Angeles County, in 2007, 11 Hispanic women and 7 African American women died during pregnancy, childbirth, or puerperium (LABBN, 2009).
  • Hispanic women make up 46% of all women in LA County, but 50% of all maternal deaths.
  • African-American women make up 9.2% of all women in LA County, but 31.8% of all maternal deaths.
  • White women make up 28.9% of women in LA County, but only 4.5% of maternal deaths. (California Department of Health Services, Center for Health Statistics, Vital Statistics, 2007 from: LA Best Babies Network).
  • In LA County, according to LA Best Babies Network’s 2009 report, the leading cause of maternal death is obstetric hemorrhage.
  • American-born Black women are twice as likely than American-born White women to give birth too early too babies that are too small and who are twice as likely to die within the first year of life. This is not a result of lack of prenatal care, poverty, or unhealthy lifestyles. Even Black women who have healthy behaviors and are have a high level of education and wealth, are twice as likely to give birth too early at a rate double the rate of White woman with less than a high school diploma (Lu & Halfon, 2003).

This is not just a health care crisis–it is a public health emergency”

(Amnesty International)

According to Lu & Halfron (2003),  “Eliminating disparities requires interventions and policy development that are more longitudinally and contextually integrated than currently prevail.” (p.1). If we are to improve birth outcomes, there is a need to address  the political, social, systemic and historical reasons for maternal-infant health inequities and disparities in communities of color. We need to hear  from the voices of women themselves.  We need more birth workers of color, which is why we developed our  Perinatal Support Specialist Training.

There are various factors that contribute to maternal mortality, prematurity and high cesarean rates for women of color including behavioral issues and racism stressors (which are within the domain the individual woman can change or learn to cope with (like stress reduction techniques). But it is all to easy to “blame the victim”. African-American perinatal disparities are due in significant part to domains outside the individual pregnant woman’s control. Things like medical system failures, racism, prejudice, and  inequality are why Birth is a social justice issue, according to Amnesty International (2010).Download full report here.

REDUCING MATERNAL MORTALITY

In 2000, 189 countries pledged to end extreme poverty worldwide through the achievement of eight Millennium Development Goals (MDGs). MDG 5 was set to improve maternal health with the goal to reduce maternal mortality by three-fourths by 2015 (Target 5.A). As Americans, we  think that maternal and infant deaths occur “over there” in lesser developed regions who do not have our wealth, advanced technology and highly trained medical experts. Many believe that here in America where the majority of births occur in hospitals with obstetrical doctors and nurses, maternal death is a phenomenon of the past. However, maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities.

Maternal Health is a Human Right”

(Amnesty International)

Amnesty International  framed maternal deaths as a human rights issue when they published Deadly Delivery: The Maternal Healthcare Crisis in the USA (2010)  As shocking as it is, in America today, women die of childbirth related causes all too often. This is especially true in communities of color-African-American/Black,, Hispanic, Native-American women die at 4-5 times the rate of Caucasian/White Women.  According to the American Public Health Association, maternal mortality is the leading perinatal health disparity between blacks and whites in America. African-American women die of pregnancy-related causes at 4- 5 times the rate of Caucasian women–a startling statistic which has not changed in over 4 decades. Maternal death rates are also higher for Hispanic and Native American women. Maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While some of the recorded increase is due to improved data collection, the fact remains that maternal mortality ratios have risen significantly. Download full report here.

Maternal mortality is the leading perinatal health disparity between Blacks and Whites in America. African-American women die of pregnancy-related causes at 4- 5 times the rate of Caucasian women– a startling statistic which has not changed in over 4 decades”

(American Public Health Association)

The USA spends more than any other country on health care, and more on maternal health than any other type of

Amnesty Maternal Mortality Chart describes how childbirth is a social justice issue, and respectful and equitable childbirth care is a Human Right.

hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 49 other countries. Maternal deaths are only the tip of the iceberg. During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health. According to Amnesty International, “This is not just a public health emergency – it is a human rights crisis. Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.” (from Deadly Delivery: The Maternal Health Crisis in the USA).

From $13 billion to $20 billion a year could be saved in health care costs by developing midwifery care, demedicalizing childbirth and encouraging breastfeeding.”

(Frank Oski, M.D., Professor and Director, Department of Pediatrics, Johns Hopkins University School of Medicine)

The consequences of maternal deaths are far reaching, leaving a void in the a family and the society she would have contributed to. A crucial solution to preventing avoidable maternal deaths and injuries is quality and accessible care to all women. The leading non-governmental organizations (NGOs) have determined that there are several factors contributing to maternal deaths. One of them is lack of access to skilled birth attendants at birth.

Solution: Many leading organizations have recommended skilled midwifery care as a solution to reduce maternal deaths.

Maternal Deaths and The Safe Motherhood Quilt

The USA spends more than any country on healthcare and more on maternal health than any type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 countries

(Amnesty International)

Leading public health organizations have confirmed that the solution to ending maternal mortality is increasing more skilled attendants at birth such as nurses, physicians and midwives. The International Confederation of Obstetricians and Gynecologists (FIGO) along with International Confederation of Midwives (ICM) released a  Call-to-Action in their joint statement which  calls for training more midwives to address maternal deaths worldwide.

Quite possibly the most recognizable Direct-Entry Midwife in America is  Midwife Ina May Gaskin, MA, CPM, Ph.D.(hon.),. She is  one of the founding midwives  of the The Farm Midwifery Center in Summertown, TN  who authored Spiritual Midwifery, and many other books. Ina May was one of the first publicly recognized birth practitioners to raise  awareness of  the issue of maternal death in America–and the disparities in race, income, insurance status, etc. each patch reveals.

Ina May began quilting,  and enlisted  others to contribute.  People came together  to  contribute patches, to remember the mothers. This is what came to be called   The Safe Motherhood Quilt.

Safe Motherhood quilt

Safe Motherhood Quilt depicts the deaths of mothers from pregnancy and childbirth-related causes in the U.S.

Each patch is hand-sewn by volunteers and memorializes the tragedy of women’s lives lost. Ina May created the traveling quilt to bring awareness to the issue and to help create a political will to save women’s lives. Ina May gathered the stories of maternal deaths through news clippings and personal communications from families, nurses and doctors, and has become the keeper of the stories around these tragedies. Many themes emerge from these tales: lack of support after birth to care for the postpartum mother, complications following cesarean section, and other reasons.

In the U.S, .there are 18.5 maternal deaths per 100,000 live births, up from 12.4 deaths per 100,000 births in 1990. We rank 60th in the world, and below virtually every other developed nation. We’re close to triple the rate of the U.K. and eight times that of Iceland, the world’s leader. American maternal mortality rates rose over a 20-year period at a rate that places the U.S. in the company of war-torn countries like Afghanistan and impoverished nations like Chad and Swaziland, according to a new report. (According to a study reported in the Lancet by the Institute for Health Metrics and Evaluation, a global health research center at the University of Washington amd reported in the Huffington Post in May 2014). “The USA spends more than any country on healthcare and more on maternal health than any type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 countries” (Amnesty International, 2010).

Stories like those from the Safe Motherhood Quilt underscore the need for skilled maternity care providers — both licensed and non-licensed — to provide crucial support for mothers not only during labor, but more urgently, pregnancy and postpartum. Midwives are associated with lower rates of cesarean and other interventions and good birth outcomes yet only 7% of U.S. births are attended by midwives, in hospital or-out-of -hospital. Community-Based Doulas provide pregnancy support, labor support and after-birth support. Even though Doulas and Midwives are used very infrequently in the U.S., they were the most highly-rated providers that American women encountered during their maternity care experience, according to Childbirth Connection’s Listening to Mother’s Survey II (Correy, Declerq & Applebaum, 2006).

REDUCING INFANT MORTALITY

In addition, infant mortality is a grave problem in the United States, affecting a disproportionate number of African-AA-Mom-HospAmerican babies. African-American women are 2-1/2 times more likely to give birth prematurely than  Caucasian/European-American/White women. The disparity in American-born, Black women exists across all socioeconomic levels. This means affluent, well-educated African-American women are twice more likely to too give birth  too soon. A White woman with less than a  high school degree, is twice as likely to have a full-term baby than an African-American woman with an advanced degree and a high income. So,  even after adjusting for socioeconomic status, African-American/Black  babies are twice as often  born premature. Preemies  are born  low birth weight, and premature babies are more likely to die within the first year of life.

The reasons for this phenomenon are complex–but according to Lu and Halfron (2003),  increased levels of stress hormones induced by  the individual woman’s experiences of differential exposures to   racism stressors   is believed to be the  culprit, driving up  the  pregnant woman’s blood pressure, triggering cortisol in the woman’s blood, constricting blood vessels and nutrients to the fetus and triggering early labor.  Sadly, premature babies often have lifelong handicaps  such as deafness and  blindness, and many die as well.

Globally, in  many lesser developed countries in the world, women give birth with only a friend or relative to help. These women are disadvantaged by lack of skilled professionals, infrastructure and a emergency response system. However,   in the U.S., minority women from disadvantaged communities such as  inner cities and rural areas  far too often receive an inferior quality of maternity care — this is called health inequity. We think Doulas and Midwives are the answer.

Solution: Skilled Midwives, Doulas and community health promoters are crucial to improving the quality of care provided to mothers and preventing avoidable deaths and injuries.

CESAREAN SECTION

In 2007, one million US births were by cesarean section (30%).  Women over 35 years of age were most likely to have a surgical delivery. Since 1995, Black Non-Hispanic mothers have had higher cesarean delivery rates than any other group (32% for Black women, 21% for  White women (National Center for Health Statistics). In California in 2012-2014, Black women had the highest rates of cesarean section, as they do nationally. In California, the rate is 37.7% for Blacks compared to 32.4% for Whites, and 33.1% overall in the state. The US overall rate is 32.6%, and for Black women it is 35.5% and 32% for White women from 2012-2014. Currently, cesarean section rates in the U.S. are 35%. In Los Angeles County it is 32%. The primary reason for this is that the Vaginal Birth After Cesarean (VBAC) rate has been between 1-3% in the U.S. for the past decade. Much of the high rate of Cesarean section is due to repeat Cesareans. African-American women have the highest rate of Cesarean Section in the U.S., and Los Angeles County is no exception. High rates of cesarean, especially repeat cesareans, which increase risk of morbidity, are a factor which may explain the dramatic rise in Maternal Mortality in the past decade.
(National Center for Health Statistics, 2017)

There are numerous risks of cesarean section* to mothers and infants, which include the following (*Source: Childbirth Connection) :

Risks to Mothers

  • Increased risk of infection
  • Surgical injury
  • Blood Clots
  • Emergency hysterectomy
  • Intense and longer-lasting pain
  • Adhesion formation: ongoing pelvic pain
  • Bowel blockage
  • Injury during future surgery
  • Problem in future pregnancies [including placenta accreta, placenta previa, placental abruption]

Risks to Infants

  • Surgical cuts
  • Breathing difficulties
  • Difficulty breastfeeding
  • Asthma in childhood and beyond

RESOURCES ON PERINATAL HEALTH JUSTICE

Watch the You Tube Video:  Midwives Addressing Health Disparities

Watch the You Tube Video: “Birth by the Numbers” by Eugene DeClercq, Ph.D. Summary of U.S. Perinatal Statistics

Amnesty International Report: “Deadly Delivery, The Maternal Health Care Crisis in the U.S.A.” DownloadPDF Logo 16px

Choices in Childbirth Report: “Doula Care and the Affordable Care Act in N.Y.C.” DownloadPDF Logo 16px

Lu, M.C. & Halfon, N. Matern Child Health J (2003) 7: 13. https://doi.org/10.1023/A:102253751696


References

  1. Amnesty International USA (2010). Deadly Delivery: The Maternal Health Care Crisis in the USA. Retrieved from: http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf
  2. Brenner, A. B., Zimmerman, M. A., Bauermeister, J. A., & Caldwell, C. H. (2013).Neighborhood context and perceptions of stress over time: An ecological model of neighborhood stressors and intrapersonal and interpersonal resources.American Journal of Community Psychology, 51(3-4), 544-556.
  3. Boumediene, S, Chow, J., Fridman,M, Gregory K, Korst, L., Lu, MC, et. al.(2011). Trends in Maternal Morbidity in California 1999-2005, Retrieved from: https://archive.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
  4. California Department of Public Health, Center for Health Statistics, OHIR Vital Statistics Section. (2003-2012). Cesarean Section, Retrieved from: http://publichealth.lacounty.gov/mch/fhop/FHOP2012/C-section_2012_FINAL.pdf
  5. California Department of Health (2016). 1991-2012 Birth Cohort and Birth Statistical Master Files State of California DPH. Retrieved From: http://www.ipodr.org/dashboard/dash.html
    Los Angeles Department of Public Health (2017). SPA Areas by zip code. Retrieved from: http://publichealth.lacounty.gov/
  6. Israel, B.A., Checkoway, B., Schulz, A., & Zimmerman, M. (1994). Health education and community empowerment: Conceptualizing and measuring perceptions of individual, organizational, and community control. Health Education and Behavior, 21(2), 149-170.
  7. Lu MC, Halfon N (2003) Racial and Ethnic Disparities in Birth Outcomes:A Life Course Perspective. Maternal and Child Health Journal; 7(1):13-30.
  8. Boumediene, S, Chow,J,Fridman,M, Gregory K, Korst, L., Lu, MC, et. al.(2011). Trends in Maternal Morbidity in California 1999-2005, Retrieved from: https://archive.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
  9. California Department of Public Health, Center for Health Statistics, OHIR Vital Statistics Section. (2003-2012). Cesarean Section, Retrieved from: http://publichealth.lacounty.gov/mch/fhop/FHOP2012/C-section_2012_FINAL.pdf
  10. California Department of Health (2016). 1991-2012 Birth Cohort and Birth Statistical Master Files State of Californi DPH. Retrieved From: http://www.ipodr.org/dashboard/dash.html
  11. Los Angeles Department of Public Health (2017). SPA Areas by zip code. Retrieved from: http://publichealth.lacounty.gov
  12. Journal of Perinatal Education, Supplement (Winter, 2007), Evidence Basis for Mother-Friendly Childbirth Initiative, Retrieved from http://www.motherfriendly.org/Resources/Documents/CIMS_Evidence_Basis.pdf
  13. Kozhimannil, KB, Vogelsang, A, Hardeman, R, Prasad, S (2016).Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth, J Am Board Fam Med vol. 29 no. 3 308-317 doi: 10.3122/jabfm.2016.03.150300, Retrieved from: http://www.jabfm.org/content/29/3/308.full.pdf+html
  14. National Center for Health Statistics, final natality data. Retrieved January 16, 2017, from www.marchofdimes.org/peristats.
  15. Racial and Ethnic Disparities in Birth Outcomes (Fact Sheet), Retrieved from: www.marchofdimes.org/Racial-and-Ethnic-Disparities_feb-27-2015.pdf
  16. Reese, P. Interactive: See C-section rates at every California hospital (2011). The Sacramento Bee, Office of Statewide Health Planning and Development. Retrieved from: http://www.sacbee.com/site-services/databases/article4129666.html