Alarming News On Maternal Mortality : Black Women Four Times More Likely to Die in NYC

In a disturbing trend, the maternal mortality rate among black women in the United States is now three to four times higher compared to the general population and predominately white areas. The impact of racial disparities in health care, particularly those involving black women has reached a critical level, placing both women and their children at an alarmingly high risk for pregnancy-related complications, including death. The elevated risk is not limited to rural areas alone. New York City has one of the highest rates of maternal mortality where black women are four times more likely to die from pregnancy-related causes than any other race¹. In the Bronx New York, pregnancy-related mortality is 9 times higher for black compared to white women². Elevated risk is independent of the level of education, something researchers have looked into as a potential contributing factor. The fact that the risk of maternal mortality in black women is elevated for all educational groups is a clear indication that elevated risk is not due to social status or a lack of education. The etiology behind the significantly elevated risk for black women is far more complicated; current research has attributed it to issues of systemic discrimination and limited access to healthcare, particularly high quality specialized care. Healthcare access can be directly related to US Maternity Care ‘deserts’ defined as “areas in the United States with NO obstetric care”. Access to adequate maternal healthcare should be universally available or at least available in most areas. In fact, it’s the opposite; there are many places in the United States that qualify as “maternity care deserts”. Such places have no coverage for pregnant women – this goes beyond a shortage of ob-gyn physicians. Maternity care deserts not only lack doctors but also have no birth centers, no obstetric care hospitals, and no OB/Gyn doctors or certified midwives. Women have very limited options if they are unfortunate enough to reside in one of these maternity care deserts and pregnant. Black women in particular face this challenge, mostly due to where they reside. The distribution of healthcare remains inherently biased with geographic areas qualifying as maternity deserts often found in low income rural areas in the South. Alabama has the third highest maternal mortality rate in the United States, Mississippi had the highest in 2021 with a maternal mortality rate of 82.5 deaths per 100,000 births³. For comparison, the country with the lowest maternal mortality rate in 2020 was Belarus⁴ with a rate of 1.1 deaths per 100,000. Norway was #2 with a rate of 1.7 deaths per 100,000. The United States has an overall maternal mortality rate of 21.1 deaths per 100,000 births placing it slightly above China (at 23 per 100K) but significantly below Canada (at 11 per 100K for 2020). In 2020, Ireland had a zero maternal mortality rate. The differences between countries, especially between the United States and Canada is worth noting. In fact, regardless of race, the maternal mortality rate is lower in Canada than in the United States. Given the option, pregnant women in Canada have a 50% less chance of dying from pregnancy and its related complications. It’s also worth noting that there are no current studies on black maternal mortality health related outcomes in Canada; one study did address racial disparity and found that the preterm rate was 8.9% in black women compared to 5.9% in white women In Canada⁵. Canada maintains a color blind policy towards healthcare; most of its facilities do not collect racial data. Therefore, the exact rate of maternal mortality for black Canadian women is unavailable.

Given the geographic differences in maternal mortality, one might assume location is the main cause of racial differences — i.e. the majority of black women reside in areas with insufficient or completely lacking obstetric care. Yet black women experience elevated rates of maternal mortality in major metropolitan areas as well. In New York City, for example, the five year PAMR or pregnancy associated mortality ratio was four times higher for black compared to white women over the same time period (101.1 vs 23.9 deaths per 100,000 live births between 2016 and 2020). Reviewing the data, however, reveals a geographical bias based upon the borough of residence with the highest number of maternal deaths in the Bronx, Brooklyn and Queens and relatively low numbers in Manhattan, Staten Island and the rest of New York State. The New York City Maternal Mortality Review Committee (MMRC) responded to this data by issuing 11 priority recommendations (listed in the chart below)⁶.

MATERNAL MORTALITY REVIEW COMMITTEE RECOMMENDATIONS

Based on the review of 2020 deaths, the Committee selected 11 priority recommendations related
to the top causes of death of Black and Latina women and birthing people (mental health
conditions, infection, metabolic/endocrine conditions and hemorrhage). These 11 Committee
recommendations are a citywide call-to-action for systems⁷, facilities⁸, providers⁹, and
communities¹⁰ working to eliminate preventable maternal mortality and end racial/ethnic disparities
in these deaths.

SYSTEMS LEVEL

Hospital systems should provide annual training and simulation to all providers (including
emergency medicine, critical care, anesthesiologists, and obstetrical providers) treating
pregnant or postpartum women and birthing people in the components of the Safe
Motherhood Initiative ACOG District II Postpartum Hemorrhage Safety Bundle, and support
and audit the appropriate implementation.
Hospital systems should ensure that they have robust referral systems in place for pregnant
women and birthing people with complex chronic illnesses with appropriate sub-specialty
doctors and nurses during pregnancy and inter-conception periods.
Hospital systems, in collaboration with community partners, should pilot a tiered level
complex obstetric rehabilitation program model (including telehealth, alternate care
platforms and home visits) for pregnant women and birthing people with significant chronic
disease at hospital discharge.
Health departments should develop an education program, including anti-stigma training
and training about racialized and class-based responses to behavioral health disorders, for
providers who treat substance use or mental health disorders, addressing the
comprehensive care needs of reproductive aged women and birthing people with substance
use and mental health disorders.
Health departments should partner with professional organizations to implement a
campaign to educate providers about the use and benefits of opioid agonist therapy in
pregnancy and the risks of withdrawal for pregnant women and birthing people and their
fetus during and after pregnancy.
FACILITY LEVEL
Birthing hospitals should provide counseling and guidance to all pregnant women and
birthing people who seek alternatives to blood transfusion regarding blood transfusion
alternatives and the components of the alternatives.
Healthcare facilities should develop and enforce systems to audit outpatient records during
wellness visits for pregnant and postpartum women and birthing people with high-risk
conditions for complete assessment and treatment plans.
Birthing facilities should develop a system of follow-up for missed appointments that
includes exploring barriers to care and strategies to overcome the barriers (that respects
the agency of the person) with a priority focus on pregnant and postpartum women and
birthing people with chronic illnesses.
PROVIDER LEVEL
Primary care providers and specialists treating chronic illness or mental health disorders
should ensure that women and birthing people are connected to providers offering
comprehensive reproductive health care services.
COMMUNITY LEVEL
Community boards should assess the availability of walkable, affordable healthy food
sources and safe spaces for exercise and play for adults and children, and plan for ongoing
remediation.
Community-based organizations should create ongoing health information campaigns to
educate the public on the long-term health implications of chronic illnesses in pregnancy and
postpartum periods.

References/Notes :

7 Interacting entities that support services before, during, or after a pregnancy – ranges from healthcare systems and payors to public
services and programs.
8 A physical location where direct care is provided – ranges from small clinics and urgent care centers to hospitals with trauma centers.
9 An individual with training and expertise who provides care, treatment, and/or advice.
10 A grouping based on a shared sense of place or identity – ranges from physical neighborhoods to a community based on common
interests and shared circumstances.

Source: https://www.nyc.gov/assets/doh/downloads/pdf/data/maternal-mortality-annual-report-2023.pdf

The Health Dept concluded by stating they will continue actively monitoring this issue and “conduct maternal mortality surveillance,” Data collected will be available via the NYC Open data platform with an annual report available at the NYC Health Department website (https://www.nyc.gov/site/doh/data/data-publications/special-reports.page)

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