3.1.1 Maternal mortality ratio
Maternal Mortality
Maternal mortality is defined as death that occurs during or within 42 days after the end of a pregnancy that is caused by or aggravated by pregnancy or pregnancy management. In general, many of the same factors that influence racial inequities influence maternal mortality, such as: access to health care, poor sanitation, pre-existing medical conditions, use of drugs and alcohol, malnutrition, unstable housing and poverty. In addition, lack of education, early or child marriage, or neglect to women and girls due to structural sexism are other factors that influence pregnancy health and mortality rates. According to the National Library of Medicine, primary medical causes of maternal mortality are hemorrhage, pregnancy-induced hypertensive disease, puerperal sepsis, uterine rupture, anemia, infection, labor and delivery mismanagement, and non-medical abortions. Particular emphasis is also placed on conditions that arise during or after pregnancy, specifically high blood pressure, hypertension, cardiomyopathy and weakened heart muscles.
It is generally accepted that many deaths during pregnancy are preventable. Women who have access to health insurance which allows for prenatal and postpartum care, stable housing and food access, and are aware of any pre-existing conditions are less likely to experience maternal mortality. However, in the United States, basic-level insurance such as Medicaid may not cover full care during pregnancy. According to The Commonwealth Fund, compared to women with private insurance, women on Medicaid were more likely to receive no postpartum visit, returning to work within two months of birth, less autonomy regarding medical decisions, and discrimination based on insurance status. Additionally, a woman with limited healthcare access or who uses drugs or alcohol during pregnancy may develop health conditions that are missed or ignored, increasing mortality risk.
Research by BMC Public Health has demonstrated that women who receive less maternal education were more likely to experience maternal mortality, suggesting that increased education and awareness of potential risks during pregnancy may decrease mortality rates. In addition, BMC also reports that women who are experiencing intimate partner violence or neglect are 25% less likely to receive adequate care, and 20% less likely to have skilled delivery care. Pregnancies as a result of sexual assault are also at an increased risk of severe complication or death as a result of systemic discrimination or racism (70% of Black women report having experienced sexual violence before they turn 18), lack of trust of the health care system, medical discrimination and trauma, or domestic violenece.
Race and Maternal Mortality Rates
Women of color are two to three times more likely to die during pregnancy than non-Hispanic, white women. In general, much of the research pertaining to maternal mortality and race suggests that because women of color are exposed to more risk factors caused by systemic racism and discrimination, they are more susceptible to increased mortality risk during pregnancy. These risk factors include: poverty or low socioeconomic status, access to prenatal care, decreased physical health and strained mental health. These factors, in addition to the consequences that experiencing systemic racism and discrimination can have on life trajectories and physical and mental health stability create an increased risk for mothers, even if they experience healthy, full-term pregnancies. It is important to note that these factors on their own are not enough to determine why women of color have higher maternal mortality rates than non-Hispanic white women, but when evaluated together within the greater context of systemic racism, they can provide insight into how racial inequalities impact women’s health.
Women who experience poverty or lower socioeconomic status have less access to health care or quality prenatal care during pregnancy. According to the Centers for Disease Control and Prevention (CDC) Health Disparities and Inequality Report of 2013, 14.7% of Black, non-Hispanic women are below the federal poverty level, compared to 10.8% of white, non-Hispanic women. Additionally, 14% of Hispanic women, 17.7% of Native American women, and 12.6% of women who identify as being multi-racial fall below the federal poverty line. This shows that women of color are more likely to experience poverty or lower socio-economic status than white women, which increases the risk of limited access to healthcare. Additionally, 22.1% of Black, non-Hispanic women, 41.6% of Hispanic women, and 33.7% of Native American women do not have health insurance, compared to 14.6% of white women. However, it should be noted that women of color experience higher maternal mortality rates in all income brackets in the United States.
The same report also shows that, regardless of income level, 21.3% of Black, non-hispanic people, 31% of Hispanic people, and 26.7% of Native American people characterized their overall health as poor, compared to 13.1% of white, non-hispanic people. The same groups also had higher numbers of average unhealthy days in a 30 day-period for both physical and mental health, averaging around 4-6, while white people reported an average of 3.4 for both. This suggests that people of color are more likely to experience strained physical and mental health, which can impact health during pregnancy.
Structural racism and historical discrimination against women of color influence these factors that increase the risk of maternal mortality. Economic, housing, education, and social discrimination can increase stress, restric access to community support sistems, and negatively impact health in relation to having stable shelter and access to food and nutritional services. Additionally, medical discrimination against women of color, in which medical professionals provide lower quality care or are reluctant to listen to a mother’s concerns, also makes it more likely that a preventable complication is missed or ignored. Living with generational stress and trauma caused by systemic racism paired with the restrictions to basic necessities such as stable housing, healthcare access, and food increase the risk of poor health not only generally, but particularly during pregnancy, as prenatal care may be limited or poor quality. As a result, maternal mortality and infant mortality rates for people of color increase in proportion to statistics for white women.
Disparate Outcomes in Washington, DC
In Washington, DC, the maternal mortality rate for the general population as of 2019 is 35.6 deaths per 100,000 births, compared to the national rate of 29.6. For Black women, the mortality rate increases to 71.9 deaths per 100,000 births, compared to the national average of 63.8. The maternal mortality rate for white women in DC is suppressed due to the rate being lower than 10, with a national average of 26.1. The maternal mortality rate in DC is higher than both Maryland (25.0) and Virginia (29.5), and the maternal mortality rate for Black women is higher than white women in both states. The reasons why maternal mortality is higher in DC may be for several reasons, specifically access to birthing centers and health care and systemic discrimination against the Black community, which make up 44% of the DC population, the largest of any racial group.
A primary component of the higher maternal mortality in DC is access to health care and its distribution throughout the city. Wards 7 and 8, in which at least 90% of the community is comprised of Black residents, there are only 4 facilities in each ward that provide prenatal care. This is in comparison to Ward 2, which has 12 and has a 73% majority of white residents. Additionally, in 2017, Providence Hospital’s Birthing Ward, which provided low-cost services for impoverished communities in Northeast DC, and United Medical Care’s Obstetrics Ward (UMC), the only full-service birthing center in Southeast DC (Wards 7 and 8) closed. UMC was DC’s only public, non-for-profit hospital. The UMC Obstetrics Ward was closed after an investigation by DC regulators found a series of mistakes that resulted in a newborn contracting HIV and the death of a pregnant woman who reported trouble breathing. Both hospitals had poor ratings from patients about quality of care and had been losing business prior to their closure. As a result of both closures, mothers, which are majorly women of color, are forced to travel either to Maryland or Virginia or to other parts of the city for prenatal care and delivery.
In general, residents of Ward 7 and 8, located east of the Anacostia river, have to travel out of their neighborhoods for medical care. Less than 25% of Medicaid users in these areas have access to medicare they need inside their zip codes. Many have to travel to the central parts of the city and are more likely to call 911 for health services. This same trend applies to pregnant women, especially with the closure of UMC and Providence Hospital’s birthing centers. While deliveries may occur in emergency rooms versus birthing wards, access to postpartum and prenatal care often require travel to other zip codes and coordination between community centers offering services to impoverished communities and hospitals may be difficult. Additionally, in DC, basic Medicaid may only covers up to 60 days of postpartum care, or 1 to 2 visits, further restricting health care access to new or expectant mothers in lower socioeconomic communities.
In DC, the highest number of births are from Black women, with 4131 reported in 2019. Because of systemic discrimination against people of color, particularly in regards to stable health care infrastructure, these women are at a higher risk for maternal mortality. As discussed above, because access to specialists and high quality medical care is distributed primarily in communities with a higher white population, women of color who live outside of the areas are increasingly likely to have restricted access to prenatal and postpartum care, which ultimately results in increased maternal mortality.
Black People Account For 90% Of Pregnancy-Related Deaths In DC
DCist published an article in late April 2022 revealing that Black people accounted for 90% of pregnancy related deaths in DC. The article is based on the Annual Report of the Maternal Mortality Review Committee (MMRC) established in coordination among the Office of the Chief Medical Examiner (OCME), DC Health (DOH), and the Mayor’s Office of Talent and Appointments (MOTA) in 2018. The report found that the maternal mortality rate and the pregnancy-related mortality rate for the District of Columbia are higher than the national average, 23.1 (vs. 20.7) and 44.0 (vs. 28.4) deaths per 100,000 live births respectively. Furthermore, the incidence of maternal mortality is disproportionately higher among the Black population in DC. The report underscored the significance of social determinants of pregnancy outcomes as driving these results.
The Methodology
The MMRC investigated pregnancy-associated death under specific definitions as outlined below:
Table 1: Definitions of key indicators
| Indicator | Definition |
| Maternal Death | A death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. |
| Pregnancy Related Death | A death during or within one year of pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy (includes maternal deaths within 42 days and pregnancy-related deaths 43 days to one year following the termination of pregnancy). |
| Pregnancy-Associated Death | A death during or within one year of pregnancy, regardless of the cause (includes maternal deaths and pregnancy-related deaths). |
| Pregnancy-Associated, but not Related Death | A death during or within one year of pregnancy, from a cause that is not related to pregnancy |
| Severe Maternal Morbidity | Unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health |
Source: Maternal Mortality Review Committee Annual Report 2022
The report’s period of analysis ranges from 2014-2018 where 36 deaths were reported lost during pregnancy or within one year following the end of pregnancy from any cause.
The investigations began after the deaths occurred, were reported, and after relevant parties reconciled the data. The committee reviewed information relating to seven key areas: Maternal history (demographic information, gravidity and parity, a summary of pre-existing medical conditions, a summary of prenatal care received, medications prescribed); summary of hospitalizations; circumstances surrounding death; Chief Medical Examiner(CME)/ Metropolitan Police Department(MPD) scene investigation reports; autopsy reports; maternal risk factors and protective factors including family constellation; social history, and community indicators- to include social determinants of health, Adverse Childhood Experiences (ACEs), employment, education level, housing location, community supports/available resources; district government agency involvement.
The MMRC then used this information to make determinations regarding the following questions with respect to each death:
- Was the death pregnancy-related?
- What was the underlying cause of death?
- Was the death preventable?
- What were the factors that contributed to the death?
- What are the recommendations and actions that address those contributing factors?
- What is the anticipated impact of those actions if implemented?
The focus of the MMRC are the systems (such as hospital/midwife/doula services, DC courts/MPD, DC Department of Health, DC department of Human Services, DC department of Healthcare Finance, etc.) an individual interacted with to determine recommendations for improving these services and systems with the aim of preventing future maternal mortality.
Findings
The racial disparity in pregnancy-associated deaths is stark and there is also a geographic dimension, with the majority of deaths reported in Wards 7 and 8 of the District of Columbia.
The leading causes of deaths of pregnant persons are outlined below (see Table 5). These conditions are more prevalent among Black persons (regardless of whether they are pregnant) than in white persons. This indicates the existence of structural racism that negatively impacts social determinants of health that in this case leads to disparities in pregnancy outcomes.
Recommendations
Preventative action is not limited to improving the systems that provide medical and care services. Given the structural racism reflected in the findings of the report a solution would involve a holistic and wide ranging approach that for example may involve preventive care such as early screening, measures to establish economic security such as affordable housing, steps to ensure community safety, and even ensuring safe and affordable transportation.
Curbing High Rates across DC, MD, and VA
In DC, Mayor Muriel Bowser implemented Thrive by Five DC, a health and early learning initiative aimed towards perinatal health and wellness, early childhood development, and education. As a part of this initiative, Mayor Bowser launched the annual National Maternal and Infant Health Summit in 2018 as part of the Maternal and Infant Health Initiative. The summit aims to raise awareness for women’s health and wellness, particularly as it relates to combating maternal mortality. In 2018, DC also passed the Maternal Mortality Review Committee Establishment Act, which required the city to form a panel of local experts and residents experienced in maternal care to example causes of maternal deaths and recommend preventative measures. As of January 2020, the panel had met four times since its formation in April 2019.
DC Councilmembers have also proposed several bills to combat maternal mortality. Ward 6 Council member Charles Allen introduced the Maternal Health Care Improvement and Expansion Act of 2019, which proposed expanded maternal health services covered by insurance, specifically postpartum visits and transportation stipends, a consolidated maternal health and wellness center, and mandatory implicit bias training as education requirements for medical professionals. Allen also introduced the Investigating Maternal Mortalities Emergency Amendment Act of 2019, which required mandatory reporting of all maternal deaths occurring in DC for the Office of the Chief Medical Examiner to investigate. Also in 2019, DC Council passed the Perinatal Health Worker Training Access Act, which would require the Department of Health to distribute grant funds to establish a perinatal health worker training program in Wards 5, 7, and 8. Finally, in 2021, Councilmember Christina Henderson (At-Large) introduced the Maternal Health Resources and Access Act of 2021, which establishes a pilot program for Medicaid reimbursement for doula services, requires a feasibility study to establish a birthing center east of the Anacostia River, and provides transportation subsidies for rides to maternal health appointments. As of present, only one new maternity ward is in development in Southeast DC at St. Elizabeth’s Hospital, but is not expected to open until Fall 2024.
Aside from action from the DC City Council, several nonprofit and advocacy movements are combating maternal mortality. The DC Primary Care Association, a non profit health advocacy organization, created the Maternal Health Equity Lab in 2018, which brings maternal health experts together along with women who have experienced maternal health care in the city to design strategies to combat maternal mortality The organization is currently working with DC Department of Health to inform future health policy. Another organization, the March for Dimes’ Better Starts for All Program has a full service women’s health clinic called the Mama and Baby Bus, which visits two sites in DC: the Marshall Heights Community Development Organization and the Far Southeast Family Strengthening Collaborative, as well as one site in Prince George’s County, MD: The University of Maryland Capital Region Health. The clinic aims to reduce the gap of maternity health resources in Wards 7 and 8.
In Virginia, the Virginia General Assembly passed House Bill 2546, which established a maternal mortality review team and required the Department of Health to investigate risk factors, trends, and individual cases that result in maternal mortality. Also in 2019, Governor Ralph Northam committed to eliminating the disparity between white and Black women’s maternal mortality rates by 2025, proposing a $22 million plan to be implemented over two years. In this plan, Northam calls to extend postpartum Medicaid insurance for up to a year after birth, allow for home visits to be reimbursed by Medicaid, study the possibility of Medicaid coverage of doula services, assist with addiction treatment for expectant mothers, and increase funding for the Long-Acting Reversible Contraception Program, which provides low-income women with contraception. In 2021, the Virginia General Assembly voted to expand Medicaid coverage to doula services,becoming one of only a few states to do so.
Similarly, in Maryland, Governor Lawrence Hogan announced a $72 million, four year funding program in 2021 to reduce maternal mortality in the state. The plan would include funding for expanding existing women’s health services, reimbursing home visits, covering doula services, and creating an initiative to screen expectant mothers for anxiety and depression and increase access to mental health services. This program is part of the Statewide Integrated Health Improvement Strategies program, which listed maternal mortality as one of its top three priorities. In late 2021- early 2022, Maryland Department of Health received a $1.1 million grant from the CDC to investigate maternal mortality causes and trends over a three year period. In both Maryland and Virginia, advocacy groups such as March of Dimes and other women’s health organizations advocate for increased government funding and investigation into maternal mortality, particularly in regards to the disparities between white women and women of color.