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Vol. LXV, No. 23
November 8, 2013

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‘A Very Urgent Issue’
NICHD Seminar Reviews Maternal Mortality in Women of Color

On the front page...

Dr. Maria J. Small

Dr. Maria J. Small

When a woman dies in pregnancy or childbirth, the world cracks in two: the Time Before and the Time After, when nothing is the same. In the biblical account of Jacob’s wife, “Rachel travailed, and she had hard labor…And Rachel died.” Stories and songs about motherless kids persist in all cultures—from Snow White, Oliver Twist and Lord Voldemort to Blind Willie Johnson’s, “Motherless children have a hard time when mother is dead.”

We might think that these primal tales of maternal loss are of another time and place, but we would be wrong. In maternal death rates, the U.S. ranks behind almost 50 other nations, including Bulgaria and Iran.


“Yet the U.S. spends more on maternity care per birth than any other nation,” according to Dr. Jo Ivey Boufford, president of the New York Academy of Medicine. She recently spoke at NICHD’s Health Equity Seminar, “Maternal Mortality in Women of Color: Observations, Status of Research, Future Directions,” held at Natcher Conference Center.

Boufford was joined by speakers Dr. Kimberly D. Gregory, vice chair of women’s health care quality & performance improvement, Cedars-Sinai Medical Center; and Dr. Maria J. Small, assistant professor of maternal and fetal medicine, Duke University Medical Center.

“It’s about time we all paid closer attention to this issue,” said NICHD deputy director Dr. Yvonne Maddox in opening remarks. The current status of pregnancy-related maternal mortality in women of color is troubling:

  • Nationally, black women have a 4-times-greater risk of pregnancy-related complications than do white women and the magnitude of this disparity is increasing.

  • According to a 2008 CDC report, the rate of pregnancy-related complications for blacks is 36.1 per 100,000 live births, compared with 9.6 for whites and 8.5 for Hispanics.

  • In New York City, black women are nearly 7 times more likely to die from pregnancy-related complications than are white women.

  • In California, black women are 4 times as likely to die from childbirth as white women.

  • Nationally, the increasing numbers of cesarean sections contribute to this trend.
The panel at the health equity seminar included (from l) moderator Dr. Uma Reddy of NICHD, Small, Dr. Kimberly D. Gregory and Dr. Jo Ivey Boufford.

The panel at the health equity seminar included (from l) moderator Dr. Uma Reddy of NICHD, Small, Dr. Kimberly D. Gregory and Dr. Jo Ivey Boufford.

Photos: Ernie Branson

A maternal death is one that occurs up to 42 days after discharge. In the U.S., among the most common causes are pre-eclampsia/eclampsia (hypertension of pregnancy), cardiovascular disease and hemorrhage.

“This is a very urgent issue,” Boufford said. “The drop in the death rate overall is not paralleled in the maternal mortality rate…we need to keep this issue in front of the legislators.”

The population of women giving birth is changing, she said. They are older, more overweight and likely to have non-communicable diseases such as diabetes or heart disease. Black women tend to have more pre-existing conditions and inadequate health care.

Yet clinical management hasn’t kept pace. And the systems for prevention (including contraception), response, reporting and review are fragmented.

Moreover, black women within a low-risk category still have higher mortality rates: “The protective effects of a rise in socioeconomic status [SES] are not as great as we would want,” Boufford said.

Gregory echoed these findings. Even as global rates are falling, maternal mortality is on the rise in California and the [rest of the] U.S. “This reflects poorly on the U.S.,” she said.

Regarding black women, “I’m going to go out on a limb here and acknowledge that we are different,” said Gregory, who is African American. “Across the world, the maternal mortality risk for black women is higher. SES is not the only risk factor…Even if we only look at educated, affluent women, studies have shown black women still do worse.”

According to the allostatic load theory, “black women may be less resilient,” when subjected to an acute stress, she said, “because they are constantly all revved up.”

Gregory said black women may be less resilient under stressful conditions “because they are constantly all revved up.”

Gregory said black women may be less resilient under stressful conditions “because they are constantly all revved up.”

Allostatic load is the wear and tear on the body when exposed to repeated or chronic stress. The body’s stress response is vital for managing acute threats, but if activated repeatedly over the long run, it can damage the body, especially the cardiovascular system.

As context, Gregory cited a 2002 Institute of Medicine report that African-American patients are treated differently for many clinical conditions, including receiving less pain medication than other patients, even though the African-American patients have the same medical condition.

“Cultural competency may not be enough,” Gregory said, calling for tailored clinical treatment protocols. “Why don’t we develop protocols that treat black women differently in a good way?”

Small noted that, worldwide, women of African descent have higher maternal mortality rates, whether they live in the U.K, the U.S. or Uganda.

With an eye to U.N. Millennium Developmental Goal #5—to improve maternal health—“the U.S. is going backwards,” she said.

For example, one of the indirect causes of maternal mortality is diabetes, which is on the rise. “Few studies examine BMI for ICU admission…yet obesity is a significant contributor.”

In addition, because a maternal “near miss” event (a severe morbidity or complication of childbirth) is more common than a maternal death, studying “the near miss can be useful in improving quality of care,” she said.

She pointed to “the Hispanic paradox.

“Hispanics may have better outcomes even though they have lots of risk factors we associate with adverse health,” she said. These outcomes may be linked to family and community networks and diet.

In North Carolina, “near miss” events, however, are higher among Hispanic mothers.

More research is needed on psychosocial factors, she said, including the role of social support as a stress mediator.

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