Racial disparities in maternal health outcomes difficult to erase

When Lynette Granger had her first child four years ago, she described both her pregnancy and delivery as going smoothly. “My first pregnancy was amazing, no complications, sickness or anything,” she said. When Granger, who resides in the West Side Chicago neighborhood of Humboldt Park, became pregnant with her second child last year however, complications developed almost immediately.

Three months into her pregnancy Granger was diagnosed with a short cervix, which carries a 1-in-2 chance of causing premature birth. As a result, Granger was ordered to remain in bed. At six months her water broke, and at seven months she delivered her daughter.

Granger’s child had to stay within the neonatal intensivecare unit at the University of Illinois Medical Center for three weeks. With her thoughts solely on the health of her child during that time, it wasn’t until months after her daughter was released from the hospital and safely at home before Granger began to think about the toll the experience had taken on her own health, or the risks she now faces if she and her partner ever decide to have another child.

During her second delivery Granger experienced excessive bleeding to the point where doctors considered performing a C-section. Because of those concerns, her physicians told her future pregnancies would be considered high-risk. “That’s what scares us about possibly having a third child,” Granger said. “Overall I think it’s scary for my body and what it could do to my organs and my insides.”

The health difficulties Granger experienced during her second pregnancy and delivery have become increasingly more common among women throughout the U.S. in recent years. While rates of maternal complications and death have been declining for years in other industrialized nations, the U.S. rate has been rising.

The rate at which women have been diagnosed with severe maternal morbidity rose 200% from 49.5 per 10,000 hospitalized deliveries in 1993 to 144 occurrences per 10,000 in 2014, according to the Centers for Disease Control and Prevention.

The rise in maternal complications has coincided with an increase in maternal deaths, with the rate rising from 17 for every 100,000 live births in 1990 to 26.4 deaths by 2015, according to a 2016 Lancet study.

In Chicago, communities where maternal complications such as pre-term birth and cesarean sections are high are many of the same areas that experience high rates of infant mortality, according to Brielle Treece Osting, director of the maternal and infant mortality initiative for EverThrive Illinois, a not-for-profit woman and child health advocacy group.

“Because so many of the factors that drive infant mortality also drive maternal mortality, we can sort of implicitly connect the dots there,” Osting said. “So, in places that have a higher rate of infant mortality, we can assume that

While rates of maternal complications and death have been declining for years in other industrialized nations, the U.S. rate has been rising.

they also have higher rates of maternal mortality—in the city of Chicago, these areas are very much concentrated in the West and South sides of the city.”

Osting said race appears to be the primary factor for the disparities found in both infant and maternal mortality. Figures from the Chicago Public Health Department indicate that the pre-term birth rate was relatively similar across income levels, but when compared by race, the rate among African-American women was nearly 40% higher than the rate among white women.

One contributing factor to the disparity, according to Osting, is the effect of chronic stress that black women experience because of racism, which she said has sort of a weathering effect on the body. Indeed, studies over the years have found an association between black women reporting being racially discriminated against and higher rates of preterm and low-birthweight deliveries.

But another factor involves what Osting says has been a historic discrepancy in the way black people, and black women more specifically, have been treated in the healthcare system compared with white patients. She said such separate and unequal treatment has led to fewer opportunities for black mothers to access routine follow-up care and to poorer outcomes.

“Physicians and other providers do need to take that into account when serving these patients,” Osting said. “I hesitate to say that we need to treat all patients equally when it’s really about meeting all patients where they’re at.”

Meeting patients where they reside has been one of the objectives of the University of Illinois Hospital & Health Sciences System’s approach toward maternal care in higherrisk neighborhoods.

Dr. Tamika Alexander, associate director of the OB-GYN residency program at the University of Illinois College of Medicine, splits her time between serving patients at the Mile Square Health Center clinic in Englewood on the city’s South Side, which is part of the UI system’s federally qualified health center network, and the University of Illinois Medical Center.

Alexander said it was not unreasonable for healthcare providers to conduct follow-up care for up to nine months to a year after mothers have given birth to make sure they have the appropriate resources. She said she envisioned such follow-up care to involve a multidisciplinary team that would include pediatrics, social workers, as well as an OB-GYN.

UI Health providers schedule visits with mothers one to two weeks after delivering for follow-up checks, while patients who are on Medicaid are assigned a case manager who monitors their progress and contacts mothers for reminders of when they need to get certain tests or procedures done.

But despite such approaches, Alexander acknowledged sometimes there are simply not enough resources to meet all of the need. She said a major obstacle is in trying to provide evidence-based care in the neighborhoods, where accessing some of those resources would require patients traveling several miles to the system’s main hospital near downtown.

“I think the biggest challenge in working in the community is providing patients with a high level of care without the subspecialists’ input,” Alexander said. ●

so, recommendations are given to improve health like taking certain vitamins or losing weight. “It’s a lot easier to have healthy moms and babies before they get pregnant,” Compton-Phillips said.

The problem is some women only have access to healthcare—particularly certain Medicaid members— because they are pregnant. The coverage usually expires 60 days after delivery. Further, women who are poor are more likely to face challenges that prevent them from having healthy pregnancies, such as limited access to nutritious food or prenatal care. About 50% of the babies Providence delivers are from mothers on Medicaid, which reflects national trends.

Social interaction

“There are a whole slew of social factors that impact health outcomes and that plays a role when we are talking about higher complications in pregnancy,” said Dr. Rose Molina, an OB-GYN at Beth Israel Deaconess Medical Center in Boston who has written about maternal mortality.

To identify women at risk for such complications, Providence has set up a tool in its electronic health record. Various questions about the mother’s circumstances are documented and depending on the responses, physicians will be alerted when extra precaution should be taken.

While care practices before and 1 during pregnancy are important, so is care afterward, ACOG’s Hollier said. Women can die from pregnancy-related reasons up to about a year after labor.

To address this, the specialty society in May updated its guidelines for postpartum care. Instead of a one-time checkup six weeks after delivery, obstetricians are encouraged to contact mothers within the first three weeks postpartum and provide ongoing follow-up care as needed.

“What this does is it really emphasizes the need to ensure that the woman is getting the right healthcare for her specific situation,” Hollier said. The guidelines also help to ensure women on Medicaid because of pregnancy get the appropriate follow-up care before they lose access.

The ACOG is also working on guidelines to address women’s long-term risk for heart disease after pregnancy. Hollier said more women are dying from cardiac issues, while deaths from hemorrhage and high blood pressure are falling. The ACOG expects to have the guidelines released by May 2019.

“Women who have pregnancy complications like pre-eclampsia or diabetes have an increased risk of developing heart disease later in life. We want to better identify these Women and how best to take care of them,” Hollier said. ●