Pittsburgh Post-Gazette - Women's Health
Black maternal mortality rates are rising. Pittsburgh groups have responded in creative ways
Maternal deaths from childbirth have been increasing in the U.S. in recent years, in a nation with the highest rate of maternal mortality among developed countries, and the gap widens for people of color, particularly Black mothers.
Maternal death for Black Pittsburghers was also higher than 97% of similar U.S. cities — and Black residents in general died younger than their white counterparts, according to a 2019 report from the Gender Equity Commission, made up of local public health and sociology experts. (The GEC had planned a follow-up report, but the commission appears to be moribund.)
The Pittsburgh area, however, has a number of groups pursuing an array of solutions, many of which are focused on confronting social determinants of health, from issues of access to financial concerns, which are often as basic as having a means to get to appointments. Preliminary evidence shows change is happening, and those involved in the fight agree collective effort is crucial to sustain burgeoning success.
“It’s going to take a village,” said Margaret Larkins-Pettigrew, senior vice president and chief clinical diversity, equity and inclusion officer at Allegheny Health Network, as well as an OB-GYN.
The Commonwealth Fund, which created a scorecard for health system performance among U.S. states, reported that national maternal mortality rates doubled from 2018 to 2021. The U.S. Centers for Disease Control and Prevention has estimated that 84% of these deaths are preventable.
In 2021, according to that same scorecard, the maternal mortality rate was highest for American Indian and Alaska Native birthers, at 118.7 deaths per 100,000 that year. Black birthers were next with a rate of 69.9 per 100,000. (Whites, in comparison, die at a rate of 26.6 per 100,000.)
“There are changes to our RNA [a crucial part of our bodies’ code] because of continued weathering. Their immune systems could be depleted; they could be more prone to eat poorly,” Larkins-Pettigrew said.
Weathering refers to the constant discrimination Black women face, which wears over time, both psychologically and physically. “This only covers a narrow piece of what happens to Black women when they go into their pregnancy journey, and it’s why we have to focus on prevention,” Larkins-Pettigrew said.
Non-Hispanic Black women also have more preterm births than white women, and health disparities are partially to blame, according to an August paper published in the American Journal of Preventive Medicine by researchers from various institutions, including the University of
Pennsylvania Perelman School of Medicine. The team looked at National Center for Health Statistics data from millions of patients during 2019, with factors including smoking habits, cardiovascular health, education level and insurance status. Black women at the time of delivery were more likely to have hypertension and diabetes and to be obese, but they smoked less than their white counterparts.
Researchers discovered that a third of these health disparities could be explained by social factors; Black patients, for instance, were also younger and less likely to have a college education and private insurance than white patients.
“We want to look more in-depth and capture with more granularity how social factors influence health,” said Sadiya Khan, a preventive cardiologist and a cardiovascular epidemiologist at Northwestern
University, who was the senior author on the AJPM paper. “It’s surprising that these factors only explain about a third of the findings.”
The local GEC report also found that Black birthers in Pittsburgh were three times more likely to give birth to a baby of “extremely low weight” and two times more likely to experience a fetal death compared to white birthers, despite starting prenatal care around the same time.
The COVID-19 pandemic likely exacerbated the problem.
“We wanted to [look at] before COVID because there are so many disparities related to COVID” that could have muddied the ability to extract a correlation about race, preterm births and socioeconomic status alone, said Khan.
“It’s quite possible that disparities may have widened, and that’s an important question for future research,” she said.
Larkins-Pettigrew said the preterm birth study was interesting, and that it calls on communities to intervene early to make a meaningful difference. One way to do that is to offer widespread services to pregnant women.
Pittsburgh is moving in that direction, with a host of services — some of them fairly new — available.
First Steps, which launched locally in 2021 through AHN, is a collaboration between multiple health institutions, including UPMC and The Midwife Center. The program intends to reduce Black infant mortality through multiple avenues, including partnering with doulas, reducing racial disparities and expanding pregnancy support.
When a First Steps program was employed in Cleveland, it was correlated with a decrease in the deaths of Black babies by 20% over a 5-year period.
“It’s really about how Black women are entering their pregnancy journey,” said Larkins-Pettigrew.
UPMC Health Plan members, as well as those on Medicaid and CHIP, have free access to Baby Steps, a maternity program that assigns a case manager to pregnant people at the start of their pregnancy.
“We start with the mom from day one, and we engage dad or whoever is in the household in the process,” said Diana Byas, the manager of Baby Steps. “We realized that if they’re engaged with the program early on, they really do have a healthy [birth] outcome.”
Baby Steps tackles issues from family planning to covering car repairs, so patients can get to their doctor appointments.
“Every mom who has issues gets help,” said Byas. “If they don’t have food in the house, or they don’t have transport to get to the food, if they can’t get to a doctor, we help with that.”
Baby Steps frequently partners with the UPMC Health Plan Neighborhood Center, which opened late last year in East Liberty. The center also addresses various aspects of social determinants of health, including help with employment and finances and connections to outside services. They have food distribution boxes on-site for families, as well as job fairs, an eye clinic, dental pop-ups, a citizenship class, a home ownership program and events with partners offering their own services.
“We take a holistic approach to health,” said Thomas Washington, the Neighborhood Center program director. “We try to knock down barriers related to social determinants of health.”
Since opening, the center has seen 4,500 visitors and helped people find employment and buy homes, Washington said. Such bridges can allow families to catch up where they may have been falling behind, potentially addressing health equity in a way a physician alone cannot.
Doulas, aids who assist women throughout their pregnancies, provide another important resource to improve the health of mothers and babies. Studies show that in births where a doula is present, birthers report more satisfaction with the process and have better outcomes. Doulas are not medical doctors but are trained to work with and advocate for the birther.
A doula program launched at Community College of Allegheny County in September, with students able to get certified in nine weeks. In partnership with the nonprofit Masters of Maternity, the program’s curricula include cultural- and race-specific education to address racial health disparities.
Among the instructors is Pennsylvania Doula Commission president Gerria Coffee, who noted that doulas play a major role in protecting the birth experience and health of the mother.
“In central and rural Pennsylvania, access [to doula services] is an issue,” said Coffee. “We’re working to make doulas more readily available to those on Medicaid. Once Medicaid takes it on, we’re hoping private insurers will do the same.”
Coffee hopes that hospitals and health organizations will take “a very serious look” at their policies, staffing education materials and algorithms to check for ingrained biases that could be hurting Black patients. She referenced a 2016 study in which half of white medical students surveyed thought Black patients felt less pain than whites.
“By now, those are our physicians,” she said.
Even then, it’s not enough to simply address physician bias and call it a day. Larkins-Pettigrew thinks the overhaul should be more widespread in order to see actionable change for Black patients. What she calls “cultural humility” has to be individual and intentional, she said.
“It’s a constant, long-term self-reflection. All of us need to practice,” said Larkins-Pettigrew. “It’s about really trying to see each individual for who they are.”