Black pregnant women already at high risk
As I read about the tragic death of Wogene Debele due to COVID-19, some aspects were eerily familiar but still deeply disturbing. The 43-year-old Ethiopian immigrant and married mother of four contracted the virus approximately eight months into her pregnancy. Her labor was induced prematurely due to her illness, and she died on April 21, about one month after her last son was born.
Her family said that when she went to the hospital on March 19 she was told that she did not appear sick enough to be tested and was sent home. She returned on March 25 and never left alive.
It reminded me of an occasion when I was taking care of an African American woman on the labor floor triage unit some years ago. The nurse commented that the patient did not appear to be as sick as the symptoms she expressed and was doubtful of the patient’s narrative. However, I pressed on with the evaluation and discovered that the patient had a potentially dangerous laboratory abnormality that required several more days in the hospital to treat.
I also recall another African American patient in her early pregnancy that I saw in the emergency room of another hospital. Out of an abundance of caution, the ER doctor felt that she needed a CT scan to evaluate for a pulmonary embolism. I was consulted to provide the patient with the potential risks and benefits of this test in her stage of pregnancy.
While we agreed that the test was needed, I was still a little surprised at the positive result based on the clinical appearance of the patient but very thankful for the superb clinical skills of the doctor who ordered the test — and the patient’s willingness to comply.
Black pregnant patients, frankly all pregnant patients, might sometimes not be deemed to be as sick as they actually are until in some cases it is too late.
As we treat black pregnant women in America, we also have to keep in mind that largely due to social factors that have little to do with their actual genetic makeup, they are at higher risk for severe morbidity and mortality in pregnancy.
It is highly likely that these risks will be amplified during the pandemic, just like they have been amplified for the larger African American community.
Why are black women in America at higher risk? I vividly recall in the early years of my career, more than 20 years ago, that poverty was used to explain these disparities. However, we know so much more than we did then. We now know that the chronic stress from racism in America (both institutional and otherwise) has a detrimental impact on the health of African
Americans, leading them to have the onset of chronic diseases such as diabetes and hypertension, seven to 10 years earlier than their white peers. These stressors not only increase their likelihood of experiencing illnesses at a younger age but increase their risk of dying at a younger age.
Implicit bias exists. It negatively affects the care that black women receive. We should assume we have these biases and act to counteract them, because even if we as healthcare workers do not think we are biased, it is irrelevant — by definition, these biases are unconscious.
Thanks to the work of other experts, we now recognize that these stressors not only affect a woman but can predispose her children and even grandchildren to being more susceptible to chronic diseases through epigenetic effects.
We now know that adverse childhood experiences can affect the long-term health of individuals and increase the risk of mental illness as well as susceptibility to drug use and interpersonal and self-directed violence. The prevalence is highest among non-Hispanic black children in America.
We should know that African Americans still have higher rates of unemployment, are less likely to have a college degree and less likely to own a house than their white counterparts. A collegeeducated black woman earns 70% of a similarly educated white man.
All I have mentioned is just the tip of the iceberg in terms of the inequities faced by African Americans and black people from all over the world who call America their home.
It is not helpful for us to ignore these inequities or pretend they do not exist. But if we acknowledge them and improve our support for black pregnant mothers and be mindful of our own behavior, we can begin to make a positive difference — a difference that can potentially help to repair damages to generations past and present and lead to a healthier life for African American children for generations to come.