We must remedy disparities in US maternal health [column]

As a Black obstetrician/gynecologist, I cringe at articles like the one that drew national attention last month.

On Feb. 23, Roni Caryn Rabin wrote a New York Times article detailing maternal deaths witnessed during the first year of the COVID-19 pandemic. The article pointed out the disparate rates of maternal death among Black and Hispanic women.

Pregnancy and childbirth, as well as postpartum care, are supposed to be happy times in a pregnant patient’s life. Unfortunately, this is not always the case.

The maternal mortality ratio is defined by the World Health Organization as death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to, or aggravated by, pregnancy.

In the United States, 23.8 out of 100,000 women die annually during pregnancy and childbirth. That number is three to four times higher in pregnant Black patients.

In 2018, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics, there were 17 maternal deaths for every 100,000 live births in the U.S. — a ratio more than double that of most other high-income countries. In contrast, the maternal mortality ratio was three per 100,000 or fewer in the Netherlands, Norway and New Zealand, according to a report from The Commonwealth Fund.

Cardiomyopathy, thrombotic pulmonary embolism and hypertensive disorders contributed more to pregnancy-related deaths among Black women than among white women. These are all conditions that can be diagnosed and treated.

During my 16-year medical career, I have personally witnessed maternal death. It shook me to my core and led me to join forces with, and become a founding member of, Patients R Waiting. Patients R Waiting is a nonprofit organization whose mission is to eliminate health disparities by increasing diversity in medicine. We have three areas of focus: 1) increase the pipeline of minority clinicians; 2) make the pipeline less leaky; and 3) support minority clinicians in practice.

Diversifying medicine is vital to closing health disparity gaps such as Black maternal mortality. A number of factors contribute to these health disparities, but one problem has been a lack of diversity among physicians. African Americans make up 13% of the U.S. population, but only 5% of U.S. doctors and 7% of U.S. medical students. Research shows that cultural congruence helps to improve communication, trust, patient understanding and compliance. In addition, research shows that doctors from marginalized communities are not only more likely to return to their communities to practice, but are more likely to deliver better outcomes for their patients.

Many health care providers in marginalized communities and beyond knew the COVID-19 pandemic would widen health disparity gaps, especially those among pregnant people. Health disparities exist because of a multitude of reasons, including social determinants of health, systemic racism, implicit bias, and current and historic inequalities. The COVID-19 pandemic exposed a flawed health care system and widened health disparity gaps.

Last September, the CDC issued an urgent notice strongly recommending that pregnant people be vaccinated against COVID-19. At that time, there were 125,000 laboratory-proven COVID-19 infections in pregnant patients, 22,000 hospitalizations of pregnant patients, and 161 maternal deaths (22 maternal deaths in August 2021 alone). At that point, only 140,000 pregnant people had received their first COVID-19 vaccinations.

Pregnant patients who get COVID-19 are more likely to experience severe disease, be hospitalized, admitted to the intensive care unit, and die.

Why is this?

Pregnant patients are usually younger and healthier, without medical problems. But normal changes during pregnancy can increase the risks of severe conditions. These normal changes need to happen for adaptation to pregnancy. But these changes can lead to higher risks of medical complications such as high blood pressure, pneumonia, flu, kidney infections and of course, COVID-19.

According to the CDC, there was an increase in preterm birth rates, growth-restricted newborns, preeclampsia (high blood pressure in pregnancy), blood clots and stillbirth among pregnant patients who were infected by COVID-19 and unvaccinated.

This data and science tell us that we must put forth steps to reverse this trend. Commonsense measures — which include hand hygiene, wearing masks, social distancing and getting fully vaccinated — are still recommended as we near the end (hopefully) of this deadly pandemic.

On May 21, 2021, the U.S. Food and Drug Administration expanded the use of monoclonal antibody therapy for treatment of mild to moderate COVID-19 to include pregnant people. Monoclonal antibodies are antibodies developed to augment the immune response and help prevent severe illness. Monoclonal antibodies may be offered within seven to 10 days of the onset of symptoms. Clinical trials have shown a significant decrease in hospitalizations and death in high-risk patients, such as pregnant people.

So what can we do to remedy disparate health care for pregnant people?

The solutions are not simple. They can be addressed from short-term and long-term perspectives. In the short term, we can promote person-centered care models — we must listen to patients and rectify our own implicit biases, and we must build, nurture and sustain trust. Second, patient safety increase when we promote safe medical care for everyone. We must create safe spaces for everyone; build mutual respect, dignity and empathy; and provide effective communication. Third, we must provide excellent treatment; this includes learning and sharing the best practices of high-performing hospitals with great patient outcomes.

Regarding long-term solutions, I refer to the five elements described by the Institute for Healthcare Improvement. These five elements include: 1) prioritizing health equity; 2) using structure and process to achieve equitable outcomes; 3) addressing systemic racism; 4) addressing social determinants of health; and 5) partnering with community organizations, such as Patients R Waiting.

As a Black obstetrician/gynecologist practicing in Lancaster County and the central Pennsylvania region, I know that the task of eliminating health disparities is great. Through mentorship, advocacy, service and cultural humility, that task can be addressed.

As former first lady Michelle Obama once said, “We should always have three friends in our lives — one who walks ahead who we look up to and we follow; one who walks beside us, who is with us every step of our journeys; and then, one who we reach back for and we bring along after we’ve cleared the way.”

Dr. Sharee Livingston is chair of the Department of Obstetrics and Gynecology at UPMC Lititz, a founding member of Patients R Waiting and co-founder of the Diversifying Doulas Initiative.