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The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature

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Abstract

Background

The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women.

Methods

A literature review was conducted to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014.

Result

Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women.

Conclusions

The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system.

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References

  1. Center for Disease Control and Prevention. Maternal Mortality Rates in the United States, 2020. 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm. Accessed August 2022.

  2. Center for Disease Control and Prevention. Pregnancy Mortality Surveillance System. 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed August 2022.

  3. World Health Organization. Maternal Mortality. 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality. Accessed August 2020

  4. Howell EA, Zeitlin J. Quality of care and disparities in obstetrics. Obstet Gynecol Clin North Am. 2017. https://doi-org.proxygw.wrlc.org/https://doi.org/10.1016/j.ogc.2016.10.002

  5. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 [published correction appears in Lancet. 2017. Lancet. 2016. https://doi-org.proxygw.wrlc.org/10.1016/S0140-6736(16)31470-2

  6. Hirshberg A, Srinivas SK. Epidemiology of maternal morbidity and mortality. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.07.007

  7. World Health Organization. Trends in maternal mortality 2000–2017. 2019. https://apps.who.int/iris/bitstream/handle/10665/327596/WHO-RHR-19.23-eng.pdf?sequence=13&isAllowed=y. Accessed August 2020.

  8. Holdt Somer SJ, Sinkey RG, Bryant AS. Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality. Semin Perinatol. 2017;41(5):258–65. https://doi.org/10.1053/j.semperi.2017.04.001.

    Article  PubMed  Google Scholar 

  9. Kramer MR, Strahan AE, Preslar J, et al. Changing the conversation: applying a health equity framework to maternal mortality reviews. Am J Obstet Gynecol. 2019. https://doi-org.proxygw.wrlc.org/10.1016/j.ajog.2019.08.057

  10. Howell EA, Ahmed ZN. Eight steps for narrowing the maternal health disparity gap: step-by-step plan to reduce racial and ethnic disparities in care. Contemp Ob Gyn. 2019;64(1):30–6.

    PubMed  PubMed Central  Google Scholar 

  11. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting Black lives - the role of health professionals. N Engl J Med. 2016. https://doi-org.proxygw.wrlc.org/10.1056/NEJMp1609535

  12. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017. https://doi-org.proxygw.wrlc.org/10.1016/S0140-6736(17)30569-X

  13. Amankwaa LC, Records K, Kenner C, Roux G, Stone SE, Walker DS. African-American mothers’ persistent excessive maternal death rates. Nurs Outlook. 2018. https://doi-org.proxygw.wrlc.org/10.1016/j.outlook.2018.03.006

  14. Jain JA, Temming LA, D'Alton ME, et al. SMFM special report: putting the “M” back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: a call to action. Am J Obstet Gynecol. 2018. https://doi-org.proxygw.wrlc.org/10.1016/j.ajog.2017.11.591

  15. Morris T, Schulman M. Race inequality in epidural use and regional anesthesia failure in labor and birth: an examination of women’s experience. Sex Reprod Healthc. 2014. https://doi-org.proxygw.wrlc.org/10.1016/j.srhc.2014.09.006

  16. Lange EMS, Rao S, Toledo P. Racial and ethnic disparities in obstetric anesthesia. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.04.006

  17. Moroz L, Riley LE, D'Alton M, et al. SMFM special report: putting the “M” back in MFM: addressing education about disparities in maternal outcomes and care. Am J Obstet Gynecol. 2018. https://doi-org.proxygw.wrlc.org/10.1016/j.ajog.2017.11.592

  18. Collier AY, Molina RL. Maternal mortality in the United States: Updates on trends, causes, and solutions. Neoreviews. 2019. https://doi-org.proxygw.wrlc.org/10.1542/neo.20-10-e561

  19. Ozimek JA, Kilpatrick SJ. Maternal mortality in the twenty-first century. Obstet Gynecol Clin North Am. 2018. https://doi.org/10.1016/j.ogc.2018.01.004.

    Article  PubMed  Google Scholar 

  20. Vilda D, Wallace M, Dyer L, Harville E, Theall K. Income inequality and racial disparities in pregnancy-related mortality in the US [published correction appears in SSM Popul Health. 2019. https://doi-org.proxygw.wrlc.org/10.1016/j.ssmph.2019.100477

  21. White AA 3rd, Stubblefield-Tave B. Some advice for physicians and other clinicians treating minorities, women, and other patients at risk of receiving health care disparities. J Racial Ethn Health Disparities. 2017. https://doi-org.proxygw.wrlc.org/10.1007/s40615-016-0248-6

  22. Lister RL, Drake W, Scott BH, Graves C. Black maternal mortality-the elephant in the room. World J Gynecol Womens Health. 2019. https://doi-org.proxygw.wrlc.org/10.33552/wjgwh.2019.03.000555

  23. Mehra R, Boyd LM, Magriples U, Kershaw TS, Ickovics JR, Keene DE. Black pregnant women “get the most judgment”: a qualitative study of the experiences of black women at the intersection of race, gender, and pregnancy. Womens Health Issues. 2020. https://doi.org/10.1016/j.whi.2020.08.001.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Gadson A, Akpovi E, Mehta PK. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.04.008

  25. Jain J, Moroz L. Strategies to reduce disparities in maternal morbidity and mortality: patient and provider education. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.04.010

  26. Coley SL, Zapata JY, Schwei RJ, et al. More than a “number”: perspectives of prenatal care quality from mothers of color and providers. Womens Health Issues. 2018. https://doi-org.proxygw.wrlc.org/10.1016/j.whi.2017.10.014

  27. Fryer K, Munoz MC, Rahangdale L, Stuebe AM. Multiparous Black and Latinx women face more barriers to prenatal care than White women. J Racial Ethn Health Disparities. 2021. https://doi.org/10.1007/s40615-020-00759-x.

    Article  PubMed  Google Scholar 

  28. Kozhimannil KB, Hardeman RR, Henning-Smith C. Maternity care access, quality, and outcomes: a systems-level perspective on research, clinical, and policy needs. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.07.005

  29. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and Whites. Proc Natl Acad Sci U S A. 2016. https://doi.org/10.1073/pnas.1516047113.

    Article  PubMed  PubMed Central  Google Scholar 

  30. The American College of Obstetricians and Gynecology. Low-dose aspirin use for the prevention of preeclampsia and related morbidity and mortality. 2021. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/12/low-dose-aspirin-use-for-the-prevention-of-preeclampsia-and-related-morbidity-and-mortality. Accessed September 2023.

  31. Liese KL, Mogos M, Abboud S, Decocker K, Koch AR, Geller SE. Racial and ethnic disparities in severe maternal morbidity in the United States. J Racial Ethn Health Disparities. 2019. https://doi.org/10.1007/s40615-019-00577-w.

    Article  PubMed  Google Scholar 

  32. United States Census Bureau. Quick Facts United States. 2022. https://www.census.gov/quickfacts/fact/table/US/IPE120221#qf-headnote-a. Accessed May 2023.

  33. Association of American Medical Colleges. Physician Specialty Data Report. 2021.https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-black-african-american-2021. Accessed May 2023.

  34. Howell EA, Brown H, Brumley J, et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. J Obstet Gynecol Neonatal Nurs. 2018. https://doi.org/10.1097/AOG.0000000000002475.

    Article  PubMed  PubMed Central  Google Scholar 

  35. New York City Department of Health and Mental Hygiene Bureau of Maternal Health. 2015. Pregnancy-Associated Mortality New York City, 2006–2010. The NYC Department of Mental Health and Hygiene: New York. https://www1.nyc.gov/assets/doh/downloads/pdf/ms/pregnancy-associated-mortality-report-2011-2015.pdf. Accessed January 2023.

  36. Cox KS. Global maternal mortality rate declines-except in America. Nurs Outlook. 2018. https://doi-org.proxygw.wrlc.org/10.1016/j.outlook.2018.08.001

  37. Oribhabor GI, Nelson ML, Buchanan-Peart KR, Cancarevic I. A mother’s cry: a race to eliminate the influence of racial disparities on maternal morbidity and mortality rates among Black women in America. Cureus. 2020. https://doi-org.proxygw.wrlc.org/10.7759/cureus.9207

  38. Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet. 2020. https://doi.org/10.1016/S0140-6736(20)32076-6.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Howell EA, Zeitlin J. Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Semin Perinatol. 2017. https://doi-org.proxygw.wrlc.org/10.1053/j.semperi.2017.04.002

  40. Alliance for Innnovation on Maternal Health. Reduction of peripartum racial/ethnic disparities. 2016. https://saferbirth.org/psbs/archive-reduction-peripartum-disparities/. Accessed August 2020.

  41. Congress.gov. S.1600. Maternal Care Access and Reducing Emergencies Act. 2019. https://www.congress.gov/bill/116th-congress/senate-bill/1600/text. Accessed August 2020

  42. Congress.gov. H.R.3688. MOMS Act of 2021. 2021. https://www.congress.gov/bill/117th-congress/house-bill/3688/text?q=%7B%22search%22%3A%5B%22MOMS+Act+of+2021%22%2C%22MOMS%22%2C%22Act%22%2C%22of%22%2C%222021%22%5D%7D&r=5&s=4. Accessed January 2022.

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Authors and Affiliations

  1. Department of Public Health, Milken Institute School of Public Health – The George Washington University, Washington, DC, USA

    Keisha E. Montalmant

  2. Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA

    Anna K. Ettinger

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KM conceptualized the paper, conducted the literature review, and drafted the manuscript. AE helped conceptualize the paper and reviewed drafts and the final manuscript.

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Correspondence to Keisha E. Montalmant.

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Montalmant, K.E., Ettinger, A.K. The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01816-x

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