THE STATE OF THE FIELD

Legislation Addressing Disparities in Birth Outcomes and

Maternal Mortality among

Black Mothers and Infants

By Ryan Sutherland

Arecent study by the Organization for Economic Cooperation and Development found that among the top economically developed nations, the United States ranks first for child mortality and 47 th in the world among all nations for maternal mortality. 1 More than 50,000 American mothers each year will experience life-threatening, pregnancy-related complications and two women will die each day in childbirth resulting in over 700 annual pregnancy-related deaths. A Centers for Disease Control and Prevention (CDC) report determined that 60% of these maternal deaths were preventable. 2

While public health reforms have greatly reduced historical rates of infant and maternal mortality globally, the United States has experienced an increase in maternal deaths in the last decade. Moreover, maternal mortality rates and differences in birth outcomes vary demographically—very low infant birth weight (VLBW), high rates of preterm birth (PTB), the elevated prevalence of infant mortality (IM) and high rates of maternal mortality (MM) disproportionately affect non-Hispanic Black women and their children and represent clear racial and ethnic disparities in birth outcomes in the United States. These disparities must be addressed. 3

Specifically, addressing medical practitioner bias and widespread systemic racial discrimination, mitigating environmental and social stressors, eliminating barriers to care and enacting new culturally-informed policies to increase access to high quality health care, lower cost insurance, maternal education, nutritional food and affordable housing for Black women is imperative to help address this racial disparity in maternal and child health. More than 50,000 American mothers each year will experience life-threatening, pregnancyrelated complications and two women will die “ each day in childbirth. 60% of these maternal In order to accomplish these goals, urgent national policy reform is needed to address the issue of disparities in birth MOMMA’s Act, in the 116th congress by Rep. Robin Kelly (D-IL). S. 3392 (115 th ), the Modernizing Obstetric Medicine Standeaths are preventable. ” outcomes among Black mothers in order to improve maternal and child health. While the recent passage of H.R. 1318, the Preventing Maternal Deaths Act/ S. 1112, the Maternal Health Accountability Act (Public Law No: 115-344) and H.R. 6085/S. 3029, the PREEMIE Act (Public Law No: 115- 328) represent important legislative steps toward addressing these issues, more can be done to ensure the safety and health of Black pregnant women and their children.

Several bills that are important for supporting maternal and child health were not enacted in the 115 th Congress (2017–2018) and have not yet been reintroduced in the 116 th congressional session (2018–2019). Moreover, several that have been reintroduced before the 116 th congressional session have not yet been passed into law.

H.R. 5761, the Ending Maternal Mortality Act to establish the National Strategy to Combat Maternal Mortality; S. 3363/H.R. 6698, the Maternal CARE Act; and S. 3494, the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act were not enacted during the 115th Congress and have not been reintroduced in the 116th congress.

H.R. 5977 (115 th ), the MOMMA’s Act has been reintroduced as H.R. 1897, the dards (MOMS) Act has been reintroduced in the 116 th congressional session by Sen. Kirsten Gillibrand (D-NY) as S. 116, the MOM’s Act. Senator Elizabeth Warren introduced a plan to address maternal mortality among black mothers by linking quality of care delivery to provider and healthcare facility incentives.

These bills and plan coincide closely with the goals expressed in Healthy People 2020 to reduce maternal mortality, infant mortality, low birthweight, and preterm births among all Americans. If passed into law, these acts will continue to support women’s maternal health and to address disparities in birth outcomes. 4 These bills are described in more detail below.

Furthermore, supporting future Connecticut state bills similar to SB 304: An Act Establishing A Maternal Mortality Review Program And Committee Within The Department Of Public Health in the Connecticut State Legislature that was passed into law in 2018 (Public Act No. 18-150) is important to guarantee funding and resources for an evidence-based review of statewide maternal mortality rates. African American voters make up approximately 9% of Connecticut’s population and 13% of the national population and depend on policymakers and constituents to improve maternal and child health and wellbeing at both the state and national levels.

Wikimedia Commons

Front of the Centers for Disease Control and Prevention Museum in Altanta, Georgia.

Background

Higher rates of very low infant birth weight (VLBW), preterm birth (PTB), infant mortality (IM) and maternal mortality (MM) disproportionately affect non-Hispanic Black mothers and their children and represent clear racial and ethnic disparities in birth outcomes and maternal health in the United States. 3

In 1850, United States census data estimated the infant mortality rate among Blacks to be 353 deaths per 1000 live births compared to 217 deaths per every 1000 live births for Whites. 5 Because of improvements

in hygiene and sanitation at the turn of the 20 th century, this rate continued to decline into the 21 st century; however, Blacks have always had a higher infant mortality rate than Whites. Margaret Heckler, former Secretary of Health and Human Services, chaired the 1985 Report of the Secretary’s Task Force on Black and Minority Health that extensively outlined racial and ethnic disparities in health and helped bring these issues national attention. 6 In response to this report, the Centers for Disease Control and Prevention (CDC) started the Pregnancy Mortality Surveillance System in 1986 to determine trends in maternal and child mortality, measures used as proxies to estimate national healthcare quality.

Presently, Black mothers are three to four times more likely than White mothers to die in childbirth regardless of socioeconomic or educational status and 11.4 infants before the age of one year die per 1,000 live births among non-Hispanic Black mothers, a rate that is double that of non-Hispanic White mothers. 7 Although infant mortality rate (IMR) for Black infants declined from 2005 to 2012 paralleling decreases among infants of all races, Black IMR has increased in the past half-decade while White IMR continues to decrease. These gaps represent a disturbing pattern that urgently needs to be addressed: Black pregnant women and Black infants are dying at higher rates than women and infants of other races.

Many factors contribute to the maintenance of this trend. Variable access to insurance and quality medical care centers, and a higher rate of Cesarean sections among Black women partially accounts for the disparity in birth outcomes. Only 23% of Black patients—compared to 63% of White patients—gave birth in safer-rated hospitals, and the same study showed that the quality of hospital accounts for nearly 50% of disparity in birth outcomes. 8 Additionally, low-risk Black mothers were more likely to have unnecessary Caesarean section than Whites, a procedure usually reserved for high-risk pregnancies. 9 This invasive surgical procedure puts Black mothers at a higher risk for death and medical complications, especially when performed at lower quality a motivating factor in the selection of lower quality hospitals and results in higher rates of negative birth outcomes: uninsured neonates have a higher risk of death and illness than those who are insured. 11 The Kaiser Family Foundation notes that 11.7% of Blacks are uninsured (as compared to 7.6% of Whites), putting Black neonates at an

increased risk of mortality and morbidity. 12 However, in states that expanded Medicare

under the Affordable Care Act, infant mortality rates were reduced 50% more than in

congress.gov

states that did not expand coverage. 13

Several further explanations that account for this difference in birth outcome cite environmental, behavioral, social and

H.R. 1897, the MOMMA’s Act, was reintroduced in the 116 th Congress on March 27, 2019.

genetic risk factors. Higher rates of environmentally and genetically-influenced chronic and acute health conditions (heart disease, diabetes, inflammation, etc.), environmental stress due to poverty and unsafe living conditions which can in turn influence cigarette, drug and alcohol use, low rates of exercise, higher exposure to pollution and chemicals in highly-segregated, densely-populated and poor neighborhoods, as well as poorer nutrition and higher rates of obesity during pregnancy lend to negative birth outcomes among Black women. 14,15 Pregnancy-related hypertension, also known as pre-eclampsia, is one of the leading causes of death of Black pregnant women and is 60% more common and more severe within this population. 16 Furthermore, lower socioeconomic status coupled with systemic barriers preventing access to prenatal and postnatal care (lack of transportation, insurance, maternal education, etc.) also puts Black women and their children at higher risk of death or negative birth outcomes. 17,18

Finally, internalized, institutional (medical), and personally mediated racism and persistent sexism offer more nuanced explanations for these disparities in birth outcomes, and have prompted the United Nations to call on the United States to “eliminate racial disparities in the field of sexual and reproductive health.” Consistent minority stress results in “weathering,” a term coined by Arline Geronimus to describe the process by which low socioecocause marked health declines in African American women, and this affects birth outcomes and maternal health. 19 For example, the Black Women’s Health Study found that consistent discrimination and minority stress correlates with the presence of fibroid tumors, maternal bleeding, and low birthweight infants among pregnant minority women. 20 Systemic prejudice and social stigmatization within and beyond the clinic must urgently be addressed through policy reform in order to address gaps in infant

and maternal mortality and wellbeing.

Overall, differential birth outcomes among Black women are a consequence of complex and interlocking social, behavioral, environmental, and genetic risk factors coupled with systemic racism and sexism. Several pieces of legislation have been introduced to the House and Senate and can have a profound impact on maternal and child health disparities within and beyond the Black community. H.R. 5761 (115 th ), the Ending Maternal Mortality

Act to establish the National Strategy to Combat Maternal Mortality; S. 3363/H.R. 6698 (115 th ), the Maternal CARE Act; S.

3494 (115 th ), the Maximizing Outcomes for

Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act; H.R. 1897 (116 th ), the MOMMA’s Act;

and S. 116 (116 th ), the MOM’s Act, promote

research and evidence-based maternal edu

cation, and continue to support women’s

maternal health and address disparities in hospitals. 10 Moreover, a lack of insurance is nomic status and persistent discrimination birth outcomes among Black mothers. Black mothers are three to four times more likely than White mothers to die in childbirth regardless of socioeconomic or educational status, and 11.4 infants before the age of one year die per 1,000 live “ births among non-Hispanic Black mothers, a rate that is double that VOLUME 7 of non-Hispanic White mothers. 14 ”

The passage of H.R. 1318, the Preventing Maternal Deaths Act (incorporating S. 1112, the Maternal Health Accountability Act) as Public Law No: 115-344 will have a pronounced impact on Black mothers and infants, and will improve general maternal and child health nationwide. Organizations including the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the Association of Women’s Health, Obstetric, and Neonatal Nurses, and the Preeclampsia Foundation supported this piece of bipartisan legislation.

Bill/Plan Summaries

S. 1112/H.R. 1318, Preventing Maternal Deaths Act (became Public Law No: 115-344 on December 21st, 2018): “To support States in their work to save and sustain the health of mothers during pregnancy, childbirth, and in the postpartum period, to eliminate disparities in maternal health outcomes for pregnancy-related and pregnancy-associated deaths, to identify solutions to improve healthcare quality and health outcomes for mothers, and for other purposes.” 21,22

H.R. 5761, Ending Maternal Mortality Act (not enacted in 115 th congress, not reintroduced in the 116 th congress): “To direct the Secretary of Health and Human Services to submit to the Congress on a biennial basis a national plan to reduce the rate of maternal mortality.” 23

S. 3363/ H.R. 6698, Maternal CARE Act (not enacted in 115 th congress, not reintroduced in the 116 th congress): “A bill to support States in their work to end preventable morbidity and mortality in maternity care by using evidence-based quality improvement to protect the health of mothers during pregnancy, childbirth, and in the postpartum period and to reduce neonatal and infant mortality, to eliminate racial disparities in maternal health outcomes, and for other purposes.”

S. 3392, Modernizing Obstetric Medicine Standards (MOMS) Act (not enacted in the 115 th congress): “Authorize and expand the Alliance for Innovation on Maternal Health (AIM) Program at HHS through 2023; Create a grant program to help states and hospitals implement the maternal safety best practices; Improve reporting on pregnancy-related and pregnancy-associated deaths and complications. HHS will encourage states to voluntarily submit a yearly report with findings from a state Maternal Mortality Review Committee (MMRC) on maternal deaths.” 24 In Connecticut, there were 8 pregnancy-related deaths between 2011–2014. Data for 2014–present has not yet been released. These data only record deaths in hospital settings, and do not fully demonstrate pregnancy-related deaths within a year after birth. More research needs to be done on this topic to address the impacts of health disparities on women post-delivery. 30

11.4 infants before the age of one years old die per 1,000 live births among non-Hispanic Black mothers in the United States, a rate that is double that of non-Hispanic White mothers.

Black mothers are three to four times more likely than White mothers to die in childbirth regardless of socioeconomic or educational status. 7

Although educational status is protective for White pregnant mothers (higher educational attainment corresponds with a lower risk for infant mortality), Black mothers receive no similar protective benefit. In fact, those with higher education might be at greater risk for pregnancy-related complications. 31

Black infants are twice as likely as White infants to be born significantly underweight. 32

One in six black infants are born preterm in the United States. Premature delivery is three times higher among Black mothers than White mothers and puts children at significant risk for a lifetime of potential health issues and medical expenses. The Institute of Medicine estimated that preterm births cost the United States $26 billion annually in healthcare costs and imposes significant financial and emotional strain on families.

Only 23% of Black patients—compared to 63% of White patients—gave birth in safer-rated hospitals. Hospital quality accounts for nearly 50% of disparity in birth outcomes.

States that expanded Medicare coverage under the Affordable Care Act experienced a 50% decrease in infant mortality. 8

Lack of family insurance puts children at higher risk for mortality and morbidity. 11.7% of Blacks are uninsured compared to 7.6% of Whites. 12

Differential birth outcomes among Black women are a consequence of complex and overlapping social, behavioral, environmental, and genetic risk factors and systemic racism and sexism.

The United Nations called on the United States to “eliminate racial disparities in the field of sexual and reproductive health and standardize the data-collection system on maternal and infant deaths in all states to effectively identify and address the causes of disparities in maternal- and infant-mortality rates.” 33

H.R. 1318 and 5761 and S. 1112, long with the other bills/plans listed above, will address maternal and infant mortality by establishing committees to review pregnancy-related and pregnancy-associated deaths and improve maternal and child health.

H.R. 5977, MOMMA’s Act (not enacted in the 115th congress), would promote hospitals’ adoption of safety best practices for childbirth, postpartum coverage of women under Medicaid and CHIP, and implicit bias training for health care providers.

S. 3363/H.R. 6698, Maternal Care Access and Reducing Emergencies Act (introduced in the 115th congress), supporting implicit bias trainings for healthcare professionals and promoting maternity care medical homes. 25

H.R. 5761, Ending Maternal Mortality Act (introduced in the 115 th congress), requiring the Department of Health and Human Services to outline a plan to reduce maternal mortality by 50% in 10 years. 23

S. 3392, Modernizing Obstetric Medicine Standards (MOMS) Act (introduced in the 115th congress), to promote data collection and adoption of best practices for childbirth safety. 26

S. 3494, the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act, expands health coverage for women post-birth and establishes a series of Medicaid and the Children’s Health Insurance Program (CHIP) requirements and programs related to maternal health. 27

H.R. 6085/S. 3029, the PREEMIE Act (introduced in the 115 th congress, became Public Law No: 115-328), supports federal services and research for preemies (preterm birth babies) and their families (the original PREEMIE Act was passed in 2006 (P.L. 109-450). 28

Senator Elizabeth Warren has also unveiled a plan to link medical providers’ and facilities’ funding to care quality delivered to black women in order to improve maternal health outcomes in this subgroup. 29

These acts have presently not been brought to a vote before the United States Senate or the House, and are currently in committee. H.R. 1318 is in the Committee for Health on Health under the Committee for Energy and Commerce, S. 1112 is in the committee for Health, Education, Labor and Pensions, H.R. 5761 is in the subcommittee for Energy and Commerce.

Over 20,000,000 Black and African American women reside in the United States. African Americans make up approximately 9% of the Connecticut population. VLBW, PTB and IM disproportionately affect black women and infants, and must be addressed through policy reform and evidence-based research, and these initiatives are dependent upon your support.

White House - Clark Kennedy

Signature of 44 th United States president, Barack Obama, on the Affordable Care Act.

Cautionary Notes

Maternal mortality and infant mortality is an issue that affects everyone, and it not only an issue that resides within the Black population. Furthermore, although risk of maternal and infant death is higher among Black women and children than in other races, being Black is not a risk factor in and of itself. Care should be taken to address the complex and interlocking social, behavioral, environmental, and genetic risk factors and systemic racism and sexism that cause differential birth outcomes and affect maternal health among the Black population from a rights-based, intersectional and patient-centered approach that recognizes institutional shortcomings as the major driver of differential health outcomes, not race. As Eichelberger et. al note in “Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology” published in AJPH Perspectives, “Enough is enough. Race is a social construct and the overwhelming statistics we present are attributable to a broken racist system, not a broken group of women. Evidence-based outrage is the objective, logical conclusion.” 34

Next Steps and Conclusions

First, it is imperative that Connecticut voters support legislation that protects diversity and addresses systemic medical racism. Steps need to be taken to increase the availability of demographically-similar OB-GYNs and other professionals within the communities of women they serve, encourage medical professionals to practice culturally sensitive and patient-centered care, include diversity and cultural competence training in medical training curricula to address and undo medical racism, and increase the availability of doula and midwives and low cost pre-, inter-conception and postnatal care, especially among patients who have had previous adverse pregnancy outcomes. It is also important to look to guidelines such as the Council on Patient Safety in Women’s Health Care’s patient safety bundle to address peripartum ethnic and racial disparities for assistance in implementing equitable care and developing best practices. Furthermore, supporting and extending ACA and Medicaid coverage, investing in community-led urban renewal projects specifically concerning access to high quality healthcare, and improving access to social services and evidence-based maternal education results in a decreased rate of infant mortality and improves maternal wellbeing. 35

These objectives can be achieved by passing legislation to support local advocacy organization such as midwifery and doula

Flickr - Nancy Pelosi

Felicia Willems, a member of the MomsRising group, expresses her thanks to the Affordable Care Act at the 2 nd anniversary of the signing of ACA.

programs, Commonsense Childbirth, Black Women Justice Mission, Black Women Health Imperative, Black Mamas Matter, National Birth Equity Collaborative, and SisterSong, and by funding research such as the Maternal Health Task Force at the Harvard T. Chan School of Public Health, The Black Women’s Health survey, and the Perinatal Epidemiological Research Initiative (PERI) are important ways to address Black maternal and child mortality. Furthermore, the Building U.S. Capacity to Review and Prevent Maternal Deaths initiative co-led by the CDC, Merck for Mothers, and the Association of Maternal and Child Health Programs is a new, evidence-based research program to decrease maternal mortality.

Supporting H.R. 1897 (116th), the MOMMA’s Act, and S. 116 (116th), the MOM’s Act and reintroducing similar legislation to H.R. 5761 (115th), the Ending Maternal Mortality Act to establish the National Strategy to Combat Maternal Mortality, S. 3363/H.R. 6698 (115th), the Maternal CARE Act, and S. 3494 (115th), the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act—bills that will address maternal and infant mortality—are the best ways that policymakers and voters can ensure that continued government funding and influence is directed toward addressing differential birth outcomes and maternal mortality among Black mothers and children.

www Ryan Sutherland is a Master of Public Health candidate at the Yale School of Public Health. His research focuses on the intersection of international development and public health, centering on homelessness, mental health, refugee rights, substance use, and maternal and child health. He can be contacted at ryan.sutherland@yale.edu.