How hospitals can reduce maternal mortality–even in a pandemic

In recent years, extreme disparities in maternal mortality in the US have been brought to light. In 2018, the rate of maternal mortality in the US was 17.4 maternal deaths per 100,000 live births, a much higher rate than other wealthy developed countries. Yet Black women are twice as likely to die giving birth as white women.

Black women are more likely to have chronic conditions that increase the likelihood of maternal mortality and more likely to lack access to post-natal care. But even healthy, educated, wealthy black women have dangerous complications and die in childbirth, often because providers do not listen to their concerns or take their symptoms seriously.

Hospital quality and segregation

The quality of care at hospitals and patients’ ability to choose at which hospital they give birth may have a large effect on maternal outcomes. A recent study in Health Affairs, led by Dr. Teresa Janevic, assistant professor at the Icahn School of Medicine at Mount Sinai, examined the relationship between residential segregation, delivery hospital quality, and maternal mortality.

Janevic and colleagues found that neighborhood racial and socioeconomic makeup strongly impacted maternal mortality. Women who lived in zip codes with the highest concentration of poor Black residents had a life-threatening condition or emergency procedure during childbirth 4 out of every 100 deliveries. Women who lived in neighborhoods with the lowest concentration of poor Black residents only had a serious complication during childbirth in 1.7 out of every 100 deliveries.

Women in poorer communities of color are more likely to lack access to care or have a chronic condition, but that’s not at all the whole story behind the maternal outcomes disparity. According to Janevic et al., 35 percent of the difference in outcomes is due to care quality issues at the delivery hospitals. Hospitals serving poorer communities often have fewer resources and may not be as equipped to handle emergencies during childbirth, but residents of these communities rarely have the choice to give birth at higher-quality hospitals. The study found that about one third of women who lived in mostly Black neighborhoods delivered in hospitals serving mostly Black communities, while only 1% of women from mostly white neighborhoods delivered in hospitals located in predominantly Black neighborhoods.

To help solve this problem, we need a massive improvement in the quality of maternity care at all hospitals in the U.S. — but at the same time, we need to look into the housing policies that perpetuate highly racially and economically segregated communities.

Giving birth during Covid-19

Advocates for maternal health–and specifically the health of Black mothers–have sounded the alarm about the potential for worse maternal outcomes during Covid-19. They fear that the pandemic will lead to more deaths of Black women during childbirth, not necessarily because of the health effects of the virus, but because of the effects on hospitals.

“Any emergency [or] any change from the way we do things impacts women of color and poor women disproportionate to other women,” said Dr. Kameelah Phillips, obstetrician and gynecologist at Calla Women’s Health in Manhattan, in The Boston Globe.

Specifically, policies that bar partners, doulas, and other visitors from labor and delivery rooms are concerning. Often, it is the presence of these advocates that listen to mothers when they are in labor and take lifesaving actions when something seems amiss.

“With doulas not being allowed in, it really presents a problem for folks that were already marginalized if that was a support system that they were seeking,” said Jamarah Amani, Executive Director of the Southern Birth Justice Network, in Roll Call.

Another concern is that hospitals will push women to induce labor or have a cesarean section when it is not necessary, so they can get patients out of the hospital faster and reduce their potential exposure to Covid-19. Having a c-section is associated with a higher rate of complications during birth, which can be life-threatening if not monitored carefully. Activists have already heard stories about this happening.

While we remain vigilant about Covid-19, we should not throw out policies that exist to help mothers advocate for themselves and give birth safely– especially because there is no evidence that banning family members from the delivery room is helpful to mothers.

In fact, the pandemic makes policies to protect mothers more urgent, including:

• Extending Medicaid coverage for new mothers beyond just six weeks after birth;
• Increasing access to prenatal and postnatal care;
• Programs to improve hospital quality and train all providers to prepare for complications;
• Programs and reimbursement methods to reduce unnecessary inductions and c-sections;
• Provide coverage for midwives through Medicaid, so all women have access to non-invasive birth techniques and someone to advocate for them; and
• Expand training in shared decision making for all providers so that the treatment preferences of women are taken into account and not ignored.