July 1, 2020

The coronavirus epidemic has exacerbated health disparities across the board, and it may have the same impact on maternal health. To help maternal health champions create targeted strategies to help vulnerable patient populations, we outline below the current disparities in maternal health, as well as three factors stemming from the Covid-19 crisis that may make the situation even more severe.

The US maternal health crisis

Long before Covid-19, the United States was already struggling with a different public health crisis: dismal maternal health outcomes. From 2000 to 2017, the global maternal mortality ratio decreased by 38%, while the U.S. ratio increased by 58%. According to CDC data, there are 17.4 maternal deaths per 100,000 live births in the United States—and 60% are preventable. And even more prevalent than pregnancy-related mortalities, which increased at a rate of 62% between 1993 and 2014, are severe maternal morbidities, which increased at a rate of 190% over that same timeframe.

While this nationwide crisis affects every community, Black and Native American patients fare the worst. The mortality rate for Black patients is 3.3 times the rate for white patients. For Native American patients, it's 2.5 times the rate. Transgender and gender non-conforming patients are also particularly at risk, though less research has been conducted on these populations.

How will Covid-19 affect maternal health equity?

Covid-19 is poised to make a bad situation even worse. Health care leaders can expect to see maternal health outcomes worsen—especially for Black and Native American patients—due to three factors:

  1. Exacerbated social determinants of health across marginalized communities

    The unemployment rate is higher than at any other point since the Great Depression–particularly for women of color. As of May, Hispanic women experienced an unemployment rate of 19.5%, compared with 17.2% for Black women and 11.9% for white women. A sudden loss of income can lead to housing instability and food insecurity. These social needs are both risk factors for increased incidences of pregnancy-related mortality and morbidities, including gestational diabetes mellitus, hypertension, and hemorrhaging.

    Moreover, Black people who remain employed are more likely to hold jobs deemed "essential," leading to a significantly higher risk of exposure to the new coronavirus. And although pregnant people are considered high-risk if they contract the virus, many cannot stop working or work remotely.

  2. Reduced use of, and access to, pre- and post-natal care

    Even as providers open their doors again, pregnant patients remain fearful of Covid-19 exposure and face new financial pressures. Some may consider skipping appointments, worsening existing disparities in pre- and post-natal care utilization. Even before Covid-19, only 75% of Black pregnant patients and 79% of Hispanic pregnant patients initiated care during the first trimester, compared with approximately 89% of white pregnant patients.

    To address exposure concerns, OB programs have drastically changed the way they provide care, including increased virtual visits. However, telehealth is less feasible for patients in rural areas, tribal lands, and low-income communities with limited access to internet, cell service, and smartphones. In addition, some patients with physical or cognitive disabilities may face challenges when accessing telehealth services, despite accessibility mandates under the Americans with Disabilities Act. And providers may struggle to track higher-risk pregnancies as prenatal checkups become virtual.

  3. Limited access to support systems

    Social distancing requirements can also limit pregnant patients' access to their social support networks, networks that play a significant protective role against post-partum depression. Not only do OB patients rely on the emotional and physical labor of their family and friends to overcome major obstacles to their recovery—but social support is also important during delivery. Pregnant patients who receive continuous labor support are less likely to require intervention or pain medication, and more likely to report satisfaction with their birth experience. Additionally, support networks can help advocate on the behalf of the patient and prevent incidents of bias and mistreatment. However, amid a Covid-19 surge, many providers decided to limit the number of visitors allowed in the delivery room to prevent the spread of Covid-19, which can lead to worsened outcomes for Black patients in particular. One study found that more than 10% of Black mothers reported that they were treated unfairly during their hospital stay because of their race and ethnicity.

Toward a more equitable future

Now, more than ever, provider organizations must engineer strategies that provide explicit, targeted support for their most vulnerable patients. To learn more about maternal health inequity in the United States, review our cheat sheet, Snapshot of Maternal Health Inequity. Stay tuned for additional guidance on the root causes of these disparities, as well as best practices to advance maternal health equity.

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