A new study published Monday in The Lancet found that Black women who live in areas with greater access to care still face a "disproportionately" high maternal mortality risk compared with white women living in underserved areas.
For the study, which was conducted by Surgo Health, researchers looked at 13 million live births and maternal deaths from Black and white women ages 10 to 44 between 2014 and 2018.
To measure levels of vulnerability and maternal health, researchers created a "maternal vulnerability index" (MVI), which assigned a score of zero to 100 to each state in the country.
The researchers based the index on 43 determinants of maternal health, which were grouped into six themes — reproductive healthcare, physical health, mental health and substance abuse, general healthcare, socioeconomic determinants, and physical environment.
In addition, they calculated racial disparities to identify the areas that have the highest risk levels. Then, they estimated the association between race, vulnerability and maternal death, low birth weight, and preterm birth.
Each of the six themes received individual scores. The researchers also calculated an overall score from zero to 100. A lower score suggests that a patient is less vulnerable to adverse maternal health outcomes.
The counties with a high proportion of white women had an overall median score of 36, while the counties with a high proportion of Black women had a median score of 55.
While people of color are known to face a higher risk of dying during or after childbirth, this study is the first to analyze this disparity through a geographic lens, according to a news release from Surgo Health.
"This is the first time anyone has quantified disparities in exposure to determinants of adverse health across the United States specifically for maternal health outcomes, nationwide, at a granular geographic level--and considered how multi-dimensional exposure contributes to the well-established racial disparities in maternal health outcomes," said Sema Sgaier, CEO of Surgo Health and a co-author of the study.
And while the study found an increased risk among black women generally, the researchers also noted that black women who live in the least vulnerable areas were more likely to die, experience preterm birth, or have a baby with low birth weight than white women living in the most vulnerable areas.
For instance, Black women in the least vulnerable areas are 44% more likely to have a newborn with low birth weight than white women in the most vulnerable areas. According to the news release, the gap between the two groups cannot be fully explained by factors included in the MVI.
"The findings suggest the root causes of racial inequities are complex, and that in addition to factors captured in our index, other strong social and societal factors are at play. These might include unconscious bias on the part of providers, attitudes, and beliefs among patients, and hyperlocal disparities in access to care. We need to dig deeper to determine what forces are causing these shocking disparities in outcomes," Sgaier said. (González, Axios, 4/5; Valerio et al., The Lancet, 4/3; Gans, The Hill, 4/5; Surgo Health news release, 4/3)
By Sophia Duke-Mosier and Julia De Georgeo
While the findings from this study are troubling, they are not groundbreaking. In 2019, an article in the American Journal of Public Health discussed the root causes of maternal and infant health disparities.
"The legacies of slavery today are seen in structural racism that has resulted in disproportionate maternal and infant death among African Americans," the authors wrote. "The deep roots of these patterns of disparity in maternal and infant health lie with the commodification of enslaved Black women's childbearing and physicians' investment in serving the interests of slaveowners."
"Even certain medical specializations, such as obstetrics and gynecology, owe a debt to enslaved women who became experimental subjects in the development of the field," they noted. In particular, the role of racism and the legacies of slavery can be seen in these disparate outcomes.
Many organizations want to address this issue — but they don't always know how to address it correctly. Even when organizations invest in maternal health, many take "a colorblind approach" that does not provide support to the most at-risk racial groups.
Several issues are driving maternal health inequity in the United States, including structural racism and insufficient efforts to combat unconscious bias and racism at the interpersonal level. While structural racism plays a significant role, organizations often contribute to disparities in maternal mortality by allowing false medical beliefs and biases to persist.
Ultimately, we cannot equate race with class and assume the maternal health disparities are issues of resources.
To effectively address the disparities driving maternal mortality, organizations need to:
1. Ensure evidence-based care standards are embedded into frontline practice
All organizations should ensure their obstetrics patients receive the highest quality, evidence-based care throughout their delivery. To do this, organizations must ensure that staff are aware of best practices and can easily follow them.
2. Track performance and identify care gaps
Once organizations have no-regrets safety protocols in place, maternal health champions should institute ongoing feedback mechanisms to monitor adherence to care standards and identify other gaps in maternal care.
3. Tap into system- and community-based resources to extend impact
With this intel in hand, clinical leaders should make targeted investments by tapping into resources outside their traditional purview: across the system and in the community.
To successfully address these disparities, clinicians must recognize and address their implicit biases and organizations must structurally embed strategies to support and advocate for Black women's needs. (Owens/Fett, American Journal of Public Health, 10/2019)
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