Report: Black women more likely to die from pregnancy-related causes

Ten years ago, Tania Alicea had just given birth to a stillborn baby when the nurse midwife who was by her side, Heather Findletar Hines, noticed excessive bleeding.

“She was hemorrhaging to death,” recalled Hines, who now heads Stony Brook University School of Nursing’s midwifery program.

Other nurses and doctors had left the room, so Hines said she called for help, preventing Alicea from becoming yet another Black woman to die from pregnancy-related causes.

“I went through the hemorrhage, but it could have been a lot worse,” said Alicea, who's now 39. “I could have died.”

Sixty women on Long Island and 473 statewide died of pregnancy-related causes between 2010 and 2019, according to the state Department of Health. Between 2015 and 2019, the most recent year state data was available, Black women were four to five times more likely to die than white, Hispanic and Asian women, the data shows.

Experts, and a state Health Department report on maternal mortality released April 13, say most of those deaths were preventable. The root causes of the higher Black maternal mortality rate include discrimination, health care providers ignoring patients’ concerns, lack of follow-up care, and inadequate education of pregnant women of potential complications, experts said.

There are many more women who have severe pregnancy-related consequences, or morbidity, but survive, and they’re also disproportionately Black, said Martine Hackett, director of public health programs at Hofstra University and co-founder of Birth Justice Warriors, which works to reduce maternal and infant mortality numbers. 

“The rule of thumb I’ve seen is that for every maternal death, there are about 100 maternal morbidity cases,” she said.

The higher rates among Black women of certain health conditions, such as obesity and diabetes, are factors in the higher maternal death rate, said Dr. Dawnette Lewis, associate director of ambulatory maternal fetal medicine, and of patient quality and safety, at North Shore University Hospital in Manhasset. Other reasons include lower median incomes and education levels, which are tied to worse health outcomes in general, she said.

But that only partially explains the large gap, she said. Other factors, including conscious and unconscious bias among health care providers, are affecting Black pregnant women’s care, Lewis said.

“What the data shows is that for Black patients, even if they’re college-educated, they have a worse outcome than white women who have a high school or less than a high school education,” she said.

In 2018, 51.2% of women who died of pregnancy-related causes in New York were Black, non-Hispanic, even though only 14.3% of births statewide were to Black women, the state report shows.

Discrimination probable or definite factor

The report from the state Health Department’s maternal mortality review board and maternal mortality and morbidity advisory council found that in 46% of maternal deaths, discrimination was a probable or definite factor.

Among the types of discrimination cited are patients’ concerns of being dismissed because of her race, gender or weight, a belief among women of color that they were disrespected when interacting with health professionals, lack of stable housing due to structural racism, and slower ambulance response in disadvantaged communities.

Alicea, of Mastic, recalled how when she was pregnant in 2009, she drove herself to an emergency room in “excruciating pain.” But she waited in an almost-empty waiting room for two hours until she was finally seen and then rushed into surgery. She had a ruptured left fallopian tube.

She doesn't know for sure why she wasn't examined right away, but believes being Black and on Medicaid could have been factors.

“As Black women, we don’t want to make a scene,” Alicea said, explaining why she didn’t loudly protest the long wait. “We just want to be heard and be seen, but we don’t want to come off as the stereotypical angry Black woman.” 

Alicea later became a nurse midwife and now works with Hines.

Hines said health professionals may have "an unconscious bias" and not realize they are treating Black, poor or other types of patients differently. It can be especially hard to root out unconscious bias because "you don't even know you're doing it," she said. That's one reason why "we need to have more providers — nurses, doctors — who look like their patients, caring for their patients," Hines added.

Pain more likely to be dismissed

Hines said Black women’s pain is more likely to be dismissed, and that can lead to greater risk of potentially dangerous complications.

Multiple studies have shown that Black patients are less likely to receive pain medication than whites or receive lower doses, and that physicians are more likely to underestimate the pain of Black patients.

A 2016 study published in the Proceedings of the National Academies of Sciences found that about half of white medical students surveyed said at least one false belief about Black people's biology was possibly, probably or definitely true. Those with incorrect beliefs were more likely to rate a Black patient's pain as lower than a similar white patient's, and to make less accurate treatment recommendations, researchers found.

The health department report shows New York has a bigger gap between Black and white maternal mortality than the nation as a whole.

Hackett said higher rates of residential racial segregation in New York than in much of the country likely is a reason. Where someone lives has a big effect on their health, including their stress level, she said.

Johanne Morne, deputy director for community health at the state Health Department, said the state has made “tremendous efforts” to address maternal mortality. But, she said, “The issues of health inequity, the issues of continuing forms of racism across our systems of care” contribute to the continuing racial gap.

“For the people providing care, how aware are they themselves, how aware are we ourselves, of some of the stigma and discrimination that we hold, or assumptions we may make of an individual based on our perception of the individual who sits in front of us?” she asked.

Recommendation: Expand Medicaid benefit

One of the report’s key recommendations was to expand Medicaid coverage for postpartum care from 60 days to one year. The new state budget includes that expansion, which will be funded with a combination of federal and state money, health department spokeswoman Samantha Fuld said.

Hackett said extending care “will help a lot.” About a quarter of pregnancy-related deaths in 2018 occurred 43 days to one year after the end of pregnancy, the state report says.

The Centers for Medicare and Medicaid Services began allowing states to expand Medicaid coverage to one year on April 1.

The agency’s administrator, Chiquita Brooks-LaSure, said at a recent health journalism conference in Austin, Texas, that maternal health is “an area of intense focus for me personally and the agency, and across the administration.” The agency is gathering and sharing “best practices” on maternal health from states “so they can learn from each other on what’s working," she said.

Philadelphia-based Pew Charitable Trusts is working on an initiative with nine states and Washington, D.C., in which, within states, different agencies collaborate with each other, and with community-based organizations and health providers, on maternal health, said Maura Dwyer, a senior manager with Pew’s Health Impact Project. Findings on what’s most effective are expected this summer. Listening sessions and interviews with pregnant women ensure their input, Dwyer said.

New York also has held listening sessions with and distributed surveys to pregnant women, said Lewis, who is the physician lead at North Shore for the state’s birth equity improvement project.

Northwell Health, which owns North Shore, last month announced a center for maternal health concentrated especially on reducing Black maternal mortality and morbidity. The center will ramp up efforts to connect pregnant women with resources and, early on, identify patients most at risk for pregnancy-related health complications, to focus even more intensely on them, Lewis said.

In 2020, Suffolk created a maternal mortality task force, now chaired by Hines. Hackett criticized Nassau for not creating a similar task force and for a “lack of attention to this as an issue.”

Nassau Health Commissioner Dr. Lawrence Eisenstein said in a statement that “Black maternal morbidity and mortality is a national issue that the Nassau County Health Department takes very seriously. We continue to engage with the state’s task force, and our health care workforce makes up of some of the most highly qualified experts on the topic to tackle the issue head on.”

Hines said midwives and doulas are a key part of preventing bad outcomes, because they can spend more time with the woman before, during and after pregnancy and spot potential problems that an overextended nurse or doctor might miss.

Alicea said her belief that she was not taken seriously when she was in severe pain 13 years ago helps fuel her current work as a nurse midwife.

“If someone brings something up, I don’t care if it sounds crazy to someone else, I validate the woman’s concerns and I investigate it so they can feel like they’re heard,” she said. “You can identify important things that could potentially save them one day.”

By David Olson

david.olson@newsday.com@DavidOlson11

David Olson covers health care. He has worked at Newsday since 2015 and previously covered immigration, multicultural issues and religion at The Press-Enterprise in Southern California.