Why It Matters
Too many women are harmed or die during childbirth in the US. The racial inequities are particularly troubling.
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How Can You Address Maternal Mortality Inequities?

By IHI Multimedia Team | Thursday, November 1, 2018

Nov 1 blog post

The medical community comprises committed professionals who want the best outcomes and experiences for those we serve. However, our technical expertise and good intentions can fall well short of that mark for birthing women, particularly women of color.

This message comes through loud and clear in a recent publication, Battling Over Birth: Black Women & The Maternal Health Care Crisis in California, assembled by Black Women Birthing Justice. It is a collection of the experiences of 100 black women who had a child between 2011 and 2015.

In the book, one woman recalled: 

When I was pushing my son out . . . I was like, “I kind of want to be on my knees. Like I would feel better.” And they were just like, “No, we have to do it this way or the baby is not [coming out].” I wonder if his collar bone would be broken? It would’ve gone in a way that felt comfortable, you know? 

Another woman recounted:

They started the Pitocin . . . That did not do it. I didn’t dilate anymore. But now the interventions have started. Now, because I’ve had the Pitocin, now we’ve got to do this, and we’ve got to do that. And it was somewhere along this process where I lost my voice. I lost what I wanted and what we had decided her introduction to this world would be. So, I ended up getting an epidural . . . I had to sign a waiver right then and there, that if I’m paralyzed that I’m not going to sue y’all. And I was like you’ve got to be kidding me. Is this really happening to me?

One woman shared:

The whole time it was like, “No. No. Why are you touching me? What is your name? Could you introduce yourself before you start feeling me up? What are you putting in my veins? Can you tell me what you’re doing? No. No I don’t want that. Okay. Why are there six people in this room, can you just get out?” I was just trying to give birth and you can’t even respect that. It’s ridiculous!

Some of the accounts in this report are positive, but many more women describe feeling disempowered and disrespected. They recall fear, coercion, and medical interventions without consent. All women are vulnerable to negative experiences during the birthing journey, but persons of color are disproportionately at risk. These are stories of harm and are a product of systems, processes, and beliefs that need to be reexamined and realigned.

Disturbing Trends

Just as patient engagement and patient safety are linked, birth experience and birth outcomes are intertwined. This has powerful implications when it comes to maternal mortality.

You’ve probably seen the alarming headlines:

While most births in the US result in healthy moms and babies, there is reason for profound concern. Over the past decade, maternal health experts and advocates have tried to raise the alarm about the dramatic increase in maternal mortality and morbidity. Before 1990, the US had declining mortality rates that were comparable to many European nations. Then, between 1990 and 2015, the rate rose approximately 250 percent to 26.4 deaths per 100,000 live births, nearly three times the rate for women in the UK and six times the rate in Sweden.

The racial inequities are particularly shameful. Black women in the US are nearly three times more likely to suffer a pregnancy-related death than white women. In New York City, black women can be up to 12 times as likely to die from pregnancy-related conditions. And these racial inequities persist after controlling for factors like education, poverty, and income. The underlying factors that contribute to these poor outcomes and inequities have been associated with a broad range of both health care and non-health care factors.

Bundles Are Not Enough

The CDC lists cardiovascular disease, hemorrhage, and embolism amongst the leading causes of maternal mortality that occur during the birth process. Evidence suggests that many of these adverse events and the associated deaths and injuries could be reduced with reliable and timely implementation of safety protocols. For example, a recent study demonstrated a 20 percent reduction in severe maternal morbidity from hemorrhage between 2014 and 2016 in the state of California. The authors point to multipronged intervention efforts, including adoption of the American College of Obstetricians and Gynecologists hemorrhage safety bundle. These efforts have promising implications as the bundle implementation was strongly associated with improved outcomes. 

Assuring reliable identification and response to obstetric emergencies deserves our improvement energy. Yet, as these efforts in California have led to a decline in severe maternal morbidity, inequities between black and white women persist. Additional approaches are needed.

Partner with Women for Improvement

With our professional privilege comes power, responsibility, and moral obligation. If we remain deaf to the voices of those we serve, harmful birth experiences will persist. We can choose to prioritize the experiences of pregnant women alongside clinical safety metrics. In doing so, we bring humility to our improvement agenda. Let’s put the voices of women of color first and allow them to set the path forward.

IHI is embarking on a series of initiatives to improve maternal infant health experience, outcomes, and associated racial inequities . If you or your organization are interested in further exploring these issues, please reach out with your thoughts and interest in the comments section below.

Trissa Torres, MD, MSPH, FACPM, is Chief Operations and North America Programs Officer, Institute for Healthcare Improvement (IHI). Quin Bottom-Johnson is an IHI Project Coordinator.

Editor’s note: Learn more about IHI’s work to reduce inequities in maternal outcomes and deliver respectful maternal care to all women at a Special Interest Breakfast at IHI National Forum (SIB10: Reducing Disparities in Maternal Mortality: IHI’s Current Efforts in the US) on Wednesday, December 12th from 7:00-7:45 AM.

You may also be interested in:

Pro Publica – Why Giving Birth Is Safer in Britain Than in the US

Maternal & Child Health and Equity are featured tracks at this year's IHI National Forum.

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