Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths

Abstract

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance.

Key Points

• Structural racism contributes to maternal deaths.

• Coordination of postpartum care is critically important.

• U.S. health care system is complex and not patient friendly.

Keywords

maternal mortality - structural racism - health care access - racial disparities

Publikationsverlauf

Eingereicht: 20. Januar 2022

Angenommen: 24. April 2023

Artikel online veröffentlicht:
06. Juni 2023

• References

• 1 Mensah GA, Wei GS, Sorlie PD. et al. Decline in cardiovascular mortality: possible causes and implications. Circ Res 2017; 120 (02) 366-380
• 2 Bainbridge D, Martin J, Arango M, Cheng D. Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012; 380 (9847): 1075-1081
• 3 Cannon JW, Holena DN, Geng Z. et al. Comprehensive analysis of combat casualty outcomes in US service members from the beginning of World War II to the end of Operation Enduring Freedom. J Trauma Acute Care Surg 2020; 89 (2S, suppl 2): S8-S15
• 4 Chazotte C, D'Alton ME. Maternal mortality in New York–looking back, looking forward. Semin Perinatol 2016; 40 (02) 132-135
• 5 Badreldin N, Grobman WA, Yee LM. Racial disparities in postpartum pain management. Obstet Gynecol 2019; 134 (06) 1147-1153
• 6 Johnson JD, Asiodu IV, McKenzie CP. et al. Racial and ethnic inequities in postpartum pain evaluation and management. Obstet Gynecol 2019; 134 (06) 1155-1162
• 7 Eichelberger KY, Alson JG, Doll KM. Should race be used as a variable in research on preterm birth?. AMA J Ethics 2018; 20 (01) 296-302
• 8 Howell EA, Janevic T, Blum J. et al. Double disadvantage in delivery hospital for Black and Hispanic women and high-risk infants. Matern Child Health J 2020; 24 (06) 687-693
• 9 Shah LM, Varma B, Nasir K. et al. Reducing disparities in adverse pregnancy outcomes in the United States. Am Heart J 2021; 242: 92-102
• 10 Geronimus AT. Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weathering hypothesis. Soc Sci Med 1996; 42 (04) 589-597
• 11 Pardo C, Atallah F, Mincer S, Minkoff H. Reducing perinatal health disparities by placing equity at the heart of performance improvement. Obstet Gynecol 2021; 137 (03) 481-485
• 12 Guarnieri M, Balmes JR. Outdoor air pollution and asthma. Lancet 2014; 383 (9928): 1581-1592
• 13 Bell ML, Ebisu K. Environmental inequality in exposures to airborne particulate matter components in the United States. Environ Health Perspect 2012; 120 (12) 1699-1704
• 14 Bottalico DM, Johnson GD, Chazotte C, Karkowsky CE. Maternal anemia associated with walkable distance to healthy food sources in Bronx, New York. Spat Spatio-Temporal Epidemiol 2015; 12: 19-25
• 15 Katznelson I. When Affirmative Action Was White. New York, NY: W. W. Norton & Co.; 2005: 140
• 16 Ferre-Sadurni L. What happens when Black people search for suburban homes. New York Times; . Accessed November 18, 2019 at: https://www.nytimes.com/2019/11/18/nyregion/fair-housing-discrimination-long-island.html
• 17 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
• 18 Yeats WB. The Second Coming. Accessed November 14, 2021 at: https://www.poetryfoundation.org/poems/43290/the-second-coming