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African-American, Native American and Alaska Native women die of pregnancy-related causes at a rate about three times higher than those of white women, the Centers for Disease Control and Prevention reported on Tuesday.
The racial disparity has persisted, even grown, for years despite frequent calls to improve access to medical care for women of color. Sixty percent of all pregnancy-related deaths can be prevented with better health care, communication and support, as well as access to stable housing and transportation, the researchers concluded.
“The bottom line is that too many women are dying largely preventable deaths associated with their pregnancy,” said Dr. Anne Schuchat, principal deputy director of the C.D.C.
“We have the means to identify and close gaps in the care they receive,” she added. While not all of the deaths can be prevented, “we can and should do more.”
Maternal health among black women already has emerged as an issue in the 2020 presidential campaign. Senator Kamala Harris, Democrat of California, and Senator Elizabeth Warren, Democrat of Massachusetts, have both raised the glaring racial discrepancies in maternal outcomes on the campaign trail.
“Everyone should be outraged this is happening in America,” Ms. Harris recently said on Twitter. She blamed the deaths on racial bias in the health system.
The American College of Obstetricians and Gynecologists, which was not involved in the C.D.C. report, recently acknowledged that racial bias within the health care system is contributing to the disproportionate number of pregnancy-related deaths among minority women.
“We are missing opportunities to identify risk factors prior to pregnancy, and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women,” Dr. Lisa Hollier, immediate past president of the American College of Obstetricians and Gynecologists, said in a statement.
The United States has an abysmal record on maternal health, compared with other high-income countries. Even as maternal death rates fell by more than one-third from 2000 to 2015 across the world, outcomes for American mothers worsened, according to Unicef.
The C.D.C. examined pregnancy-related deaths in the United States from 2011 to 2015, and also reviewed more detailed data from 2013 to 2017 provided by maternal mortality review committees in 13 states.
The agency found that black women were 3.3 times more likely than white women to suffer a pregnancy-related death; Native American and Alaska Native women were 2.5 times more likely to die than white women.
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Obstetric emergencies involving complications like severe bleeding caused most of the deaths at delivery. Disorders related to high blood pressure accounted for most deaths from the day of delivery through the sixth day postpartum.
A leading cause of pregnancy-related deaths was cardiovascular disease, which is not typically associated with young pregnant women.
Heart disease and strokes caused more than one-third of pregnancy-related deaths, the C.D.C. found. Cerebrovascular events, such as strokes, were the most common cause of death during the first 42 days after the delivery.
Cardiac disease, which disproportionately affects black women, may be present in a woman before pregnancy, but it also may appear during pregnancy. If heart disease goes undetected, it may become acute after the baby is born.
Indeed, a greater proportion of the deaths among black women occurred in the later postpartum period, between seven weeks and a year after the delivery, compared with white women, the C.D.C. found.
“When we look at the proportion of pregnancy related deaths by cause, the proportion due to cardiomyopathy has been increasing,” said Dr. Hollier, referring to a condition of weakened heart muscle. “It can occur in all women, but it is more common among black women.”
African-American women have higher rates of obesity and are more often overweight, which can increase the potential for problems during pregnancy and beyond. Yet obesity has risen among all Americans, noted Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative.
“That’s not the driver,” he said, referring to higher mortality among black women. “It requires a different level of awareness and attention, but you shouldn’t die of obesity. You shouldn’t die of hypertension.”
One of the surprises in the new report was how often death occurred after childbirth. More than half of pregnancy-related deaths occurred after the day of the delivery, and the heightened risk to a new mother persisted for as long as a year.
“Health issues of pregnancy don’t just end when the baby comes out, and that hasn’t gotten the attention it should,” said Lynn P. Freedman, director of the maternal death and disability program at Columbia University’s Mailman School of Public Health.
New mothers should seek medical care if they develop symptoms such as chest pain, shortness of breath, heavy bleeding or a slow-healing C-section incision. Redness or swelling on the leg could indicate a blood clot, while a fever can be a sign of infection; headaches are another important warning sign that should not be ignored.
The physiological changes brought on by pregnancy can exacerbate underlying health problems and may increase the risk of developing other ailments after pregnancy, Dr. Hollier said.
Women who have gestational diabetes during pregnancy, for example, will face an increased risk of developing cardiovascular disease later in life.
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Overall, maternal deaths are rare: Some 700 deaths related to pregnancy occur each year, while there are 3.8 million births.
While 13 white women die for every 100,000 live births, the rate for Hispanic women is even lower: 11.4.
The figure for African-American women is 42.8 for every 100,000 live births, and for Native American/Alaska Native women, 32.5.
Age also increases the risk. Mothers aged 40 and over have a pregnancy-related death rate of 76.5 per 100,000 live births.
Concern about high pregnancy-related death rates among black women has already resulted in some changes in policy.
A new federal law, the Preventing Maternal Deaths Act, provides grants to states that investigate pregnancy-related deaths, including deaths occurring up to a year after the birth. The American College of Obstetricians and Gynecologists this week released new guidelines for treating heart disease during pregnancy.
The standard postpartum doctor visit for new mothers is typically scheduled for six weeks after delivery. The college now says that postpartum care should be an ongoing process, rather than a single appointment, and that services and support should be tailored to the woman’s individual needs.
Women should have some contact with a care provider within the first three weeks postpartum, and a comprehensive visit no later than 12 weeks after birth. Women qualified for Medicaid, the government health care program for low-income people, because they were pregnant often lose coverage sixty days after giving birth.
The C.D.C. found that 18.5 percent of pregnancy-related deaths occurred one to six days postpartum, and that 21.4 percent of these deaths occurred between the seventh and 42nd days after delivery.
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