COVID-19 amplifies racial disparities in maternal health

Advocates, lawmakers are working to make changes to curb maternal deaths

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Posted May 14, 2020 at 5:00am

Days before her death, Amber Isaac tweeted about her negative experiences receiving pregnancy care at her local hospital in the Bronx. 

Isaac, a 26-year-old black woman pregnant with her first child, raised concerns about "incompetent doctors." She worried about her low platelet count and felt her concerns were not being heard at Montefiore Medical Center, where her mother Renita Isaac has worked for 25 years, her partner Bruce McIntyre told CQ Roll Call.

“Amber was facing neglect from the health care system. Even when she was vocally expressing her concerns, she was still not given fair treatment,” he said. “Her platelet levels were so low that her blood was water-like.”

She died shortly after an emergency cesarean section in late April, a month before her due date, in the midst of the COVID-19 pandemic. 

“Knowing that her platelet levels were that low, they still wanted to operate,” he said. “They let us down.”

Maternal mortality, or the death of a woman up to a year following the end of a pregnancy, has hit African Americans especially hard for decades, and experts worry the current COVID-19 pandemic will exacerbate racial disparities. Centers for Disease Control and Prevention data illustrate that COVID-19 death rates among black and Latino people are substantially higher than those of white or Asian individuals.

McIntyre with his newborn baby.

In Isaac's case, hospital officials said they did their best. 

“Ninety-four percent of our deliveries are minority mothers, and Montefiore’s maternal mortality rate of 0.01% is lower than both New York City and national averages. Any maternal death is a tragedy. Our hearts go out to Ms. Isaac’s family, especially to her mother, our longtime colleague," said a Montefiore Medical Center spokesperson.

The United States already lags behind other wealthy nations in maternal health, with 17.4 deaths per 100,000 live births. That number is 2.5 to 3.1 times higher for black women, CDC data released earlier this year show.

The overall number is down from 26.4 maternal deaths per 100,000 in 2015, but is far above the 9.2 deaths per 100,000 in the United Kingdom, 9 per 100,000 in Germany, or 3.8 per 100,000 in Finland.

“What we’re witnessing during this time of pandemic is not the first time we have seen communities of color disproportionately affected by a crisis,” said Michelle Williams, dean of the faculty at the Harvard T.H. Chan School of Public Health, during a House Homeland Security panel discussion. “Here we are with COVID-19 and we are still seeing a disproportionate burden of morbidity and mortality on black and brown communities.”

Angela Aina, interim executive director for the Black Mamas Matter Alliance, a coalition that advocates for black maternal health, said that with many hospital systems overwhelmed right now, many facilities have changed labor delivery policies including whether a doula or family member can accompany a woman. 

“The pandemic came and just made these issues and a lot more, much, much more worse,” she said. “From a consumer perspective, it has significantly increased people’s wants and needs for birthing centers and home births.”

But some women have been searching for a midwife for weeks or months, said Jamarah Amani, a Florida-based community midwife and executive director of the Southern Birth Justice Network.

She said the shift to telehealth for prenatal care can also increase risks.

“That is challenging because things can get missed. If we are talking about black women who are already at higher risk for complications and not being able to be seen in person for several weeks, there is a higher likelihood that something would be missed,” Amani said.

Risky situations

Experts point to several factors that could increase complications now or later.

Amani said women tell her they are being pressured into situations that could pose health risks. 

“What I'm hearing is that people are being pushed into inductions and C-sections because they don't want people sitting in hospitals for long periods of time,” said Amani. “We know you’re more likely to have a C-section if you’re induced. We know that if you have a C-section, you’re more likely to have complications, and your baby is more likely to have complications. So that’s scary.”

The refusal of hospitals, often overwhelmed with treating COVID-19 patients, to permit doulas to accompany women into delivery in an effort to limit medical workers there also may be an issue, said Amani.

“With doulas not being allowed in, it really presents a problem for folks that were already marginalized if that was a support system that they were seeking,” especially during the pandemic, she said.

She has also seen an increase in breeched babies, due to decreased movement of women during the pandemic.

The impacts of the pandemic on different socioeconomic groups could contribute to rising maternal mortality rates, Aina of BMMA emphasized.

“The other thing that is not getting a lot of attention during the COVID-19 pandemic is the fact that, again, black and brown women are also the ones who are working in grocery stores and the ones that are still being called in to clean houses and things of that nature. Quite a number of them are still pregnant or have recently given birth or are in that postpartum period,” she said.

Neel Shah, a Harvard Medical School assistant professor of obstetrics, gynecology and reproductive biology, said every week he answers calls from pregnant women with COVID-19 symptoms and encourages them to isolate themselves, although isolation brings its own risks.

“Isolating everyone takes all of the existing inequities in society and it throws them into a pressure cooker. We’re seeing the impact on pregnant people prenatally, as they're in labor, and as they’re at home caring for their infants without very much support,” he said.  “People who are being disproportionately impacted by this virus are the very people that our health system has failed to adequately care for historically.”

Joia Crear-Perry, an OB-GYN and founder and president of the National Birth Equity Collaborative, said the worries of isolated women may lead to increased postpartum depression and anxiety, which she said was already underdiagnosed before the pandemic.

“People are grieving the loss of what they perceived their birth experience would be and in that grief they are traumatized, and we really don't have a structure to help them walk through this,” she said during a recent panel discussion.

Women who had imagined family members being present for the delivery or coming to help after childbirth are realizing that is no longer possible, she said.

Policy pushes

Advocates and lawmakers are working to make changes to curb maternal deaths. 

McIntyre is seeking to use his grief to curb racial disparities in maternal care and plans to speak with multiple senators next week. Lawmakers in both parties expressed concern this year about maternal mortality before the pandemic struck. 

“This is an ongoing issue and of course it is worse because of the risk of COVID-19,” said Sen. Debbie Stabenow, D-Mich. “But even without COVID-19, we have more women of color who are losing their lives during childbirth or infant mortality for children that don’t make it through the first year of their life.”

Stabenow said there is a growing need to extend Medicaid coverage for pregnant women and new mothers, a policy that also gained support among House Democrats. 

Republicans like Rep. Jaime Herrera Beutler of Washington are also pushing to address maternal mortality.

In November, the Energy and Commerce Committee approved two bipartisan bills to address maternal mortality by voice vote, but they have not seen floor action. One would authorize coverage under Medicaid and the Children's Health Insurance Program for one year postpartum, up from the current 60 days, and boost funding for states that opt for that expansion. The other would authorize new programs that would address maternal health.

Crear-Perry said the Medicaid extension would be a “win for both parties and moms.”

Coverage for midwives is another issue. Amani, the midwife, says that while her state, Florida, covers out-of-hospital births through Medicaid, this isn’t the case in much of the country.

The BMMA coalition is advocating for two bills to increase the perinatal workforce. They are part of a broader bill package known as the Momnibus, which is supported by 93 groups including the American College of Obstetricians and Gynecologists. 

The first bill would authorize recruitment and retention grants to encourage the growth and diversification of the perinatal workforce, including midwives, doulas and physician assistants.

The second bill would authorize the Department of Health and Human Services to award grants to improve maternal outcomes and reduce bias and discrimination in maternal care.

“It's really important that this be a moment like we’ve seen with other moments of tragedy and trial in our country where we emerge from those times with more conviction as a society to create laws and policies that reflect our common core values,” said Sen. Cory Booker, D-N.J., who supports legislation to extend postpartum Medicaid coverage.