Dr. Tonya Adkins, M.D., is a certified obstetrics and gynecology specialist for the nonprofit HealthWorks for Northern Virginia, but despite her credentials and expertise as well as good health insurance, she still almost died in the process of childbirth, a danger that remains all too possible in the U.S., especially for black women like her.
About 700 women die annually in the U.S. as a result of complications related to pregnancy or delivery, according to the U.S. Centers for Disease Control and Prevention.
That means the U.S. has one of the highest maternal mortality rates in the developed world, and it is among the few nations to see its rate worsen in the past 25 years with reported pregnancy-related deaths jumping from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths in 2015.
The risk of maternal mortality, defined by the CDC as death during or within one year of the end of a pregnancy, is particularly concerning for black women, who are about three times more likely to die from pregnancy-related causes than other women.
According to the CDC, black women experienced 42.8 deaths per 100,000 live births from 2011 to 2015, compared to 32.5 deaths for American Indian and Alaskan Native women, 14.2 deaths for Asian and Pacific Islander women, 13 deaths for white women, and 11.4 deaths for Hispanic women.
“There are multiple causes of this much increased maternal morbidity and mortality, and it’s not one solution to the problem,” Adkins said. “There are multiple solutions, but until we deal with the biggest one, which I think is racism in healthcare, we won’t be able to solve this problem.”
Eradicating maternal mortality in general and the disparities in who gets most affected by that issue in particular is a daunting task.
Fortunately, there appears to be no shortage of people willing to tackle it, judging by the crowd that filled the Northern Virginia Family Services’ office conference room in Oakton this past July.
About two dozen healthcare providers and community advocates, including Adkins, joined the regional nonprofit for a roundtable on maternal health organized by Sen. Tim Kaine (D-Va.) to learn more about the challenges facing patients and workers and to discuss possible solutions.
A member of the Senate Health, Education, Labor, and Pensions Committee, Kaine is one of 18 cosponsors of the Maternal Care Access and Reducing Emergencies Act introduced by Sen. Kamala Harris (D-Calif.) on Aug. 22, 2018 to address pregnancy-related disease and death.
Now in the Senate finance committee, the Maternal CARE Act calls for the U.S. Department of Health and Human Services to establish a grant program to support implicit bias training for health professionals with a priority for those in obstetrics and gynecology.
The act also requires the Centers for Medicare and Medicaid Services, in conjunction with the Health Resources and Services Administration, to award grants to up to 10 states for pregnancy medical home programs that are shown to reduce adverse outcomes and racial disparities with a priority for pregnant women and postpartum mothers enrolled in Medicaid.
If adopted, the act would task the National Academy of Medicine with studying and making recommendations on how medical schools can incorporate bias recognition into clinical skills testing for students.
The Maternal CARE Act was inspired partly by a pregnancy medical home program launched by North Carolina in 2011 that provides financial incentives, staff support, and other resources to maternity care providers as they work to improve the quality of care and health outcomes.
The North Carolina Department of Health and Human Services has credited the initiative with lowering the pregnancy-related mortality rate for black women, which went from five times that of white women in 2004 to almost even in 2013, according to the Maternal CARE Act.
In comparison, the pregnancy-related mortality rate for Virginia went from about 80 deaths for black women and 38 for white women per 100,000 live births in 2004 to 60 for black women and 33 for white in 2013, the Virginia Office of the Chief Medical Examiner reported in 2016.
From 1999, when the state began reporting these deaths, to 2014, black women in Virginia died from pregnancy-related causes at more than twice the rate of their white counterparts with 79.3 deaths for every 100,000 births, the Office of the Chief Medical Examiner found in its annual report released this past April.
While on the Senate HELP Committee, Kaine has examined infant mortality issues, and the Virginia chief medical examiner data spurred the senator to do the same for maternal mortality.
“I knew if I could get a great group of experts around the table, people who work in the trenches…they would give me some good ideas about things we could do at the federal level to help,” Kaine said.
July’s roundtable discussion in Oakton as well as a similar forum that Kaine assembled in Hampton on July 12 focused on the difficulties that women face in accessing quality prenatal and postpartum care, including transportation and language barriers.
One issue that Kaine says he was previously unaware of is Medicaid’s existing 60-day cutoff for postpartum services.
Though most pregnancy-related deaths occur before, during, or shortly after the day of delivery, close to 12 percent of maternal deaths happen 43 to 365 days after birth, according to the CDC’s May 10 Vital Signs report, which notes that the proportion of deaths among black women during this period is greater than that of white women.
“If you're dealing with a mother with a chronic health condition, with postpartum depression, there’s a whole series of things, where if you cut it off at 60 days, you are actually removing services at what might be the most vulnerable moment in the life of that mother and the baby,” Kaine said.
Expanding Medicaid compensation for postpartum services from 60 days to a year would carry costs for the federal government, but it could save money long-term by taking care of health issues before they develop into lasting conditions that require more services, Kaine says.
“I think that would be fantastic,” Jenny Delgado, a postpartum nurse at Inova Fairfax Hospital, said. “If we could at least get that done, that would be so helpful for the health of our moms.”
Other challenges will need more than a simple legislative fix to rectify.
The role that racism plays in the high maternal mortality rate for black women is evident in the disparity’s persistence across income and education spectrums, and it manifests in a variety of ways, from providers’ dismissive treatment of patients to systematic discrimination in access to housing, food, clean water, and other necessities, according to Northern Virginia Family Services director of health access and nutrition services Ondrea McIntyre-Hall.
Research suggests that dealing with racism takes a toll on people’s physical and mental health, a process that McIntyre-Hall calls “weathering.” Pregnancy complications like hypertension and preeclampsia are not exclusive to black women, but they may be at more risk for them from the combined stresses of racism, sexism, and having a child.
While these issues go beyond interpersonal interactions, mandatory bias training for healthcare workers would help individuals identify and dismantle prejudices and build more trusting and respectful relationships with patients, argues Birth in Color RVA co-founder and reproductive justice and maternal health advocate Kenda Sutton-El.
Delgado sees education for providers and nurses as a priority. As a certified Spanish interpreter for Inova Fairfax, she often ends up giving patients information that they should have received during their pregnancy.
“Because they are Spanish speaking, either it’s not told to them in a way that they understand, or sometimes, things get lost in translation,” Delgado said. “We’ll use the interpreter phone, we’ll use a translator, but the way that they say things doesn’t connect to the patient.”
As a medical professional, Adkins has noticed that providers and even office workers sometimes adopt different attitudes and language when talking to certain kinds of patients.
“I serve patients who have no insurance or are underinsured, and our attitude is always we’re doing them a favor,” Adkins said. “Well, we’re not doing them a favor. We’re doing our job.”
Adkins says she often tells patients to bring in lists of questions to appointments because women of color in particular are not always taken seriously otherwise.
The HealthWorks OBGYN views the implicit bias training incentivized by the Maternal CARE Act as a critical step for addressing racial disparities in maternal healthcare, but not one that will singlehandedly fix discrimination in the profession.
“It has to start from when they’re very young so that they don’t grow up with that bias,” Adkins said. “Unfortunately, by the time we’ve gone through med school and residency, we already have a bias, so it might help, but it won’t solve the problem.”