T

he recent, high-profile death of Erica Garner, a 27-year-old African-American mother of two — one of them a 4-month-old infant — is a tragic example of how racism and access to health care for black mothers is a national crisis.

Not long after the birth of her youngest child, Garner had a heart attack. Four months later, an asthma attack triggered another heart attack; she died not long afterward. According to news reports, Garner’s heart had been enlarged during her pregnancy, something she didn’t know before becoming pregnant.

Her death made headlines because she was the daughter of Eric Garner, who died in July 2014 after being placed in an illegal chokehold by a New York City police officer; she was also an outspoken activist against police brutality. But it should also have made headlines on its own, a grim reminder of an issue we must solve.

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As a woman of color in the health care field with two daughters of childbearing age, I am as afraid for them today as my grandmother may have been for my mother in rural Mississippi in the 1950s. The issue of maternal health became an even more personal one in our family during the past six months. Two of my daughters’ friends barely survived childbirth. Both of these young African-American women, who were apparently healthy before their pregnancies, developed dangerously high blood pressure that took months to return to normal after the births of their children.

Because Garner died within a year of giving birth, her death is counted as a pregnancy-related death due to a complication of pregnancy. According to the Centers for Disease Control and Prevention, pregnancy complications include anemia, urinary tract infections, mental health conditions, high blood pressure, pregnancy-induced high blood sugar (gestational diabetes), severe morning sickness (hyperemesis gravidarum), and more.

As a nurse at a major Chicago hospital, I often care for infants in the nursery because their mothers are in the intensive care unit for complications experienced during or after their child’s delivery. One infant spent almost two weeks in the nursery while his mother was recovering from a heart attack due to a blood clot in her lungs (pulmonary embolism).

Maternal mortality in the United States is a scandal. A 2014 World Health Organization report indicates that our country has a higher maternal mortality rate than Iran, Libya, and Turkey, even though we spend vastly more money on health care than those countries do. Half of maternal deaths in this country are preventable.

The problem is worse for African-American women than white women. In New York state, for example, between 2013 and 2015, 54 black women died for every 100,000 births compared to 15 white women.

To be sure, the U.S. is making some progress in decreasing the leading causes of maternal death, including bleeding, infection, and high blood pressure. However, the number of mothers with cardiovascular disease and cardiomyopathy (enlarged, thickened, or stiff heart muscle) has risen to the point where heart conditions are the cause of more than one-fifth of pregnancy-related deaths.

What we are not as successful at reducing are the factors of racism that shorten a black mother’s life.

A 2016 research overview of maternal mortality and morbidity in the United States shows that maternal health and death are influenced by racism, discrimination, poverty, and poor or inadequate health care. Racism is entrenched oppression that places value on individuals based upon their race or ethnicity.

According to Dr. Camara Jones, research director on social determinants of health and equity in the Division of Adult and Community Health at the National Center for Chronic Disease Prevention and Health Promotion and a scholar at the Center for Health Policy at Meharry Medical College, three levels of racism influence individual health: institutional racism, personally mediated racism, and internalized racism. Contributing factors include societal indifference to racism and discrimination; unequal access to employment, housing, education, and pay; and perceptions that African-American women have not achieved success because they are not up to the task.

These influence the health experiences and health outcomes for African-American women, regardless of socioeconomic status and access to quality health care. According to the CDC, younger age, higher socioeconomic status, and more education do not mitigate the negative influence of racism and discrimination. On average, black women with higher incomes and college educations have worse health than white women who have not graduated from high school.

Medicaid finances nearly half of all U.S. births. That should provide many women with quality prenatal care. Yet many providers don’t accept Medicaid patients, which heightens the logistical challenges to prenatal care visits, such as difficulty getting time off work to attend prenatal care visits during traditional office hours, transportation, and child care.

African-American and poor women are more likely than other women to be treated at low-quality hospitals, increasing the chances they may experience serious complications during and after childbirth. Hospital quality can account for nearly 50 percent of the racial disparity in maternal illness.

There’s no question that some women at greatest risk for maternal death have lifestyle or behavioral risk factors that contribute to early disease and death, such as unhealthy diet, being overweight or obese, smoking, late or no prenatal care, living in substandard housing or dangerous neighborhoods, and living in communities fraught with environmental hazards.

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We must do more than just point to this injustice. A first and necessary step is to call out institutional and interpersonal racism and discrimination when we see it. Then we must take action to make changes to improve the quality of maternity health care for all mothers. The Alliance for Innovation on Maternal Health is a collaboration of health care professionals affiliated with 19 major organizations that is taking steps to do just that.

Equally important are initiatives that improve cultural and ethnic diversity of providers so mothers are comfortable with their health care providers without fear of judgment, bias, and discrimination.

Efforts to reduce stress with techniques such as mindfulness-based meditation, to reduce poverty, and to support optimal health before pregnancy are other components that can make a difference in the lives of black mothers, children, families, and communities.

From my perspective, it sometimes feels that being a poor, black mother is akin to a diagnosis that increases the risk of dying during pregnancy or soon after giving birth. By fighting the racism that contributed to the deaths of Erica Garner and so many other American women, we can also stop the need for mourning.

Wrenetha Julion, Ph.D., is professor and chair of the Department of Women, Children, and Family Nursing at Rush University College of Nursing in Chicago, an NIH-funded researcher focused on the wellbeing of families, and a Public Voices Fellow through The OpEd Project.

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  • I am sorry, but this is not racism. Why do we use that word when ever we disagree with a problem, Yes death rate is higher among black women , but it cover ALL social economic, it has nothing to do with poverty, or education . Perfect example tennis star S. Williams also had complications with her pregnancy, and lets be honest, she is educated and wealthy. Maybe we need to look at DNA. genes, and other factors. Lets be honest, and look at diet, lack of exercise, type of foods, weight, drugs, smoking, and types of food that is consumed. And does your racism also include Hispanic women, who birth complication rate is as high or high then African Americans.

  • If folks could take a deep breath it would be helpful. As a biracial physician whose mother was black (my father is white) I think I see this uniquely in some ways.

    I do believe in black community self-empowerment and to seek standards for ourselves and for our families that optimize our physical and mental wellness. So if that means our urban corner stores have rotten produce and small aisles filled with junk food, we are going to need to be creative in how we cook for ourselves. If there isn’t an app for cooking healthy in a food desert, I think there should be one. Even if we are in rural black poverty due to years of discrimination, we still can try growing our own vegetables where possible. For those kids fortunate enough not to have to cross gang lines to go to school and who live in decent school districts, the expectations do need to be higher because their success means our community’s success. Our value of each other and the black family unit has taken a beating over the past couple generations. Regardless of whose “fault” that is, it is ours to reclaim. I was taught to fight for my accomplishments because blacks aren’t often given a second chance. Perhaps that mindset would be helpful regarding our fight for our future.

    However, as a physician, I’ve had people say and behave in outrageous ways to black patients because they failed to realize I was black (some people can tell I am, others think I’m a multitude of things). I’ve had nursing staff dismiss a patient’s family telling me “they are black so you know how they are.” I’ve had a nurse bristle at the poverty and blackness a patient represented saying she could carry her own bags…she clearly had a cast on the upper extremity and couldn’t. In disgust, she walked out of the room with the patient mortified. I’ve seen the quality of patient physician rounds literally change on a turn as the physician switches from the Asian male in bed 1 to the black male in bed 2. Questions stop, the back and forth conversation that facilitates patient education ends. The black patient is “professionally” but briefly as possible told the care plan and the group moves on and if you were not paying attention, you’d never know the difference. When you go back later and talk to the black patient, you find out he doesn’t understand not because he is unintelligent but because the flyover rounds left him grossly misinformed compared to his non-black neighbor. Complicating matters is the non-raced based but equally virulent assumptions about those on Medicaid. I’ve had administrative staff clearly disclose their displeasure in assisting these individuals even for a voucher for a cab ride home. “They should get a job” and “you and I are paying for this.” Patients hear this by the way. How can we not believe racism to contribute when we look at rates of black patients not don’t receive proper analgesia or life saving interventions when other relevant factors have been accounted?

    Sadly, old school black folk (as I was taught to say), still fear us in the medical community. They tell their kids about the Tuskegee experiment and I still have to manage that issue even today as I care for patients. That’s if my patient has found a Medicaid provider who can see them in an office not overflowing with other patients? There are rural counties in which there are none, yes not a single ob/gyn. Add being black and let’s admit, this is challenging. I have patients who are so relieved I’m black because no one has taken their potentially life threatening medical issues into any account. They have been blown off and politely ignored while doctors have shot knowing glances at each other to confirm their suspicion of how “ignorant” the patient or the family appear to be. Some of these patients tell me how they avoided medical care because they did not want to endure that treatment again.

    All I’m saying is first, let us acknowledge that the sadness that results death of any mother. Let’s reflect on why the health disparities even outside of race are not only sorrowful but be concerning because an unhealthy population leads to an unhealthy future for America. Let us who are black be a source of strength and education to our people. However, let all of us stop the willful ignorance of how racism and classism permeates medical care from the front door to the OR table. Let’s all do our part whether we are patient or provider to ameliorate this.

  • I teach healthcare classes at an Adult Business and Technology School. The first assignment I give to my diverse racially dominant classes is to do a 3 page paper on Fetal Alcohol Syndrome to build awareness among my students. The majority are clueless so I believe ignorance plays a significant role in Black Maternal Health. Prenatal care is readily available at clinics. Unfortunately, many young women don’t put regular visits as a priority. Oh, that’s called Responsibility. Racism is a much easier conclusion than Responsibility. Probably a political plot. Certainly a conspiracy.

  • This is an embarassment. I was not sure how this could be tied to racism and after reading this I am convinced it is not. Sadly I read the whole piece and waited for some truths instead of the same bs racist words that get thrown around.

  • There’s a lot to unpack with this article, but how about we address one of the most egregious problem statements:

    “There’s no question that some women at greatest risk for maternal death have lifestyle or behavioral risk factors that contribute to early disease and death, such as unhealthy diet, being overweight or obese, smoking, late or no prenatal care, living in substandard housing or dangerous neighborhoods, and living in communities fraught with environmental hazards.

    We must do more than just point to this injustice.”

    As a Ph.D., and as a nurse, you should be aware that prenatal maternal health is one of the most significant predictors of health outcomes for both mother and baby, and surely deserves more than a single sentence mention in an article addressing maternal outcomes – especially if one wants to point to racism as the cause.

    For instance, hypertension (high blood pressure) is second only to cigarette smoking as a preventable cause of death in the United States. It is the leading cause of heart attacks, heart failure, stroke, and renal failure. African Americans have a 400% greater risk of developing hypertension than Caucasians (Flack, Ferdinand, Nasser; 2003). Evolutionarily, this may be because people living near the equator were more susceptible to sodium loss through sweating and developed increased sodium retention mechanisms as a way to increase chances of survival (Thompson et al.; AJHG 2004). In modern times, however, this increased sodium retention among African Americans means that it is much easier for them to develop hypertension compared to other races. It is not due to racism that blacks are genetically more susceptible to high blood pressure than other races.

    Another example is obesity. Aside from the general health risks of heart disease and stroke, Obesity during pregnancy increases the risk of the mother developing gestational diabetes, hypertension, and preeclampsia; it also increases the risk of macrosomia (large for gestational age), stillbirth, preterm birth, and infant hypoglycemia. African American women are the most obese group in the United States, with ~ 4/5 black women being obese (HHS.gov). Now, it’s true that African Americans have less access to affordable, quality sources of healthy foods, but that isn’t due to racist practices by the American health care system.

    The above demonstrates that a large percentage of maternal morbidity and mortality can be prevented by practices that need little intervention by medical doctors. Aside from being prescribed blood pressure medication, losing weight; eating a low-sodium DASH diet rich in fruits and vegetables; keeping a daily record of calories consumed; exercising for at least 30 minutes every day; quitting smoking; and limiting alcohol to no more than 2 drinks/day are all things that don’t require a physician that would significantly improve health outcomes across the board. The difficulties in sticking to the above regimen are the same for African Americans as for any other race from a low socioeconomic background: it’s hard to do consistently and cheaply.

    The rising rates of obesity in America (across all races) and the promotion of dangerous ideologies such as Health At Every Size (HAES) is indicative that people don’t like being told by their doctors that they are overweight/obese and need to eat fewer calories, eat more vegetables and get more exercise. Until people start heeding this advice instead of taking offense — claiming they were fat-shamed — obesity-related and blood pressure-related morbidity and mortality will continue no matter what color of skin you have.

    • Hi Torg,

      Thank you for taking the time to write such an in-depth comment and for providing citations to your statement. I followed up with the Thompson article and came across this link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182141/ and it seems like the same article. It is very lengthy and dense with genetic terminology and while I feel that I got the gist of it, it may have gone over my head a little as I only have an undergraduate education in biology/genetics while my graduate education is in a different field of research. My understanding from the discussion is that the data about African Americans was inconclusive. If you have the time, I was hoping to hear more from you via comments. Could you further explain how you got from this article that African Americans evolutionarily/genetically retain more salt which leads to increased risk for hypertension and therefore poorer maternal health? Also if there is data available on the prevalence of this contributing to hypertension, I would really appreciate more research links if you come across them.

      Thank you!

      Shelby

    • Hi Shelby,

      In the discussion section from the Thompson et al. (1) article you linked, they do cede that there are certain inherent study limitations, especially with the HKA method of testing molecular evolution based off nucleotide data. The African populations haven’t been living in a vacuum, undoubtedly there has been some admixture of European genes at some point in history. However, Thompson et al. continues on to say,

      “Despite these caveats, the functional role of the CYP3A5*1/*3 polymorphism, its likely fitness consequences, and its geographic distribution *independently argue* for the action of natural selection on this locus.” (emphasis mine)

      Based off their statistical models, the geographic distribution of the CYP3A5*3 allele frequencies, and the conjunction of a similar blood pressure regulating gene, AGT Met235, being in a similar geographic distribution, it is reasonable to say that this didn’t occur by chance alone.

      The enzyme that is being discussed belongs to the Cytochrome P450 (CYP) family and the CYP3A5 enzyme, in particular, converts a hormone (cortisol) into a metabolite (6β-hydroxycortisol) that causes defective sodium removal by the kidney. So, populations who have the functional (expressor) CYP3A5 enzyme tend to hold on to more sodium in their blood due to poorer removal by the kidney. They found a variant of this enzyme, CYP3A5*3, that is essentially nonfunctional. This means that populations who carry the CYP3A5*3 variant are better at removing sodium from their bodies. The researchers found that the expressor CYP3A was highest among Africans, and the nonfunctional variant CYP3A5*3 was increased in populations the farther they got from the equator and are highest among Caucasians (85-95% vs. only 33% in African Americans and 14% in native sub-Saharan Africans).

      From the Thompson article,

      “Phenotypic variability in human hypertension susceptibility could be due to genetic variation in genes that underlie salt regulation. The “sodium retention hypothesis” (Gleibermann 1973 [2]; Nakajima et al. 2004 [3] ) proposes that ancient human populations living in hot, humid areas with low sodium availability adapted to their environment by retaining salt, whereas populations in cooler, temperate climates adapted to conditions of greater sodium availability.”

      The salt regulation genes being referenced are the ones discussed above, the CYP3A family and the AGT Met235 genes, which is the human angiotensinogen gene and plays a role in the renin-angiotensin-aldosterone-system (RAAS). There is an extensive discussion on the AGT genes in the work by Nakajima et al. mentioned above (cited below).

      More from Thompson et al.,

      “Since an increased prevalence of hypertension in African American versus white populations is well documented and since blood pressure homeostasis is strongly influenced by sodium regulation and salt sensitivity, population-specific differences in susceptibility to hypertension could be explained, in part, by variation in genes related to salt regulation. This hypothesis provides a general framework for interpreting the patterns of variation observed at genes involved in sodium homeostasis.
      … An example of a possible disadvantage associated with CYP3A5*1 is complications of pregnancy: increased urinary excretion of 6β-hydroxycortisol was observed in women with pre-eclampsia (Frantz et al. 1960). Thus, whereas the selective advantage due to increased salt and water retention decreases and possibly disappears completely with increasing latitude, the selective disadvantage becomes the main influence on the overall fitness, which results in the adaptive rise in frequency of the CYP3A5*3 allele.”

      So as human populations moved farther away from the equator, salt and water retention associated with the expressor CYP3A5*1 became more harmful than helpful (e.g., more pregnancy complications such as pre-eclampsia due to higher blood pressure); decreasing their evolutionary fitness. Consequently, the nonfunctional variant, CYP3A5*3 rose in populations farther from the equator where it wasn’t as necessary to retain as much salt and water.

      Reference list
      1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182141/
      2. https://www.tandfonline.com/doi/pdf/10.1080/03670244.1973.9990329?needAccess=true
      3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1181984/

  • STAT exposes its deeply held prejudice by publishing this race baiting crap.

    Left wing socialists should look into their own mirrors, and stop blaming many/most/all health and social problems on racism, sexism, capitalism, Donald Trump and/or Republicans.

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