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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  • 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.

  • 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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