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What We See in the Shameful Trends on U.S. Maternal Health

Hokyoung Kim

Maternal deaths per 100,000 live births in 2019

MORE DEATHS
Sources: OECD, U.S. Census Bureau.

The United States has one of the highest maternal mortality rates in the developed world. To understand why, look at the states ...

One of every five women of reproductive age in Southern states live in counties with a high risk of death and other poor maternal health outcomes, such as post-partum hemorrhage, pre-eclampsia and preterm birth, according to new data from Surgo Ventures.

Those problems are even more striking when comparing the risk for white women and women of color. Women of reproductive age who are American Indian and Alaska Native are 2.6 times as likely as white women to live under conditions that create problems during and after pregnancy.

The gap between white and Black women is also concerning. Black women are 1.6 times as likely as white women to live under these unfavorable conditions. Based on 2019 data, they are also 2.5 times as likely to die during childbirth, when controlling for their age, education and income levels.

Compared with its peers’, the United States’ trajectory in maternal health has been shameful. Solving this worsening problem requires looking not just at the quality of care a woman receives but the entire environment around her — from her access to health care to the availability of food in her community.

The Maternal Vulnerability Index uses an array of maternal health and community data — six categories in total — giving a more comprehensive picture of what’s driving risk for poor maternal health outcomes in counties across America.

The data reveals that a woman’s chance of a healthy pregnancy varies greatly depending on where she lives, based on factors such as whether she has a high school diploma, her exposure to poverty, her access to OB-GYNs and midwives, and her access to abortion clinics.

How at risk are women in your county, and why? Search for your county to find out. (Higher scores indicate more risk.)

Overall maternal risk in New York County, N.Y. is low.

Reproductive healthcare: 1

Physical health: 32

Mental health: 20

General healthcare: 0

Socioeconomic status: 61

Physical environment: 91

Source: Surgo Ventures.·Notes: Maternal risk is on a scale from 0 to 100, with a higher score meaning higher risk. W.R.A. stands for “women of reproductive age.” Air pollution is determined by the concentration of particulate matter (PM2.5). Quality of outpatient care is based on the U.S. Department of Health and Services’s Prevention Quality Indicators.

A woman’s risk of poor maternal health varies largely by race, and those racial gaps vary greatly by region.

For example, there are big gaps in risk for Black versus white women in the Midwest and Northeast.

For American Indian and Alaska Native mothers, the gaps in risk compared with white mothers are largest in the West and Midwest, especially in states with American Indian reservations like Montana, South Dakota and New Mexico, suggesting that women of reproductive age living on reservations may die at higher rates and have riskier pregnancies.

Maternal risk related to

physical environment

Racial disparities in crime,

housing and transportation access

White

Native American

Black

MORE VULNERABLE

S.D.

Alaska

Miss.

N.C.

Neb.

N.M.

Pa.

N.J.

Minn.

Mont.

Utah

N.D.

N.Y.

Ohio

Kan.

0

20

40

60

80

100

MORE VULNERABLE

Wis.

Ky.

Pa.

Ind.

Neb.

N.J.

Ohio

Va.

Ill.

Mich.

Minn.

Ark.

Kan.

Miss.

N.Y.

0

20

40

60

80

100

Maternal risk related to physical environment

Racial disparities in crime, housing and transportation access

White

Native American

Black

MORE VULNERABLE

S.D.

Alaska

Miss.

N.C.

Neb.

N.M.

Pa.

N.J.

Minn.

Mont.

Utah

N.D.

N.Y.

Ohio

Kan.

0

20

40

60

80

100

MORE VULNERABLE

Wis.

Ky.

Pa.

Ind.

Neb.

N.J.

Ohio

Va.

Ill.

Mich.

Minn.

Ark.

Kan.

Miss.

N.Y.

0

20

40

60

80

100

Maternal risk related to physical environment

Racial disparities in crime, housing and transportation access

White

Native American

Black

MORE VULNERABLE

S.D.

Wis.

Alaska

Ky.

Miss.

Pa.

N.C.

Ind.

Neb.

Neb.

N.M.

N.J.

Pa.

Ohio

N.J.

Va.

Minn.

Ill.

Mont.

Mich.

Utah

Minn.

N.D.

Ark.

N.Y.

Kan.

Ohio

Miss.

Kan.

N.Y.

0

20

40

60

80

100

0

20

40

60

80

100

Maternal risk related to physical environment

Racial disparities in crime, housing and transportation access

White

Native American

White

Black

MORE VULNERABLE

S.D.

Wis.

Alaska

Ky.

Miss.

Pa.

N.C.

Ind.

Neb.

Neb.

N.M.

N.J.

Pa.

Ohio

N.J.

Va.

Minn.

Ill.

Mont.

Mich.

Utah

Minn.

N.D.

Ark.

N.Y.

Kan.

Ohio

Miss.

Kan.

N.Y.

0

20

40

60

80

100

0

20

40

60

80

100

Source: Surgo Ventures.

What’s contributing to the large gap between white and Black women?

In almost all states, three types of factors play an outsize role. White women are more likely to live in good physical environments: communities with less pollution, less violent crime and better access to high-quality housing and transportation options. They are also more likely to be in good physical health, with access to treatment and prevention strategies for sexually transmitted infections and non-communicable diseases. And they face fewer socioeconomic barriers: They are more likely to have access to educational opportunities, financial resources and healthy food options, and are less likely to face language barriers.

But there are a few exceptions — in Wisconsin, for example, the state with the single highest risk gap between Black and white women. Mental health and substance abuse play an important role, in addition to the factors described above. This includes general stress levels, mental illness such as depression, access to mental health care and use of substances like nicotine and illicit drugs.

Maternal risk related to

socioeconomic status

Racial disparities in education,

poverty and social capital

White

Native American

Black

MORE VULNERABLE

S.D.

Mont.

N.D.

Alaska

N.C.

Utah

Miss.

Neb.

Ariz.

N.J.

Pa.

Wash.

Ore.

N.Y.

N.M.

0

20

40

60

80

100

MORE VULNERABLE

Wis.

Mich.

Pa.

Ind.

Md.

N.J.

R.I.

Ohio

Kan.

N.Y.

Ark.

Tenn.

Va.

Mass.

Ill.

0

20

40

60

80

100

Maternal risk related to socioeconomic status

Racial disparities in education, poverty and social capital

White

Native American

Black

MORE VULNERABLE

S.D.

Mont.

N.D.

Alaska

N.C.

Utah

Miss.

Neb.

Ariz.

N.J.

Pa.

Wash.

Ore.

N.Y.

N.M.

0

20

40

60

80

100

MORE VULNERABLE

Wis.

Mich.

Pa.

Ind.

Md.

N.J.

R.I.

Ohio

Kan.

N.Y.

Ark.

Tenn.

Va.

Mass.

Ill.

0

20

40

60

80

100

Maternal risk related to socioeconomic status

Racial disparities in education, poverty and social capital

White

Native American

Black

MORE VULNERABLE

Wis.

S.D.

Mont.

Mich.

N.D.

Pa.

Alaska

Ind.

N.C.

Md.

Utah

N.J.

Miss.

R.I.

Ohio

Neb.

Kan.

Ariz.

N.J.

N.Y.

Ark.

Pa.

Tenn.

Wash.

Va.

Ore.

Mass.

N.Y.

Ill.

N.M.

0

20

40

60

80

100

20

40

60

80

100

0

Maternal risk related to socioeconomic status

Racial disparities in education, poverty and social capital

White

Native American

White

Black

MORE VULNERABLE

Wis.

S.D.

Mont.

Mich.

N.D.

Pa.

Alaska

Ind.

N.C.

Md.

Utah

N.J.

Miss.

R.I.

Ohio

Neb.

Kan.

Ariz.

N.J.

N.Y.

Ark.

Pa.

Tenn.

Wash.

Va.

Ore.

Mass.

N.Y.

Ill.

N.M.

0

20

40

60

80

100

0

20

40

60

80

100

Source: Surgo Ventures.

Over the past two decades, maternal mortality has increased almost 60 percent. The United States is the only Group of 7 country besides Canada to experience such a drastic decline in maternal health. (Canada saw a minor increase in pregnancy-related deaths.)

President Biden has invested funding in a variety of programs to improve maternal health, like expanding Medicaid coverage to 12 months after a person gives birth, implicit bias training for health care providers and state-level maternal mortality review committees.

Passing the Black Maternal Health Momnibus Act, which includes a set of transformative policies for maternal health, is the next important step in tackling this complicated issue. It is the most comprehensive and evidence-based legislative approach to date in addressing barriers to good maternal health for women of color.

Maternal deaths per 100,000 live births

Italy

Japan

2017

2000

Germany

U.K.

France

Canada

U.S.

0

5

10

15

20

Maternal deaths per 100,000 live births

2017

2000

Italy

Japan

Germany

United Kingdom

France

Canada

United States

0

2

4

6

8

10

12

14

16

18

20

Maternal deaths per 100,000 live births

Italy

2017

2000

Japan

2017

2000

Germany

U.K.

France

Canada

U.S.

0

5

10

15

20

Source: The World Bank.

These broad federal policies can’t fix the problem on their own, though. We also need much more targeted local action, in the form of a specific bundle of solutions tailored to the issues each community faces, because the reasons for maternal risk can vary from county to county.

Consider two counties where pregnancies are especially risky: Georgetown County, S.C., and Webb County, Texas.

In Georgetown County, local leaders could focus on non-communicable diseases and increasing screenings for sexually transmitted infections, providing low-cost transportation options to help women get to medical appointments, or offering more high-quality, affordable housing where pregnant women don’t have to worry about black mold growing in their bedrooms.

But in Webb County, risks are driven by things like English proficiency, whether a woman has a high school diploma, whether she lives in poverty or food insecurity, access to OB-GYNs and midwives, and access to abortion clinics. Decision-makers there should focus on a different set of solutions, such as expanding access to nutrition programs like WIC and SNAP, and increasing access to midwives, doulas and family planning services.

While the vulnerability index demonstrates the range of problems facing lawmakers, it does not fully explain the racial disparities. This suggests that other causes are at play. Black women face implicit biases that result in worse treatment and must endure other manifestations of racism, such as residential segregation at the neighborhood level.

Solving racial disparities in maternal health outcomes is the responsibility not only of people who work in health care. Housing authorities can help lower-income women find better living arrangements; city planners can increase access to healthy food options in underserved communities; and educators and school administrators can provide flexible G.E.D. or higher-degree options for mothers, potentially including free or low-cost daycare.

The United States is long overdue in addressing the devastating racial maternal health gap. Policymakers, researchers, community health organizations and advocates from all sectors must come together to provide a better future for all people giving birth.