To Lower Maternal Mortality, One City Is Thinking Holistically About Women’s Health

About 700 women die from pregnancy-related causes in the U.S. each year. That’s a higher rate than any other developed nation, but perhaps more alarming, it’s a rate that has risen more than 20% in the past two decades, while other countries reduced maternal mortality. It’s also a lopsided crisis. Black women are three to four times more likely to die from pregnancy-related causes than white women are. Native American and Alaska Native pregnant women are over two times more likely to die than white women. 

About half of maternal deaths are from preventable causes, like hemorrhages, high blood pressure, and infection—conditions that a primary care physician should be able to diagnose and treat relatively quickly.

In many cities and states, the maternal mortality rate is high in large part because women are uninsured, and therefore lack access to regular doctor’s visits. But in Washington, D.C., where the maternal mortality rate is about double the national average, figuring out what is at the root of the problem is a little more complicated. Over 95% of people in the District have insurance, so access is not the issue, Mayor Muriel Bowser said at a panel Tuesday at CityLab D.C. Instead, when the city began a campaign to talk to women—many of them black women— about their experiences with the healthcare system, they discovered a different challenge. 

“We found that our residents don’t feel respected in interactions [with their doctors],” she said. “It’s not enough to have insurance.”

Part of the reason women might not feel comfortable in a clinical setting has to do with implicit bias, which may cause doctors, nurses, or receptionists to treat a patient differently because of their race, class, primary language, or other factors. 

Doctors who fail to recognize their implicit bias can treat the concerns of women of color less seriously than they would the concerns of white women. That can lead to misdiagnoses or diagnoses that come so late the patient is already on the operating table, said March of Dimes President and CEO Stacey Stewart. “We have systemic challenges and racial inequity going back decades, and some people are just waking up to this fact, but some of us have been living this a long, long time,” she said. “We all have implicit bias. But the extent to which it inhibits a doctor from providing high quality, consistent care to any woman irrespective of her race, ethnicity, or language, then we have to address that and do something to counter it.”

Bowser credited high-profile stories, like those of Beyonce and Serena Williams, two famous black women who suffered dangerous pregnancy complications within a few months of each other, as one of the reasons more state and local governments have started planning maternal health programs with race in mind. 

Earlier this month, California Gov. Gavin Newsom signed into law a measure requiring implicit bias training for doctors, saying that the state “must do everything in [their] power to take implicit bias out of the medical system—it is literally a matter of life and death.” Last year, New York City launched an implicit bias training and public awareness campaign around racial disparities in birth outcomes. Houston is partnering with a local university to target programming to low-income pregnant women. Los Angeles is training doctors and community partners in free health resources, hoping to use word-of-mouth to fill in information gaps about what the city can do to help women during and after their pregnancies.

More states have taken action since the Preventing Maternal Deaths Act passed Congress in 2018, a law that supports states in establishing Maternal Mortality Review Committees to comb through every pregnancy-related death and near-fatal childbirth at local hospitals. Stewart said that before this, most states weren’t respecting the issue enough to collect data on it. “We should have been doing this a long time ago but it’s good we’re getting to it now,” she said.

In an interview later in the day with Route Fifty, Bowser said that the District is using the data their Maternal Mortality Review Committee collects to inform a strategy that focuses on the “whole woman.” That means looking not just at healthcare access during pregnancy, but at nontraditional factors that impact a woman’s health throughout her life—things like access to transportation, safe housing, health education, and nutritious food.

“Healthy women will have better chances of healthy pregnancies, safe deliveries, and healthy babies,” she said. “There are things that the government can’t control, like the generations of stress and anxiety that residents carry with them into pregnancy. But all the things we can control, we are.”

Trying to solve for all the factors that influence health is a difficult task, so Bowser said the District is turning to experts for ideas—meaning not just those who research maternal mortality, and also women who have experienced challenging pregnancies and births. Last year, D.C. hosted the first Maternal and Infant Health Summit for mayors, policymakers, and community leaders to talk about racial disparities in pregnancy outcomes. “We saw that the summit became a forum for women to talk about their birth experiences, and that has been so illuminating,” she said.

In addition to racial disparities, the summit also illuminated geographic disparities. Two of D.C.’s eight wards are separated from the rest of the city by a river, and lack convenient access to critical infrastructure like grocery stores, Metro stops, urgent care centers, and pharmacies. Pregnant women from the two wards, which are each over 90% black, usually have to travel long distances to find OBGYNs and other specialty care providers.

In these areas, services like primary care doctors are underutilized, while services like 911 and emergency rooms are overutilized, a situation that Bowser said leads to worse outcomes for mothers and their babies. “You don’t get convenient or fast service in an emergency room,” she said.

Confronted with the challenge of providing better care to a part of the city that has been underserved for so long will be an exercise in trust-building, so the city is trying new strategies to “meet residents where they’re at.” These include piloting a nurse triage line at the District’s 911 call center, which will provide people in non-emergency situations with rides to urgent care centers and connections to a primary care provider, funding community groups that provide doula care, and setting up prenatal support groups for low-income mothers.

Bowser encouraged other city leaders to think concurrently about what city-wide and neighborhood-by-neighborhood policies could look like. “We started with the premise that women should not die from childbirth in our city, and made that a priority for our government,” she said. “The more discussions we have, the more we’re learning about effective practices.”