Q&A: Black Maternal Health Week draws attention to 'amazing disparity' in mortality

Key takeaways:

• Black people face a much higher maternal mortality rate than white people.
• A family physician spoke to Healio about the inequities and how PCPs can make a difference.

Black Maternal Health Week is observed April 11 to 17.

It is well known that the United States has a maternal health crisis — one that particularly affects Black mothers. As Healio previously reported, in 2021, the U.S. maternal death rate significantly increased, and rates among Black people more than double that of their white counterparts.

In recognition of the awareness week, Healio spoke with Karen L. Smith, MD, FAAFP, a family physician and member of the American Academy of Family Physicians board of directors, to learn more about the disparities, the important role primary care providers play in prenatal care and more.

Healio: Will you briefly discuss the U.S.’s maternal health crisis? What’s going on and why is it so bad in this country specifically?

Smith: When we look at information from other developed countries, the U.S. has a much higher rate of maternal mortality. Unfortunately, our rates have doubled between the years 2018 and 2021. When we look at Black mothers, the maternal mortality rate in 2021 was twice the rate for white or Hispanic individuals, basically looking at 70 deaths per 100,000 live births. The worst part is 84% of the maternal deaths are preventable, and we're looking at these deaths that are occurring 7 days to 1 year after delivery of the baby, most of which are preventable. It's pretty significant that we are not even faring close to other countries and then we also see an amazing disparity in terms of what populations are having a high impact from maternal mortality.

Healio: Can you discuss the importance of acknowledging and discussing racial disparities in maternal death rates in the U.S.? Why should PCPs be aware of the differences?

Smith: Understanding and addressing racial disparities in maternal mortality rates can help improve health care quality and patient outcomes. By talking about these issues and educating clinicians, we can identify areas for improvement and implement targeted interventions. Primary care physicians focus heavily on preventive care, and that is a huge factor when we consider how to reduce maternal mortality. We must think about what proactive steps we can help our patients take during pregnancy and after birth to give them and their babies the best chance at a healthy life.

What makes us uniquely positioned to address the maternal health crisis and health disparities are our lifelong, continuous relationships with our patients and communities. An example is when I was a resident back in 1992, I actually assisted on a delivery of a patient. That was her fifth child. It was a precipitous delivery, meaning that baby was rapidly expunged from mom. She gave one good push, and the baby was born. I actually took care of that child who's now in his 20s. And I take care of that mother, in my practice of 32 years. So, we truly have a continuous relationship. What does that mean? It means I have an understanding of the family dynamics. I have an understanding of some of the socioeconomic issues that they're dealing with. I have a good understanding of some of the emotional issues that may come to play in that family, if they lose insurance, if they are having a change in insurance or change in job and the stress impact. That is a bonded relationship that developed over the course of time.

I also have the opportunity of taking care of multiple generations. Her son may get married, and I’d already have a good understanding of the dynamics in that family. That also gives an idea of where we can intervene to prevent poor outcomes as they start to develop their family.

Healio: What are some factors contributing to the maternal health crisis in the U.S., especially for Black mothers?

Smith: It starts with looking at social determinants of health — factors like housing and transportation, employment, health literacy — and addressing the stress that stems from these situations. Is it from a lack of job or stable employment? Difficulty even getting employment? And what happens in the household dynamics when the mother is trying to care for not only herself but also other children who may be in the household, and she is typically a strong breadwinner in that household? When we look at all of those factors, and then to go through a pregnancy, that’s quite a bit.

Having a family physician who understands and has empathy toward the needs of the mother is also key to stemming this crisis. Patients need a doctor who can help patients stay up-to-date on their prenatal visits is critical. I recently learned about some practices from our colleagues in subspecialty. In some practices, if you are of a certain BMI, if you are greater than 30, in terms of obesity, they will not take care of you during your pregnancy. And that is definitely concerning. We also know that there may be underlying chronic disorders that have not been identified — thyroid disorders, heart disorders, even lung disorders. And so, when we look at these other issues, and a woman does not have that full embrace of care, these issues fall through the cracks.

In my office, if I diagnose a woman as pregnant, we start off in that first conversation to try to address some of these factors. I used to deliver and provide that prenatal and obstetrical care, so I'm very much in tune in terms of what can happen. We also make it clear that if you start to develop any problems — if you have bleeding, if you are having symptoms of urinary tract infection, anything that can cause a preterm delivery, if your blood pressure is out of control, if you're having dizziness — these are all signs and symptoms that need to be discussed with your doctor. I just had a situation of a newly pregnant woman who came in with leg pain and swelling. She contacted her OB doctor, the office staff told her “Well, we see swelling in the legs in pregnant women” — not in the first trimester, mind you — and she came to our office. She had deep vein thrombosis. But the relationship existed for her to come back to her PCP and say, “This is what I'm experiencing.” And we diagnosed the clot and notified the OB doctor that this lady has a blood clot that needs to be addressed, that clot can move and go into her lungs. And so, it’s that type of relationship, whether we are intimately involved with the prenatal care or not, we still have that relationship with the family, with that patient.

Healio: How can PCPs help address these issues in their practice? What role do they play in maternal health?

Smith: I think the major role is access to prenatal care — especially when we look at maternal care deserts in our country. Research from the American Academy of Family Physicians’ Robert Graham Center identified 181 maternity care deserts across the country. And that means for 400,000 women, a family physician is their sole access to maternity care by a doctor. That is concerning for a developed country, that we have such a lack of access to maternity care. And what it says is that the family physician can provide that care.

Another area of concern is that many of these complications are occurring within 7 days to 1 year after the baby is born. So, what happens is mom gives birth, is in the hospital for 2 days, things are great, goes home, enjoys the baby, and mom ends up with a complication.

Oftentimes, when I refer patients to OB for prenatal care and to manage that pregnancy, I make sure I get a referral for it because I'm wanting to see that mother after that as needed immediately after she delivers the baby in order to reestablish the care. The other thing is we will do the newborn care, so mom brings the baby in and while I'm looking at the baby, I'm also going to look at mom.

There's something called a fourth trimester, which is the first 3 months after birth. That is a critical time, because what happens then, not only are we picking up on some of the medical conditions, whether it’s a cardiac issue, but we're also picking up on some of the mental health issues. Some of the deaths that are occurring are as a result of mental health conditions. And when we look at mental health, and we look at cardiac diseases, those are the ones that are taking the lives of these women. Remember that fourth trimester.

Healio: What is the take-home message for PCPs here?

Smith: Strengthen your relationship with all reproductive-age families and create that bond that allows these families to have pregnancy care from prenatal to the fourth trimester of our postpartum care. Enhance the bond with your families.

Healio: Is there anything else you would like to add?

Smith: It’s important to recognize how instrumental family physicians are to the care of entire families. I just spoke with a dad who's caring for two of his kids and his kids are assigned by Medicaid to another practice across town. I’m like, “Everything that your family needs, with all the complexities of your condition, we can take care of you and your children. We are truly a one stop shop.”

I’m in a very rural community, and oftentimes our patients don’t have access to obstetric care. So, when we look at a family physician, that is an access point to care, where good quality care is going to be very efficient.

Family physicians also embrace collaborative care. While I do offer quite a bit here, I also recognize the skills and expertise of my colleagues who also have good interests in providing quality care.