The crisis of maternal mortality

There is a women’s health crisis in this country. And it is about to get much worse.

The United States has the highest rates of maternal mortality in the industrialized world. Women are twice as likely to die from complications of pregnancy or childbirth in the U.S. than in Canada or the United Kingdom. For women of color, especially, the risk is infuriatingly, heartbreakingly, unforgivably high.

In 2020, the maternal mortality rate for Black women in the U.S. was 55 deaths per 100,000 live births. That is nearly three times higher than the rate for white women.

If, as appears likely, Roe v. Wade is overturned and abortion is widely banned, maternal deaths will rise sharply. That is a fact. As editors of The Lancet wrote this week, “justices who vote to strike down Roe will not succeed in ending abortion, they will only succeed in ending safe abortion.”

Sociologist Amanda Jean Stevenson has analyzed the effect of widespread abortion bans on maternal mortality in the U.S. She projects a 21% overall increase in maternal deaths — and a 33% increase among Black women. “Those are the only numbers that ever caused me to burst into tears as soon as I finished them,” she told the Washington Post.

Each of those deaths is a tragedy with enormous ripple effects: families torn apart; lives of promise cut short; babies left to grow up without their mothers; spouses, partners, parents, and siblings plunged into grief and racked with anger. Thinking of these losses cuts deep into my soul. This is a public health crisis that demands immediate action.

Resisting the corrosion of our national politics

I’m writing about this now for two reasons. First, these issues must be top of mind for all of us as we await the Supreme Court decision — and gird ourselves for what will be a long, hard, and essential fight to defend reproductive rights. Second, this afternoon the Harvard Chan Studio is releasing a conversation recorded last week with Sen. Bill Cassidy, Republican of Louisiana. A leading voice in the anti-abortion movement, he spoke on both abortion politics and maternal mortality. I felt it was important to respond and add context. First, though, let me explain why I believe it’s valuable to listen to that conversation.

Earlier this year, the Studio launched a series called “Public Health on the Brink,” designed to explore the urgent challenges facing our field, with a rigorous focus on solutions. In segments dubbed “View from the Hill,” jointly presented with POLITICO, the Studio invites members of Congress to talk about policy prescriptions on a wide range of public health issues, from gun violence to antibiotic resistance to pandemic preparedness.

Sen. Cassidy, for instance, has urged the creation of an emergency response fund to allow federal agencies to move more quickly in a public health crisis. He’s a significant player in efforts to enforce parity laws that require insurers to treat mental and physical health equally. And he has been outspoken in his defense of local public health officials, at a time when other prominent voices in his party have sought to strip their authority.

It so happened that Sen. Cassidy’s interview took place shortly after the leak of Justice Alito’s draft opinion overturning Roe v. Wade. Given the salience of that issue, POLITICO reporter Sarah Owermohle opened the conversation with several questions on abortion politics.

“Our politics these days have become so corrosive that our first instinct, far too often, is to demonize and isolate those with world views different from our own.”

Let me stipulate that I do not agree with Sen. Cassidy on abortion. Yet I appreciated having the opportunity to listen to his perspective. Our politics these days have become so corrosive that our first instinct, far too often, is to demonize and isolate those with world views different from our own. I believe we must fight that instinct. In fact, I’ve made that point at student orientation each of the last few years.

Quite simply, we will not make progress on any issue if we refuse to talk with those we can’t agree with on every issue.

I found it interesting to listen to Sen. Cassidy’s responses as he deflected questions about the more extreme anti-abortion proposals circulating in his party—such as efforts to bar women from traveling out of state to end a pregnancy, or to ban shipping of the pills used in medication abortions, or to restrict access to contraception. The senator describes himself as “unapologetically pro-life,” but said his own personal view was not relevant because as a practical fact, it would be impossible to enforce such restrictive laws.

I am not so sanguine; I believe we are in for an all-out assault on women’s reproductive freedom, and I dread the consequences. Indeed, it is precisely because I am so concerned that I find it important to listen to those voices leading the charge against reproductive rights. I still have faith that with an open dialog, we may be able to change some minds. I also believe that listening is a prerequisite to finding those slivers of common ground where we may be able to join forces for the greater good, despite our differences.

A crisis of terrifying proportions

After discussing abortion politics, Sen. Cassidy spoke of the importance of supporting every woman during and after pregnancy. The reporter pointed out that Louisiana has one of the worst maternal mortality rates in the country. Here is a key part of the senator’s response:

“In Louisiana, about a third of our population is African American. African Americans have a higher incidence of maternal mortality. So, if you correct our population for race, we’re not as much of an outlier as it would otherwise appear. Now, I say that not to minimize the issue, but to focus the issue… For whatever reason, people of color have a higher incidence of maternal mortality.”

He then discussed a bill he has promoted to improve home monitoring for preeclampsia and other dangerous pregnancy-related complications to minimize the burden on women who rely on public transportation to reach their doctors.

“We have a crisis in maternal mortality in this country, and it’s a crisis of terrifying proportions for women of color.”

Sen. Cassidy is right that Black women have a much higher incidence of maternal mortality. But his framing of this issue was disturbing to me as a Black woman, as an epidemiologist who has focused her scholarship on reproductive, maternal, and child health, and as the Dean of the Harvard T.H. Chan School of Public Health.

We have a crisis in maternal mortality in this country, and it’s a crisis of terrifying proportions for women of color. This is not a moment to quibble about how states are ranked. It’s not a moment to correct for race. It’s a moment to step up and declare that our rate of maternal mortality in the United States is shameful and unacceptable. It’s a moment to assert that Louisiana—precisely because it has such a large population of Black women—must seize a leadership role in making pregnancy and childbirth safer for all.

Deep inequities driving deeply unequal outcomes

It’s no mystery why maternal mortality rates are so high among Black women. They are high because of the devastating impacts of structural racism and individual bias.

More than a century ago, W.E.B. Du Bois was among the first to show that health disparities were not due to biological differences between individuals of different races, but to social factors—namely the vastly different conditions in Black and White neighborhoods in Philadelphia. His research laid a powerful foundation for our current understanding of the social determinants of health.

Take, for instance, the practice of redlining—institutionalized discrimination in home mortgage lending that had the effect of isolating people of color and depriving them of the opportunity to build wealth through home ownership. More than 50 years after redlining was banned, many of the neighborhoods that were targeted still struggle economically. Their residents, including pregnant people, have less access to quality medical care, to healthy food, to safe places to exercise. These factors, the social determinants of health, have a huge impact on health outcomes, including maternal mortality.

Another well-documented driver of disparities: During childbirth and recovery, as in other aspects of medical care, Black women have far too often been dismissed as complainers when they seek help for symptoms that can presage serious complications, such as shortness of breath or swelling legs. It happened even to Serena Williams.

Researchers have also begun to document the pernicious “weathering” effects of chronic stress among people of color. This stress, often stemming from both structural racism and individual acts of discrimination, has a corrosive effect on health over time and can affect multiple body systems, even in relatively young and otherwise healthy women. Pregnancy can magnify the impacts of weathering and lead to serious complications.

Sen. Cassidy’s bill to improve access to home monitoring for pregnancy complications certainly could be helpful to some women, including women of color, who are at a significantly higher risk of preeclampsia and other dangerous conditions. Introduced by three Democrats and two Republicans, it’s an example of politicians seeking and finding common ground because they dared to listen to one another’s ideas, even amid fundamental disagreements on core issues.

Yet this bill only addresses a tiny sliver of the issues driving our maternal mortality crisis. We must do so much more.

A dire need for more family support

We are nowhere close to providing the support systems that Sen. Cassidy described as vital. Indeed, the very states that are pushing to ban abortion are also the states with the least support for parents.

A Supreme Court amicus brief written by the American Public Health Association and other leading voices in public health noted that “states with the most restrictive abortion policies invest the least in the well-being of women, children, and families.” In Mississippi, for example, parents do not qualify for Medicaid if their annual income exceeds 25% of the federal poverty level, which this year is $5,760 for a family of three.

Read that again: A single mom with two young kids and an income of less than $6,000 a year does not qualify for the safety net of subsidized health insurance.

She would be covered during pregnancy, but Mississippi’s Republican leadership has insisted on ending that coverage two months after childbirth, though the risks to mothers can persist well beyond 60 days postpartum.

Not surprisingly, “mothers, infants, and children in these high-restriction, low-investment states have the worst health outcomes,” the amicus brief concludes.

The same brief documents the damaging effects on the mental and physical health of parents and children who are born from unintended pregnancies. We also know that when women are denied wanted abortions, they suffer long-lasting economic consequences. At this moment, some parents are struggling to feed their infants amid an unprecedented shortage of formula. This nation does not offer families the support they need, period.

A time to listen. And a time to act.

This brings me back to where I started this blog: There is a women’s health crisis in this country. And it’s about to get much worse.

We know that many complications related to pregnancy and birth are preventable. Yet instead of investing in prevention and treatment, we are poised to make pregnancy much more risky, especially for people of color and for low-income women, by denying access to safe, effective health care and stripping away bodily autonomy.

I believe in listening. I also believe in acting. We are in for a fight that must be won in multiple arenas at once: At the ballot box. In legislative bodies at every level of government. In hospitals and doctor’s offices and community health clinics. In the courts. In one-on-one conversations.

It’s a fight we must win. Let’s get to work.