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Markkula Center for Applied Ethics

Biases and System Failures Affecting U.S. Maternal Mortality

Emma Brennan ’21

Mart Production/Pexels

Emma Brennan ’21 is a senior majoring in biology and music and a 2020-21 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.

On April 13, 2021, the Biden-Harris administration announced executive actions to increase funding to address maternal mortality in the U.S., a critical step as it’s currently the highest in the developed world and still rising. Between 2000 and 2017, the U.S. and the Dominican Republic were the only countries to report an increase in maternal mortality. Many factors affect this trend, such as the increased average age of mothers, higher rates of Caesarean sections, and greater prevalence of conditions such as diabetes, hypertension, and heart disease that contribute to poor maternal health outcomes. Access to care and insurance coverage also greatly affect mortality. In addition, maternal mortality rates greatly differ by race. While non-Hispanic, white women in the U.S. are still more likely to die than women in other developed nations, mortality rates for Native American and non-Hispanic, Black women are significantly higher. Black women, in particular, are around three times more likely to die from pregnancy-related causes than white women, making their maternal mortality rate similar to those of developing nations.

While hospitals and care providers cannot be expected to single-handedly correct widespread societal issues such as insurance policy or unequal care access for rural areas, they have a responsibility to provide complete, competent care to their patients. Unfortunately, 60% of maternal deaths have been found to be preventable. In a hospital context, provider biases concerning women’s and people of color’s health issues and disorganized responses to maternal emergencies contribute to mortality. Failure to address these issues is an unethical oversight for any hospital.

The health system is often skeptical of women’s pain and symptoms, particularly those that are not as visible or do not manifest in the same ways a man’s would. Studies have shown women’s symptoms are often classified as “hysteria” or complaining and, thus, attributed to psychological issues rather than physical ones. As a result, women tend to be prescribed less pain medication and fewer opioids than men. They are, however, more likely to be prescribed antidepressants or given a referral for a mental health provider. It is easy to see how all pain and discomfort during pregnancy, birth, and the postpartum period, typical or pathological, are prone to being dismissed as “normal,” considering how tightly associated they are.

On top of these stigmas, Black mothers face the discrimination and biases experienced by people of color in the health system and beyond. For example, in a review of pain management in emergency departments, Black patients were less likely to receive pain medicine and opioids compared to white patients, even when there was evidence of traumatic injury, such as long-bone fractures.

In terms of maternal care, Black women are more likely to report unfair or disrespectful treatment by their providers and loss of autonomy during the birth process. There is such a disparity between the mortality of Black mothers and white mothers that Black women with a college education are more likely to die than white women with less than a high school education, even though advanced education is typically associated with greater income and access to quality health care as well as increased ability to advocate for one’s self. In addition to dangers arising from provider bias, experts also believe Black mothers are at a higher risk for developing health conditions affecting maternal mortality because of the stress experienced as a Black person existing in America. For example, increased stress levels resulting from discrimination have been tied to hypertension in pregnant Black women, which increases their vulnerability to serious complications during pregnancy and birth.

Problems within hospitals also contribute to maternal mortality in the U.S.. Over 50% of maternal deaths occur after birth, with nearly 20% occurring within the first week. A study conducted by the CDC’s Maternal Mortality Review Committee found that provider or health system failures played a significant role in the leading causes of mortality. Commonly cited was a lack of coordination or communication between care team members or relevant departments, lack of or outdated policies to address maternal emergencies, and inadequate training in responding to such emergencies. In addition, delayed or incorrect diagnosis by providers was also frequently implicated, causing delayed or incorrect treatment. Provider biases likely play a role in excessive mortality, especially for Black women. Along with chronic health conditions, the most common patient factor contributing to mortality was lack of knowledge of warning signs to report. This could reflect inadequate access to prenatal care during which a parent might receive this knowledge, or it could indicate failure of the provider to adequately inform patients of risks associated with pregnancy and birth.

In 2006, California took steps to reduce the impact of these factors on maternal mortality and saw a 55% reduction, finally bringing its mortality rate on par with Western Europe. The California Maternal Quality Care Collaborative began by targeting hemorrhage and preeclampsia, known to be the top preventable causes of maternal death. It provided toolkits of education about those conditions and established new protocols for hospitals to implement. For example, the hemorrhage toolkit provides standardized definitions concerning hemorrhage. This aids communication within the medical team by providing precise language to convey the seriousness of symptoms. Furthermore, policies requiring objective quantification of blood loss during every delivery add data to this communication and ensure severe bleeding does not go unnoticed. The toolkit also describes the most effective protocols for responding to a hemorrhage, supplies that should always be readily at hand, and instructions for performing regular hemorrhage drills.

Though CMQCC clearly had a significant effect on health outcomes for mothers, it did not address racial disparities in maternal mortality. Though mortality declined overall, the ratio between Black and white mortality rates has not. Going forward, hospitals should also implement implicit bias training, as stipulated by the recently implemented California Senate Bill 464. This bill, which went into effect in January 2020, requires maternal care providers to complete implicit bias training every two years.

Maternal mortality is a multi-faceted issue requiring numerous solutions to address all the societal factors that play a role in it. It also reveals how biases in our health system continue to result in grave medicals errors. However, as seen in California, it is possible for hospitals to improve their care. Hopefully, new federal funding will allow for the expansion of similar programs as well as new solutions to cover other gaps in our maternal health care.

May 4, 2021

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