‘We have no time to waste’: Fighting back against the maternal mortality crisis for women of color

By: Justin Sweitzer

March 1, 2024

Pennsylvania doesn’t just have a maternal mortality problem – it has a maternal mortality crisis. 

According to the most recent report issued by the state’s Maternal Mortality Review Committee, there were more than 100 maternal deaths in the commonwealth in 2018 – the most recent year for which data is available. And to illustrate the complexity of the issue, maternal deaths, both in Pennsylvania and across the nation, overwhelmingly impact women of color.

To measure the scope of the crisis, researchers often turn to the pregnancy-associated mortality ratio, or PAMR – a figure that measures the number of maternal deaths per 100,000 live births. In Pennsylvania, non-Hispanic Black women have a pregnancy-assisted mortality ratio that is more than double the rate of white women, and similar figures can be seen nationally, per the state’s Maternal Mortality Review Commission. 

According to data from the Centers for Disease Control and Prevention, the number of maternal deaths per 100,000 live births – which the CDC refers to as the pregnancy-related mortality ratio – was 17.6 deaths in 2019. For white women, the 2019 ratio was 14.1 deaths. For non-Hispanic Black women, the number rose to 39.9 deaths per 100,000 live births; and for non-Hispanic native Hawaiian or Pacific Islanders, the number came in at a startling 62.8 deaths per 100,000 live births. 

Democratic state Rep. Gina Curry, who co-founded the Pennsylvania Black Maternal Health Caucus, said the numbers indicate lawmakers, health care providers and others in the maternal care space need to do everything in their power, and fast, to prevent more maternal deaths from occuring in the commonwealth.

“The numbers that come out of the board that does the reporting for maternal mortality and morbidity are staggering. I can't believe that we live in a time where giving birth is probably one of the biggest risks,” Curry told City & State. “I remember giving birth myself for the first time, I was 27 years old, and somebody said to me, ‘This is the closest you'll come to death.’ I remember that. Not something you want to hear when you're about to go through that process.”

“We have no time to waste with those numbers,” Curry added.

Dr. Sharee Livingston, an obstetrician-gynecologist at the University of Pittsburgh Medical Center who also serves on Gov. Josh Shapiro’s Advisory Commission on Women, said that to address racial disparities in maternal mortality rates, particularly among Black communities, health care providers must build better relationships with the communities they serve. 

“Let’s talk to the patients, let’s talk to the families, talk to the communities and ask them, ‘What is it that we can do to help make Black birth better?’ And they'll tell you … ‘I am fearful. I have distrust.’ Those are two most common things that we see,” Livingston told City & State. “I think if we intentionally address fear and distrust, we can reverse the trend. How do you build trust? You build trust by building relationships. So we have to get (to) birthing people before their pregnancies. That means going out into the communities and engaging, walking shoulder-to-shoulder with the community, submerging ourselves into their environment so that there is less implicit bias.”

One group working to improve maternal health and prevent pregnancy-related deaths is the Maternity Care Coalition, an organization that provides educational and referral services to soon-to-be parents and also advocates for policy changes to improve maternal care.

Marianne Fray, the president and CEO of the Maternity Care Coalition, said the organization uses a “two-generation strategy” that seeks to provide support services to mothers and their babies. 

“All that means is that we work with both the birthing person and their baby,” Fray told City & State in an interview. “Some organizations might work just with the mom, or to a specific period right after birth, but then they might not really work with the baby. Or some organizations work with the baby and not the mom. We really feel that by working with both the birthing person and the baby up to the age of three, we can ensure that they’re healthy … That, we find, is key to a child’s optimal growth and well-being.”

Over the last year, Pennsylvania has made multimillion-dollar investments in maternal health programming, and has expanded the type of maternal health data that it will review and collect moving forward. Shapiro, in his 2024-25 budget proposal, is also calling for an influx of $2.6 million to go toward the development of new maternal mortality prevention strategies.

Curry told City & State that if policymakers, health care providers and other stakeholders work to address the high rates of maternal mortality in Black communities, it will reap dividends for everyone in the state, not just Black families.

“Maternal health as a whole is suffering. We’re looking at Black maternal health, which is an absolute must right now, because those numbers are crazy. The numbers for maternal health, as a whole, are extremely disturbing as well.” 

“If we solve Black maternal health, we’re gonna solve maternal health because they are intrinsically connected,” Curry said. “It’s just that Black women are dying two to three times higher than their counterparts.”

City & State spoke with Curry, Livingston and Fray about Pennsylvania’s maternal mortality crisis and how to address racial disparities in maternal mortality rates, as well as any policy changes lawmakers explore to help families and reduce deaths.

What should Pennsylvanians know about the maternal mortality crisis in the commonwealth?

SL: Four out of five deaths are preventable. People don't have to die, we will naturally see moms die, but we can work on the preventability. It’s a fixable problem – by looking deep within our systems, and sort of unmaking the cake that exists to create health disparities. If we address health disparities, we can improve health outcomes. If we improve health outcomes, we’re going to naturally see maternal morbidity and mortality rates go significantly lower.

GC: We have no time to waste. The numbers that come out of the board that does the reporting for maternal mortality and morbidity are staggering. I can’t believe that we live in a time where giving birth is probably one of the biggest risks. I remember giving birth myself for the first time, I was 27 years old, and somebody said to me, ‘This is the closest you’ll come to death.’ I remember that. Not something you want to hear when you're about to go through that process. But I think it was this stark reality that you’re bringing a life forward, but you could possibly sacrifice your own with the act of delivery. The folks who have already sacrificed, and just the fact that it is around a racial disparity, is the part that I think is the most disturbing. But maternal health as a whole is suffering. If we solve black maternal health, we’re gonna solve maternal health because they are intrinsically connected. It’s just that Black women are dying two to three times higher than their counterparts.

MF: Well, they should know, in short, that the rates are rising, and rising especially for non-Hispanic Black women at a rate of three to four times that of non-Hispanic white women. That’s according to the CDC. That’s nationally, but it's also the same in the commonwealth. Even when some communities show a little bit of improvement, there are still racial disparities that remain. So what Pennsylvanians should know is that, unfortunately, there is a persistent problem … the rates are rising, and that begs the question of why? Why do we see those disparities? The obvious answer is that there's something that's happening that is targeted toward non-Hispanic black women versus non-Hispanic white women, regardless of economics, because birth outcomes are worse for Black women whether they have means or not. Social determinants of health – income, education, housing, food stability – are impacting those rates that we're describing. But it's not just those things. It's also structural determinants of health … structural issues are upstream, meaning that they’re the root causes for what happens downstream. So if there are governing processes, economic and social policies that impact those downstream things – that’s where we really want to target our efforts, and they're much harder. They’re intransigent issues to deal with.

The Shapiro administration recently secured a $2.3 million investment in maternal health programming, and the state is also going to be publishing more comprehensive data moving forward. What kind of difference can expanded data make when dealing with components of this crisis?

SL: You have to measure what matters. It’s important that we look at data; some people need to see facts to understand because it may not happen to them, it may not impact them. Fortunately, there are more people who don’t know someone who has died than the opposite. You don't have to be a fifth grader to see, to know and understand that three to four times anything is a higher number. But it’s not like Black birthing people are just mandated to die in childbirth. It’s a problem that's fixable. Four out of five deaths are preventable.

GC: That information is critical. One of the things that we've talked about is like having every county have that one of those boards for their own county. If you have a high rate of Black maternal health deaths, you’re going to look twice and say, ‘Wait a minute.’ I would love to have it in mine, in Delaware County, because we have a desert, we have a situation where we are losing folks and often it’s covered under something else – cardiac or any of the other things that can cause death. When you really look at it, it goes under the umbrella of maternal mortality. Having access to the reporting really makes me feel like we're paying attention. Having it happen every three months makes me feel like we care. The more information we have that we're equipped with, the better opportunities that we'll be able to put funding in place.

MF: Theoretically, yes … maternal morbidity, according to the National Institutes of Health, is any health condition attributed to and or aggravated by pregnancy and childbirth that has negative outcomes to a woman’s health and well-being. … If we were to better track morbidity, it would give us more opportunity to identify critical areas where we can intervene and improve, and it integrates a lot of the committee recommendations from the Maternal Mortality Review Committee. It’s an important step in improving outcomes for pregnant people because it allows you to predict a little bit more, to evaluate it before it becomes a death. It becomes an indicator, if you will. Tracking it and being much more disciplined about that and requiring it is a way of improving, ideally, health outcomes.

What policy changes or other changes would you like to see to address maternal mortality rates in the commonwealth?

SL: The number one thing that I, as an OB-GYN physician, would like to see is the expansion of Medicaid so that we can not stop it at the 8-week mark or the 12-week mark, but extend it for an entire year. The postpartum period is a very vulnerable time for birthing people. Four out of five people suffer from anxiety and depression. Chronic issues they were dealing with pre-pregnancy and inside of pregnancy can manifest and worsen. It’s the (not the) time that we should be just dropping them from care.

GC: When we are looking at the Momnibus, we’re excited. We know that the federal Momnibus has had one bill passed. I think there are 12 in the package. That’s why it’s so important to have a bipartisan involvement here. We don't want to put a package together and (have) it just sit. We want to look at things around funding. We want to look at the Medicaid system, doula reimbursement. We had a win last year for the 12-month extension of postpartum care. That's critical, because you can find things in that time period that can help to save a birthing person's life – and their children. We want to look at mental health and maternal care, pre-preparation for birthing. We also want to be able to look at maternity deserts, the accessibility of care – because that's a big part of it. If you think about prenatal care, and you think about postpartum care, somebody might say, ‘I don't feel good, my head is hurting, but I don’t really have accessibility today, there's nobody to take me to this appointment and I have to get on the bus.’ That would take a long time. We have to really think about how we can improve access.

MF: So high-level, in order to fill that gap, to address it, it’s basic stuff: increase access to culturally competent care. That sounds easy, but it's going to require targeted investment and systems-level change. It's going to require something beyond just cultural competence training. It's going to require something like incentivizing payers and hospital systems to actively pursue improving outcomes for non-Hispanic Black moms particularly, and diversifying the perinatal workforce. Going back to that idea of upstream versus downstream, you have to have adequate educational opportunities for folks who have been historically shut out from opportunities to be able to get into the pipeline. That’s not an easy thing to do, but it’s possible if we have the will to do it. For so long, doula care was only available to those who had lots of means. There were no doulas when I was coming up, let me tell you something. I just didn't know about it. I think there’s been a lot of attention placed on doula care, but access is still limited. The most important thing is to pull paid leave across the finish line. That is House Bill 181, set to hopefully get to the floor in March. Thirty-eight percent of Black women need paid leave, but they don't take it – they can’t.