Maternal Mortality: Reducing the Pandemic's Effect on Health Inequity

This essay first appeared in the Milken Institute’s Power of Ideas collection focused on navigating the new health, financial, and social uncertainties wrought by the ongoing pandemic and a reckoning of racial injustice. The essay series features insights from thought leaders across industries. Find more coverage on the Milken Institute LinkedIn page.

By Dr. Mary-Ann Etiebet, Lead and Executive Director of MSD for Mothers

August 2020

Maternal mortality is not just a vital sign of our health system, it is a vital sign of society. In the US, a woman in 1990 had a better chance of surviving childbirth than her own daughter does today. Black and Native American women are two to three times more likely to die due to complications of pregnancy and childbirth than white women. Inequitable outcomes also persist globally. In the UK, the rate of maternal death is significantly higher for Asian and Black women than white women, and Indigenous women in Canada have twice the risk of maternal mortality compared to the general population. Today, pregnant people are giving birth in the crosshairs of a devastating pandemic, which is having disproportionate impacts on communities of color.

How can we prevent the pandemic from exacerbating maternal health inequities and reverse these unacceptable trends?

Improved access to emergency obstetric care and high-quality maternity care has contributed to a reduction in maternal mortality globally. Still, every day, more than 800 women die due to complications of pregnancy and childbirth, and 20-30 times that experience severe complications that impact their physical, mental, and sexual health. Progress to reduce maternal mortality has not been uniform—particularly along societal fault lines of sex, gender, race, and class; the women most marginalized often receive the poorest quality care.

Maternal mortality is not just a vital sign of our health system, it is a vital sign of society.

So how do we achieve a world where no woman has to die while giving life?

Improving maternal health outcomes will require championing gender equality. As Mahmoud Fathalla, MD, PhD, described: “Women are not dying because of diseases we cannot treat… They are dying because societies have yet to make the decision that their lives are worth saving.” Around the world, countries with high gender inequality are associated with high maternal mortality compared to countries with low gender inequality.

Improving maternal health outcomes will require fighting for racial equity. In New York City, focus group discussions with women of color revealed poor communication, dehumanizing care, verbal abuse, abandonment, and rough treatment; many women felt ignored by providers and devalued during their maternity care. Being pregnant while Black in New York City makes you three times more likely to suffer severe harm and disability, irrespective of your neighborhood, income, education, or other medical conditions.

Since 2011, MSD for Mothers*—our company's $500 million initiative to help create a world where no woman has to die while giving life—has invested in solutions to end preventable maternal deaths. We have learned that transformation occurs when there is a radical re-centering of the voices, experiences, and solutions of birthing people—especially those most affected and those historically excluded—at the core of our efforts.

What does this mean?

  • First, radical re-centering requires that women’s experiences across pregnancy and birth should be integrated into all solutions. This means birthing people are designing programs, informing policy, and defining how we measure success. We know that when maternal mortality review committees rely only on medical records, they characterize significantly fewer maternal deaths as preventable compared with those including women’s voices. Only by recognizing the full spectrum of opportunities to prevent death can we act on all of them.
  • Second, radical re-centering requires that we meet birthing people where they are—both literally and figuratively. We can do this by redesigning health systems to extend care and holistic social supports into homes and communities as well as by dispelling assumptions and recognizing our shared humanity when we engage. It’s as simple and powerful as asking women what they want. Their number one response: dignity and respect.
  • Third, radical re-centering requires providers to commit to shared decision making and fostering a relationship of trust. As observed by one community health worker: “It is amazing how quickly that defensive armor can be shed when a provider shows compassion and respect and listens to the patient’s story instead of creating their own.” Through the Safer Childbirth Cities initiative, our collaborators are incorporating community health workers and doulas into maternity care to create affirming and collaborative care teams.

Without radically re-centering our efforts, we have seen how progress in reducing maternal mortality and morbidity can come at the cost of increasing inequities in maternal health outcomes. To end preventable maternal deaths, we must work together to create accountability for these principles so that they become new norms and dismantle the harmful institutional cultures and structures created over decades of systemic racism and sexism. The lives of our mothers and the health of our societies depend on it.

*MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, N.J., U.S.A.