Applying a Racial Equity Analysis: Maternal Mortality in the District of Columbia

July 24, 2018
By Temi F. Bennett, Esq.

The District of Columbia has the highest maternal mortality rate in the country. Seventy-five percent of the maternal deaths recorded by D.C. health officials between 2014 and 2016 were of Black women.[1] Nationally, Black women are 243% more likely than white women to die from pregnancy or childbirth-related causes.[2] Maternal mortality is a health crisis for Black women, but rarely do we address root causes. Much of our focus is on access.

Last year the maternal ward at United Medical Center (UMC), the only hospital located in southeast DC, was closed down. When a city closes down the only maternal ward in a community that is already transportation challenged, access is certainly going to be an issue.  However, Black women are disproportionately impacted by maternal mortality in shocking numbers across the country regardless of access. This disproportionate impact on Black women requires a racial equity analysis to examine the root causes at play.

The framing of the issue is important in a racial equity analysis because it determines the solutions that are put forth. One dominant frame places blame and burden on Black women because of our poorer health status. Statements like “they are dying at such high rates because they are obese, have diabetes, hypertension, and heart disease,” are made to make the case that it is Black women’s fault; they do not want to live; they do not want to have healthy babies. The notion that Black women’s poor health outcomes are caused by our poor choices is highly accepted and perpetuated. This misinformed narrative does not acknowledge the structures and institutions that limit our choices.

Another dominant frame suggests that maternal and child outcomes are determined by class and access. Studies have repeatedly shown that normal weight Black mothers are more likely to die than white mothers who are obese.[3] Black women who live in affluent neighborhoods are more likely to die than white women living in poor neighborhoods.[4] And Black women who receive prenatal care in the first trimester are still more likely to have a poorer outcome than a white women with no prenatal care.[5] Despite access, income, and education, Black women still have higher rates of maternal mortality than their white counterparts. This evidence compels us to move beyond class arguments to finally account for race and the experience of discrimination based on race.

A key aspect of a racial equity analysis is determining how race and the experience of discrimination based on race impacts a given issue. Race is a social construct, meaning there is no biological basis for race. But, just a few decades ago, American colleges and universities still taught the existence of three races: negroid, caucasoid, and mongoloid. Scientific racism continues today and shows up in our medical system.  For example, numerous studies show that Black Americans are systematically undertreated for pain relative to white Americans.[6] Further, studies have shown that medical staff who held false beliefs about biological differences between Black and white races made less accurate treatment recommendations to Black patients.[7] A 2002 report from the Institute of Medicine found that Black Americans received less effective care than their white counterparts for nearly every disease studied.[8] These myths of biological differences can lead to an underprescription of medications for pregnant, Black women.[9]

Moreover, implicit bias of doctors and medical staff contributes to the substandard care Black women receive. This unconscious bias in the medical system manifests itself in the refusal of doctors and staff to listen, believe, and take serious the complaints of Black women.[10] This becomes a risk factor for our health. Serena Williams’s almost fatal, post birth case brought attention to this issue after medical staff continued to ignore her specific requests based on her medical history and knowledge of her body.

In addition to scientific racism and implicit bias, racism impacts Black women’s maternal mortality, and health in general, through weathering, a process of health deterioration caused by the daily racism (social and economic adversity) and micro-aggressions that Black women face.[11] This cumulative stress decreases telomere length, for example, which results in poor health outcomes through accelerated aging. Consequently, Black women become biologically seven and a half years older than our natural age. This, too impacts our maternal and child health outcomes.

Further, the feeling of being “devalued and disrespected” by medical providers during the most physiologically difficult and emotionally vulnerable time in our lives is pervasive. [12] Negative interactions between Black women and healthcare providers engender distrust of doctors and staff and cause skepticism of their treatment decisions, which can affect our treatment adherence and health outcomes.[13]

Using a racial equity analysis will help determine more accurate solutions that get to the root causes of Black maternal mortality. What solutions might we co-create with these points of departure?


[1] America’s Health Rankings, United Health Foundation (2018), https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/maternal_mortality/state/DC

[2] Pregnancy Mortality Surveillance System, Centers for Disease Control and Prevention (November 9, 2017), https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

[3] Severe Maternal Morbidity in New York City, 2008–2012, New York City Department of Health and Mental Hygiene (2016), https://www1.nyc.gov/assets/doh/downloads/pdf/data/maternal-morbidity-report-08-12.pdf

[4] Id.

[5] Id.

[6] Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, Psychological and Cognitive Sciences (2016) http://www.pnas.org/content/pnas/113/16/4296.full.pdf

[7] Id.

[8] Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine (2003), https://www.nap.edu/read/10260/chapter/1

[9] Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, Psychological and Cognitive Sciences (2016) http://www.pnas.org/content/pnas/113/16/4296.full.pdf

[10] The Propublica study and Discrimination in America: Experiences and Views of African Americans, National Public Radio, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health (October 2017), https://www.npr.org/assets/img/2017/10/23/discriminationpoll-african-americans.pdf

[11] Do US Black Women Experience Stress-Related Accelerated Biological Aging?: A Novel Theory and First Population-Based Test of Black-White Differences in Telomere Length, Human Nature (Hawthorne, N.Y.) (2010), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861506/

[12]  Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, Psychological and Cognitive Sciences (2016) http://www.pnas.org/content/pnas/113/16/4296.full.pdf

[13] “The Associations of Clinicians’ Implicit Attitudes About Race With Medical Visit Communication and Patient Ratings of Interpersonal Care”, American Journal of Public Health 102, no. 5 (May 1, 2012), https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2011.300558

One response to “Applying a Racial Equity Analysis: Maternal Mortality in the District of Columbia”

  1. Subrinnia Mason says:

    Excellent thought-provoking article revealing those deep rooted causes that plague black communities…like you pointed out, no matter what the economic status is.

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