Advancing Maternal Health Equity Research: Current Gaps and Trends

January 17, 2023 - On January 3, 2023, March of Dimes announced that it would launch its Center for Advancing Maternal Health Equity, based at the University of Pennsylvania, in collaboration with its Prematurity Research Centers. In recent years, the United States has been criticized for having the highest maternal mortality rate among developed nations.

Partially driven by inequitable access to healthcare, a study published by the Commonwealth Fund states that there are 23.8 deaths per 100,000 live births in the US. Maternal mortality rates among Black patients in the United States is nearly double that at 55.3 deaths per 100,000 live births. Comparatively, the next highest maternal mortality rate is 13.6 deaths per 100,000 live births in New Zealand, almost 43% lower than the overall average in the US and over 75% lower than the average for Black patients in the US.

“The United States, as a whole, doesn't do as well as other industrialized countries when it comes to maternal and infant health outcomes,” commented Emre Seli, MD, the Chief Scientific Officer at March of Dimes, a professor of obstetrics and gynecology, and a reproductive scientist at Yale School of Medicine. “If we put all of the people who live in the United States together, our outcomes, obstetrical, maternal, and fetal outcomes, at many levels are worse compared to countries with a similar economic and industrial status, such as Sweden, Denmark, among others.”

Racial Discrepancies in Maternal and Infant Death

According to an article published by the Kaiser Family Foundation (KFF) in November 2022, there are roughly 700 maternal deaths in the United States each year. Approximately 31% occur during pregnancy, 36% occur during labor and the first postpartum week, and the final 33% occur within the first postpartum year. These statistics alone are jarring; however, looking at differences among races sheds light on more drastic concerns.

KFF notes that pregnancy-related deaths are 2–3 times higher among American Indian/Alaskan Native (AIAN) and Black patients than White patients. Additionally, these patient populations, as well as other minority groups, are more likely to have maternal morbidities and other risk factors that could translate to poor maternal and infant health outcomes. 

Goals of the Center for Advancing Maternal Health Equity

With this data in mind, many providers, healthcare facilities, and organizations, like March of Dimes, have prioritized identifying and addressing preventable maternal and infant death issues.

“We aim to end all preventable maternal death, all fetal and neonatal preventable death, and inequities related to these subjects,” said Seli. “Of course, the ending is a lofty long-term goal, but our organization wants to work toward ending these issues.” Seli acknowledges that even if everything is perfect, there is still a risk of complications. However, he echoes existing data, noting that there is a large portion of preventable deaths.

Seli told LifeSciencesIntelligence that the primary reason behind March of Dimes starting the Center for Maternal Health Equity is to understand these significant discrepancies. As many other sources suggest, researchers and executives at the March of Dimes hypothesize that unequal access to care drives poor maternal health in the US.

“Strong data suggests that even in places where all things should be equal — like the Army, for example, where they all go to the same hospitals, doctors, and nurses — the outcome is still not the same,” asserted Seli. “Women of color still do not seem to receive the same care.”

This research aims to create actionable data on potential reasons while testing hypotheses and specific interventions. For example, in discussing issues with access to care, the first goal is to prove that there is an issue with access to care. After setting that foundation, the organization hopes to conduct real-life experiments that improve access to care and quantify the benefits or outcomes.

Preterm Birth

“There are several clinical outcomes that matter to us. One of them, probably the most important, is preterm birth — the likelihood of delivering a baby earlier than it should be,” began Seli. “Normal pregnancies are around 40 weeks. If it's earlier than 37 weeks, we consider it a preterm birth, which happens at a rate in the United States that is higher than in any other industrialized countries.”

According to Seli, the rate of preterm birth in the US is nearly 50% across marginalized communities, with Black and American Indian women being significantly more likely to experience preterm birth than White women.

“Babies that are born earlier are more likely to have complications. They may have breathing issues. They may have issues with their ability to see. Certain organs may not be as developed, especially the lungs, in babies born in a significantly earlier period during pregnancy,” explained Seli. “All these things may lead to long-term complications with metabolism, their ability to function, their ability to breathe, and their brain function. It is also associated with fetal, neonatal, and child mortality.”

In addition to preterm birth, preeclampsia is another symptom that is looked at. This is an elevated blood pressure during pregnancy that can be linked to many complications like those associated with pre-term birth. Preeclampsia is much more common in minority women and can lead providers to opt for induced deliveries, increasing the risk of preterm birth and other complications.

Cardiovascular Health

The second focus will be cardiovascular disease and cardiovascular comorbidities. Seli told LifeSciencesIntelligence that mild, moderate, and severe cardiovascular conditions — sometimes associated with metabolic disorders such as obesity — can significantly impact pregnancy outcomes and trigger pregnancy-related complications.

A 2020 publication in Circulation notes that approximately 25% of maternal deaths in the US are caused by cardiovascular disease or cardiomyopathy. Another article published in the Journal of the American College of Cardiology names cardiovascular incidences as the highest cause of maternal mortality.

Researchers note that pregnancy can exacerbate stress on the cardiovascular system by expanding blood volume, varying blood pressure, increasing cardiac output, and more. With these factors in mind, Seli notes that March of Dimes hopes to evaluate trends in cardiovascular health and maternal health equity. Additional research aims to address existing concerns.

Stress

Finally, Seli told LifeSciencesIntelligence that the center plans to research stress and its impacts on maternal health. “There is emerging data that this stress impacts people's health, pregnancy outcomes, outcomes of their children, and parental abilities,” he explained.

According to the Journal of Health Disparities Research and Practice, stress can exacerbate or trigger maternal health conditions such as preeclampsia, preterm birth, and infant mortality. The research in this publication indicated that stress associated with a partner increases maternal morbidity by 12%. Other stressors such as trauma, financial, and emotional stress increased risk by 10%, 14.8%, and 8.1%, respectively.

As little as 1–3 stressors increased maternal morbidity by 14% across the board. Additionally, those who reported seven or more stressors were 45% to have maternal morbidity. This data points to other social determinants of health that contribute to maternal mortality and morbidity, as Black women in this study were the most likely to report all stressors.

Data such as the one from this study has driven researchers at March of Dimes to conduct additional in-depth research on the relationship between stress and maternal health and inequities in stress levels.

“Our aim in putting together a research center, or starting a research center, is to pinpoint what's wrong. Our job as scientists at March of Dimes is to produce data that can be used by policymakers, politicians, journalists, and all the people who can enforce or encourage managing these things,” said Seli.