Each year in New York City, approximately 30 women die of causes related to pregnancy, with the largest burden of deaths falling on women of color. A 2016 Lancet series on maternal health put this problem in shocking perspective: The risk for Black women in New York City of dying in childbirth is double that of women living in some developing countries in Southeast Asia.
In an effort to better understand and effectively reduce maternal deaths, we at the New York City Department of Health and Mental Hygiene (DOHMH) decided to dig deeper and determine how many women in New York City are affected by severe maternal morbidity (SMM), or life threatening complications during childbirth including heavy bleeding, blood clots, kidney failure, stroke and heart attack.
We were inspired by the seminal work of Dr. William Callaghan at the Centers for Disease Control and Prevention (CDC), who developed a systematic way to identify SMM. Last year, in collaboration with the Fund for Public Health (FPHNY) with support from Merck for Mothers, we became the first urban health department in the U.S. to establish an SMM surveillance system using measurement methods developed by the CDC.
The results of this new surveillance system were alarming. Each year in New York City approximately 3,000 women suffer a life-threatening complication during labor and delivery. For every woman who dies from a pregnancy-related condition, 100 women almost die. In addition, SMM increased 28 percent in New York City from 2008 to 2012, from 197 severe events per 10,000 deliveries in 2008 to 253 in 2012, and the percentage was higher than the national rate.
The research also exposed blatant racial inequities. Black women were three times more likely to experience a severe event in childbirth than White women, and this disparity remained even after education was taken into account. In fact, Black women with college degrees or more had higher SMM rates than women of other races and ethnicities who did not graduate from high school. SMM rates were also elevated among Puerto Rican and other Latina women compared to White women.
As we like to say here at the Health Department, a person’s health should not be determined by their ZIP code. Yet, based on findings from the report, the areas with the highest SMM rates were in East and Central Brooklyn, neighborhoods which are largely Black and Latino, and poor.
What is the cause of these health disparities? A woman’s health before pregnancy and inequitable access to quality care are certainly factors, but we believe the driving force is structural racism. Structural racism is the normalization of intentional policies and systems that society has implemented – dating back to slavery and continuing to this day – to foster racial discrimination, such as red-lining, to determine which neighborhoods to invest in. The result: residential segregation, underinvestment in neighborhoods where the majority of residents are people of color, and inequitable distribution of resources. Together these factors lead to chronic stress and disease. Communities that have been historically oppressed bear the heaviest burden of negative health outcomes in New York City and elsewhere in this country.
Video: The Fight Against Severe Maternal Morbidity in Brooklyn
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The 2016 SMM report is a call to action, catalyzing attention on maternal health in New York City and identifying areas of focus to reduce and eventually eliminate the racial disparities in maternal outcomes. Now is the time to join forces with national partners. We stand with the Black Mamas Matter Alliance and support their Black Mamas Matter initiative which, “centers Black mamas to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice.”
In New York City, we are implementing a multi-faceted strategy that includes ongoing surveillance of SMM, collaboration with hospitals to assure best clinical practices during labor and delivery, and community engagement, with a particular focus on women’s health before, during and following pregnancy.
First, we will continue to doggedly track SMM and maternal deaths on an annual basis and disseminate the information widely. We will work with a diverse group of clinicians, social workers, specialists and community members to review findings and make policy and systems-level recommendations based on these findings.
Second, we will build on our strong relationships with New York City’s hospitals and birthing centers in collaboration with the American Congress of Obstetrics and Gynecologists (ACOG) District II and their Safe Motherhood Initiative (SMI). The SMI was launched in New York State in 2013 by a coalition of hospitals to develop and implement protocols for hospitals to prevent and respond to the life-threatening events associated with both SMM and maternal death.
Third, we will continue to implement home visiting programs for mothers and babies, including the Nurse-Family Partnership (NFP), Newborn Home Visiting Program, Healthy Start, and By My Side Doula program. We are expanding capacity this year and working with CenteringPregnancy, a group model of prenatal care that has been shown to reduce preterm birth (birth before 37 weeks pregnancy). Women participating in CenteringPregnancy report increased satisfaction with care, being better prepared for labor and delivery and experiencing less pregnancy-related stress in late pregnancy.
In Depth: When New Moms Get Sick, Race—and Hospitals—Matter
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Lastly, we will deepen our work in neighborhoods facing the greatest challenges. In April, the agency launched Neighborhood Health Action Centers in the South Bronx, East and Central Harlem, and North and Central Brooklyn. By the end of this year, three of these Action Centers will have Family Wellness Suites, community respite places where families and their children can be connected to neighborhood resources, city agency services and programs such as prenatal exercise, yoga, and parenting classes. We are also partnering with community-based organizations to coordinate their work with ours and to assure that the community informs our strategies and activities. Through the Sexual and Reproductive Justice Community Engagement Group launched two years ago, we are partnering with over 50 organizations to implement a community-based campaign that promotes the human right of all people to choose to have or not have children, choose the conditions under which to give birth or create a family, and to care for their children with the necessary social supports in a safe and healthy environment.
All women deserve to have access to the highest quality primary, prenatal and labor and delivery care, and to be seen by providers that they feel comfortable talking to and who treat them with respect. The unjust gaps in SMM and maternal death are unacceptable and we must work together to implement solutions to this grave problem so that all people have the same opportunity to a healthy pregnancy and a healthy life.
Hannah Searing, Deborah L. Kaplan and George L. Askew represent the Bureau of Maternal, Infant, and Reproductive Health in the Division of Family and Child Health of the New York City Department of Health and Mental Hygiene.