The Massachusetts Medical Society (MMS)
wishes to be recorded in support of the House bill 1949 and Senate bill 1334, An
Act to Reduce Racial Disparities in Maternal Health.
The MMS
is a professional association of over 25,000 physicians and medical students
and advocates on behalf of patients for a better health care system, and on
behalf of physicians, to help them to provide the best care possible. The Medical Society believes that health care
is a human right and maintains a long-standing policy to strive for universal
access to health care and nondiscrimination in health care settings
The United States has the highest
maternal mortality rate among developed nations and is the only such country
whose rate is on the rise, with a 26% increase in maternal mortality rates
between 2011 and 2014.[1]
Approximately 700 women die
annually from pregnancy related complications, and a significant number of
these deaths – roughly sixty percent – were determined to be preventable,
according to the Centers for Disease Control and Prevention (CDC). Racial disparities in maternal mortality are
staggering, with African-American, Native American, and Alaska Native women dying
of pregnancy-related causes at approximately 3 times the rate White women in
the United States.[2] Research has shown that these
disparities persist, even when controlling for factors like income, prenatal
care, and maternal age. In
Massachusetts, overall rates of pregnancy-associated mortality increased 33%
from 2012 to 2014 alone.[3] Compounding this trend, Massachusetts and the
nation are in the midst of an opioid use epidemic, which is adversely impacting
maternal health. A recent report from
the Massachusetts Executive Office of Health and Human Services (EOHHS) found
that more than a third (38.3%) of deaths among women delivering a live birth
between 2011 and 2015 were fatal opioid-related overdoses.[4] This same report recommended further assessment
of the impact of treatment engagement and retention on maternal overdose during
the postpartum period and analysis to determine factors that may predict or
protect against overdose among mothers in the first year postpartum.
There are many contributing factors to maternal
mortality and racial disparities therein.
New research provides insight into some of the contributing factors,
including a rise in pregnancy-related medical conditions, and a lack of
standardized protocols across hospitals, varied access to quality and
respectful care, implicit bias, and varied access to adequate preconception
health care and insurance. While these
factors exist at the patient-, provider-, community-, health-facility, and
system-level, at its core, racial disparities in maternal mortality are
inextricably tied to racism – be it historical and structural racism in the health
care system or implicit bias or other forms.
As
providers, it is incumbent upon us to think critically and introspectively
about the impact of unconscious or implicit bias in clinical care and what we
can do to educate ourselves and take steps to make intentional progress toward
overcoming these realities.
CDC research identifies 3-4 contributing factors per
pregnancy-related death. Given the complexity of the problem, there is no
single policy solution or intervention that can comprehensively address all the
contributing factors to this public health crisis. The Medical Society supports the creation of a
special commission to study racial disparities in maternal mortality to support
and complement the work of the state’s Maternal Mortality and Morbidity Review
Committee (MMMRC). The MMMRC reviews the
deaths of all women who die while pregnant or within one year of the end of
pregnancy, irrespective of cause, studies the incidence of pregnancy
complications, and ultimately makes recommendations to improve maternal
outcomes and prevent mortality.
A 2018 report from the MMMRC describes challenges it
faces as a result of the rise in substance use among pregnancy-associated
deaths, which have underscored the need for additional resources and a review
of the scope and methods used in the case review process.[5] The special commission created by
H.1949/S,1334 would build upon the work of the MMMRC and will 1)
assess current research and identify potential gaps or limitations; 2) research
and evaluate the extent to which implicit bias, racism, and discrimination
affect maternal mortality; and 3) recommend policy solutions. The special
commission may conduct studies with a focus on racial disparities to understand
the problem throughout Massachusetts and ultimately make recommendations to
help the state address racial disparities and reverse the trend in maternal
mortality.
The Medical Society further recommends an expansion
of the scope of the special commission to include severe maternal morbidity
(SMM), as gathering more data on maternal morbidity is a critical step
to improving maternal outcomes. SMM includes
unexpected outcomes of labor and delivery that result in significant short- or
long-term consequences to a woman’s health.
The CDC estimates that 50,000 women each year experience such life-threatening
pregnancy-related complications.[6] SMM disproportionately impacts women of color,
with African American women twice as likely to experience SMM compared with
non-Hispanic white women.[7] Understanding these adverse medical incidences
are important in their own right, plus they create an opportunity to gain
insights into lowering the rates of and disparities in maternal mortality.
Thank you for your consideration, the Medical
Society respectfully urges a favorable report on H.1949/S.1334.
[1]
American College of Obstetricians and Gynecologists, Maternal Mortality,
https://www.acog.org/About-ACOG/ACOG-Departments/Government-Relations-and-Outreach/Federal-Legislative-Activities/Maternal-Mortality.
[2]
Centers for Disease Control and Prevention, Vital Signs: Pregnancy-related
Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017,
https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm?s_cid=mm6818e1_w.
[3]
Massachusetts Department of Public Health, Maternal Mental Health &
Pregnancy Associated Deaths, https://www.mass.gov/files/documents/2018/05/07/maternal-mental-health-data-brief.pdf.
[4]
Massachusetts Department of Public Health. Legislative Report: Chapter 55 – An
Assessment of Fatal and Non-fatal Overdoses in Massachusetts (2011-2015).
Available at: https://www.mass.gov/files/documents/2017/08/31/legislative-report-chapter-55-aug-2017.pdf.
[5]
Massachusetts Department of Public Health, Substance Use among
Pregnancy-Associated Deaths – Massachusetts, 2005-2014, available at https://www.mass.gov/files/documents/2018/05/02/ma-maternal-mortality-and-substance-use-april-2018.pdf.
[6]
Centers for Disease Control and Prevention, “Severe Maternal Morbidity in the
United States,” available at https:// www.cdc.gov/reproductivehealth/maternalinfanthealth/
severematernalmorbidity.html.
[7]
Andreea A. Creanga and others, “Racial and Ethnic Disparities in Severe
Maternal Morbidity: A Multistate Analysis, 2008-2010,” American Journal of
Obstetrics and Gynecology 210 (5) (2014): 435.
