Combating Rising Maternal Mortality Rates

In North Carolina, where the Black population comprises only 22%, Black women accounted for 43% of the state’s pregnancy-related deaths from 2020 to 2022. This staggering disparity takes place despite the fact that a number of these fatalities happen under the supervision of healthcare professionals.

In 2021, the national maternal mortality rate was 32.9 per 100,000 live births while Black women experienced a 69.9 maternal mortality rate per 100,000 live births. While in North Carolina, the maternal mortality rate doubled from 2019 to 2021—jumping from 22 per 100,000 births to 44 per 100,000 births. In response to this staggering reality, in Fall 2023, the U.S. Department of Health and Human Services allocated more than $4 million across different agencies, institutions and organizations in North Carolina to address maternal deaths during childbirth. Funds from the U.S. Department of Health and Human Services will be distributed across various initiatives aimed at reducing maternal mortality rates. The initiatives will encompass a multi-faceted strategy, targeting the diverse factors contributing to increased maternal mortality. In addition to these initiatives, alternative paths such as legal remedies achieved through litigation and legislation are also being used to further address maternal mortality concerns.

DEPT. OF HEALTH & HUMAN SERVICES FUNDING

The $4 million awarded to North Carolina, via the Health Resources and Services Administration (HRSA) supports the White House Blueprint (Blueprint) for Addressing the Maternal Health Crisis which strives to improve maternal mortality rates and maternal health, particularly in underserved communities. By investing in these five initiatives, NC is directly infusing funds to cities across the state—including Charlotte, Chapel Hill Raleigh, and Greenville.

WHAT IS MATERNAL MORTALITY

The U.S. has one of the highest maternal mortality rates in the “developed” world. Understanding the definition of maternal mortality helps provide insight into who is being included in these troubling metrics. Generally, maternal mortality encompasses deaths due to complications from pregnancy or childbirth. The World Health Organization defines maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death (obstetric and non-obstetric) [including] unintentional/accidental and incidental causes.”

Examples of obstetric deaths include: omissions of treatment, incorrect treatment, or a combination thereof, and anesthesia or cesarean section complications. Examples of non-obstetric deaths or indirect maternal deaths, are deaths resulting from a previously existing disease (ex. Diabetes; obesity; asthma) or a disease developed during pregnancy that is not directly related to obstetric causes but aggravated by the physiological impact of pregnancy.

HOW THE FUNDS WILL BE DISPERSED & FUNDING GOAL

The $4 million will be dispersed through five groups of entities that work to support mothers before, during and after birth, including: Healthy Start-Enhanced; Screening and Treatment for Maternal Mental Health and Substance Use Disorder Program; Maternity Care Nursing Workforce Training Program; Alliance for Innovation on Maternal Health Program–Capacity; and State Maternal Health Innovation Program –Supplemental Funding. Directly infusing funds across the state–in Charlotte, Chapel Hill, Raleigh and Greenville NC.

Each awardee addresses a goal of the Blueprint. Healthy Start-Enhanced provides direct services to pregnant and postpartum mothers providing direct and enabling services. Services include screening and referrals, care coordination, doula services and parent education classes. Healthy Start-Enhanced also works to support community-wide efforts to address the non-medical factors that impact health outcomes, such as housing security and nutrition.

Through the North Carolina Department of Health and Human Services, HRSA is investing in the Screening and Treatment for Maternal Mental Health and Substance Use Disorder Program by supporting the training of OB/GYNs, midwives and other maternal health providers in treating mental health and substance use disorders. The funds will also provide healthcare providers with greater support including teleconsultation with psychiatrists and other mental health providers to better screen, understand, support, and provide care to patients.

Funds donated to the Maternity Care Nursing Workforce Training Program, will invest in training and deploying nurse midwives to expand the maternal and prenatal workforce on the ground and in-turn, provide greater access to care. This funding has the dual effect of giving teeth to NC Senate Bill 20, which went into effect this past October, which expanded midwives ability to practice. The Nursing and Science Department Chair, Dr. Pam Reis, appears hopeful that the combination of the HRSA funding along with the new practice requirement, will allow greater access to maternal care in rural North Carolina.

Through allocating funds to Alliance for Innovation on Maternal Health (AIM) Program, HRSA hopes to better equip birthing facilities’ ability to deal with the leading causes of maternal mortality through “patient safety bundles.” AIM works to improve the quality-of-care mothers receive and make birth safer through coming up with solutions and care plans to identify and address obstetric hemorrhage, severe hypertension, and care for those with substance use disorder, to strive for not only healthier born babies but healthier mothers.

Lastly, funding going towards the State Maternal Health Innovation Program –Supplemental Funding will help mothers and their families navigate the Medicaid eligibility and redeterminations.

Together, these awardees will work together usingin a multi-faceted framework to systematically dismantle the factors leading to increased maternal mortality rates. In addition to federal funding efforts, there have also been litigation and legislation efforts to combat the increasing maternal mortality rate.

THE BACKGROUND: CEDARS-SINAI LITIGATION AND SUBSEQUENT LEGISLATION

The U.S. Department of Health and Human Services funding comes on the tail end of significant litigation and introduced legislation aimed to call attention to the increasing maternal mortality rate amount Black women.

CEDARS-SINAI CASE

In 2017 Kira Johnson underwent a mere 17-minute, from start to finish, repeat cesarean section. Typically cesarean sections take about 45 minutes from start to finish. A repeat cesarean section is when a woman has already had at least one prior cesarean section. Repeat cesarean sections are known to carry increased risks of incision-related complications, problems with the placenta and complications related to adhesion. However, research is not definitive on the exact number of cesarean sections that are considered to be safe.

Within the hour, after Mrs. Johnson’s husband, Charles Johnson, observed blood in her catheter bag–a sign of internal bleeding–and began to plead with medical staff to provide her care and help. Mr. Johnson watched the color and life slowly fade from Mrs. Johnson for more than ten hours. Subsequently, Mrs. Johnson died after more than 12 hours of slow internal bleeding.

In both the medical malpractice lawsuit filed in March 2017 and the civil suit filed in May 2022, against Cedars-Sinai, Mr. Johnson points to racism playing a role in the treatment–or lack thereof–his wife received because. Mrs. Johnson was a Black woman. ~~and w~~While both lawsuits have been settled, sworn testimony in the civil case and peer reviewed publications by Cedars-Sinai employees and managing agents, reveal systemic racism in the delivery of health care: both across medicine generally, and particularly at Cedars-Sinai. In their sworn testimony, a Cedar-Sinai surgical technician stated,

“I can—I can write a book. I’ve heard statements. I’ve heard through the years in O.R., behind the scenes. I’ve heard racial comments toward patients that were asleep . . . just so many in comments, blatant, some underlying . . . I’m afraid if I do speak up, I’m going to be in HR written up. Oh, because of—it’s terrible, because you think your whole job is at risk . . . when I see my Black –the Black patients come in, I say an extra prayer. And that has been my creed of my career to this day; I say a silent prayer that all goes well. Because you do have racism very much so in the operating room.”

As a result of Johnson’s suits, Cedars-Sinai also took steps to address the disparity in care Black mothers receive and maternal mortality in general. First, Cedars-Sinai has given “$2.2 million in grants to nonprofits addressing racial disparities in maternal care, holding annual training on unconscious bias, conducting research to identify racial disparities and partnering with organizations and Black leaders to find solutions.”

Additionally, Cedars-Sinai is working with the California Maternal Quality Care Collaborative to “identify the causes of maternal loss of life, and any contributing factors, in order to develop evidence-based recommendations for prevention.”

Cedars-Sinai also took steps to address the disparity in care Black mothers receive and maternal mortality in general. First, Cedars-Sinai has given “$2.2 million in grants to nonprofits addressing racial disparities in maternal care, holding annual training on unconscious bias, conducting research to identify racial disparities and partnering with organizations and Black leaders to find solutions.”

PREVENTING MATERNAL DEATHS ACT

Mr. Johnson continued to fight for justice for his wife by authoring legislation [Preventing Maternal Deaths Act] with Rep. Jaime Beutler, which strives to prevents maternal deaths.

The bipartisan bill provides federal support to states to create review committees tasked with identifying maternal deaths, analyzing the factors that contributed to those deaths and translating the lessons into policy changes. While some states may have already had such a panel, the legislation specifically allocated federal funds for the first time and set out guidelines that states must meet to receive those grants. The Preventing Maternal Deaths Act was passed and signed into law by then-President Trump.

MOMNIBUS ACT

There are additional legislative pathways in North Carolina that have been proposed to combat maternal mortality rates. In North Carolina legislation entitled the MOMnibus Act was put before the NC legislature this past spring. The goal of the bill is to establish or expand programs for the prevention of maternal mortality and severe maternal morbidity among Black women.

The legislation will establish a grant program to disperse funds to eligible entities to create or expand programs striving to prevent maternal mortality. The program will provide technical assistance to grant recipients, including best practices in data collection, measurement, and evaluation reporting. Additionally, the program will implement an implicit bias training program for healthcare professionals engaged in perinatal care and enact rights of perinatal care patients who receive care at a perinatal care facility [ex. Hospital, clinic or birthing center in NC]. Perinatal care patients’ rights include the right to be informed of continuing health care requirements following discharge, the ability to receive appropriate pain assessment and treatment, and the right to receive information on how to file a complaint with the division of Health Service Regulation of the Human Rights Commission or both about any violation of these rights.

The last action on the bill was to refer the bill to House Standing– Rules, Calendar, and Operations of the House Committee.

CONCLUSION

While funding such as the HRSA is important in providing concrete monetary support in the multi-faceted framework to systematically dismantle the factors leading to increased maternal mortality rates, legal action through suit but particularly legislation, is equally important. 80% of pregnancy related deaths are preventable. Utilizing legal action will ensure sustainable and ongoing accountability–greater than one-time monetary awards or trial programs– that the policy preventions strive to accomplish.

Kiah Stith

Class of 2025, Staff Member