We can't watch black women die
October 29, 2017 12:38 PM   Subscribe

The maternal death rate in the US more than doubled between 1987 and 2013, and black women are dying at the highest rates of all. A 2016 joint report by the Texas Department of State Health Services’ Maternal Mortality and Morbidity Task Force found that black mothers accounted for 11.4% of Texas births in 2011 and 2012, but 28.8% of pregnancy-related deaths. There are various theories why — persistent poverty, large numbers of women without adequate health insurance, risk factors related to stress and discrimination. All come together in Texas, with a twist that has become one of America’s most confounding public health problems: African American women are dying of pregnancy- and childbirth-related causes here at stunningly high rates.
posted by stillmoving (31 comments total) 30 users marked this as a favorite
 
It would help if they stopped publishing racist bullshit in nursing textbooks.
posted by TedW at 12:57 PM on October 29, 2017 [38 favorites]


I work in Maternity Safety Transformation in the UK. The day I saw the US data, my jaw dropped. I can’t recall being as gobsmacked by anything in the last 2 yrs ( after Brexit & Trump)

Those data are shameful, they go against everything healthcare workers aim for, you essentially do as well as some of the developing economies, not as well as one of the worlds leading economies. Just gobsmacking.

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posted by Wilder at 1:54 PM on October 29, 2017 [25 favorites]


Quick googling and I get "As of 2012, the Bureau of Labor Statistics reported the median salary for all OB/GYNs was $301,737." Maybe its time to stand up to the AMA and the insurance lobby. At some point the shakedown needs to stop. ACA might have improved things, but it should be clear by now it didn't *solve* anything. The system is still completely opaque to those paying the costs, we need single payer so one entity can "shop" effectively or we need an transparent system where costs are stated upfront (like every single other transaction in every other industry) as well as relevant performance data. Lets see infant mortality indexed by both doctor and hospital published. Hard to hold 300K a year workers accountable when demand is completely inelastic, in the dark, and divorced from the decision making process.
posted by forgettable at 2:34 PM on October 29, 2017 [8 favorites]


We need more doctors too, they must open up more residencies. When you have one or two specialists in most states outside NY and CA they can act any way they like and people have no choice but to put up with it. It's the furthest thing from a free market. I guarantee the biggest ob-gyn clinic in town would never see another patient if people ha any choice. They have a terrible reputation but they're the only game in town for medically complicated pregnancies. I do know that very few women of color or other religions will even go in the door and I don't blame them- it skews very Judeo-Christian judgemental in there. I quit them over being told I was promiscuous when I went in to get an IUD because I'd slept with more than 5 men in my life (I was 35 and single at the time). And of course our big trauma center is Catholic. So that's not too nice if you're a pregnant woman in trouble.

There is a year wait here for most specialists and at least a month for a GP. With good insurance. And it's not like the local doctors are Einstein or anything, mostly form middling medical schools and mostly with a less than stellar reputation and not nearly enough time for their patient loads. We could ~easily~ absorb twice the number of MDs. Of course they wouldn't be able to see a patient every 15 minutes and might not be able to buy quite so many mansions and airplanes that way.
posted by fshgrl at 2:48 PM on October 29, 2017 [26 favorites]


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posted by potrzebie at 2:58 PM on October 29, 2017


Although even my rant about access to medical care being improved by having more doctors wouldn't help if they didn't realize this poor woman had a retained placenta. That seems criminal in this day and age.
posted by fshgrl at 3:04 PM on October 29, 2017 [1 favorite]


It's the furthest thing from a free market.

yeah throwing more markets at the problem is definitely going to solve the healthcare issue in America
posted by indubitable at 3:16 PM on October 29, 2017 [3 favorites]


Free market capitalism is like civil society has developed cancer. It's made of more or less the same stuff, but it just takes over everything until the host dies.
posted by Grangousier at 3:22 PM on October 29, 2017 [9 favorites]


I feel as if this is a feature and not a bug of our current political climate.
posted by batbat at 3:40 PM on October 29, 2017 [1 favorite]


(thanks mods for fixing my link)
posted by TedW at 4:07 PM on October 29, 2017 [1 favorite]


“There isn’t a single thing that explains it,” said Lisa Hollier, an obstetrician-gynecologist who heads the state-appointed Maternal Mortality and Morbidity Task Force. “There are so many different factors.”

Any doctor who says this should be forced to spend a year on Medicaid without any IAMADOCTOR ID. Every other causal factor is amplified many times over by the fact that women get a lower standard of care in the US, poor people get a lower standard of care in the US, and no one gives a shit about black people. Even when you have Medicaid, there's what it says on paper and then there's what actually happens at the one clinic that will actually accept you as a patient.

It's pretty simple: black women are at higher risk for complications from pregnancy but receive a drastically lower standard of care and are treated like draft animals when it comes to work, and you have to work in order to live, even if you just gave birth.

After the doctors, every advocate of single-payer should spend some time on Medicaid. There is this conceit that all we need to do is spend more money on poor people and things will work out. But the health care services market is collapsing and vacuuming every dollar it can find as it goes. Economically speaking, there is a demand side (which single-payer can address somewhat) but then there is a supply side, which single-payer can't address very well. It doesn't do any good to set prices if no one will accept you as a patient, and setting prices but letting the market do it's business is a recipe for a very chaotic collapse, instead of the slow collapse we in the US are living and dying through.

You have no idea just how bad a single-payer system can be unless you spend some time on Medicaid or, even better, spend some time bouncing on and off Medicaid because of the elaborate eligibility requirements.
posted by I hate nature. at 4:08 PM on October 29, 2017 [6 favorites]


Misogynoir is lethal.
posted by skye.dancer at 4:17 PM on October 29, 2017 [8 favorites]


So what’s wrong with expanding Medicaid as a universal single-payer system? Doesn’t that solve both the problems, assuming the whole point is no longer to keep the “undeserving” out but to actively try to give as much care as possible where it’s needed most?
posted by saulgoodman at 4:18 PM on October 29, 2017 [2 favorites]


Medicaid isn't single payer. Its minimal care for poor people. I've had single payer in other countries and it's nothing like Medicaid. Doctors can't refuse you for starters.
posted by fshgrl at 4:21 PM on October 29, 2017 [30 favorites]


Texastan.
posted by cjorgensen at 4:28 PM on October 29, 2017


As a general rule, means-tested programs for poor people are terrible in the US, whereas universal programs are not as bad. Medicare has its problems, but it works better than Medicaid. There's no reason to think that single payer would be as bad as Medicaid, if it were genuinely used by most people.

Having said that, there are definitely other problems: a shortage of providers, racism among providers, systemic racism and economic inequality that limit women's access beyond just whether they can pay for care, etc. Inequality kills, and this is just one of the ways that it kills people.
posted by ArbitraryAndCapricious at 4:32 PM on October 29, 2017 [3 favorites]


Of course they wouldn't be able to see a patient every 15 minutes and might not be able to buy quite so many mansions and airplanes that way.

Physician salaries are significantly higher in rural areas than in major cities. The reluctance of physicians to relocate to rural communities is generally understood to be due to cultural issues, not financial ones.
posted by telegraph at 4:34 PM on October 29, 2017 [17 favorites]


Physician salary has to cover malpractice insurance, and OB/GYN is astronomical because more than 75% of them get sued. The premiums range from $30,000 - $100,000 per year. So, you know.

Regardless, Texas is trying to alleviate poverty by eliminating poor people, most of whom are conveniently non-white, by choking access to and delivery of Medicaid.
posted by DarlingBri at 6:39 PM on October 29, 2017 [4 favorites]


Doctors have a very flashy role in healthcare delivery, but it is literally the tip of an iceberg, under the water of which is nursing quality, nursing administration and staffing levels, hospital administration and funding, access to health services, health literacy, nutrition, economic power, social inclusion, health of the local environment, occupational safety AND MORE!

Linking doctor pay incentives to patient outcomes just encourages doctors to work in a location with a patient population that has the fewest complications under the water.
posted by chiquitita at 7:31 PM on October 29, 2017 [15 favorites]


Physician salaries are significantly higher in rural areas than in major cities.

I live in a city dude. We have fuck all for specialists here. We barely have GPs. The Indian Health Service has shorter wait times and better availability than any privately owned facility - people who can usually go there. The VA has shorter wait lists for some specialities than private hospitals or practices. And those are not famously good or prompt systems. Imagine being on Medicare or Medicaid and trying to find a doctor here, it's impossible. And that is true of all small cities. It's easier in rural areas as the docs there generally accept they'll be seeing everyone local .

There are clearly not enough doctors in the US to meet demand. And residencies is the bottle neck from what I've been told.
posted by fshgrl at 7:57 PM on October 29, 2017 [4 favorites]


California has bucked the trend by gathering data, focusing on a range of quality of care indicators and providing evidence based toolkits. In 2013 for the US as a whole the rate for maternal deaths was 22/100k, while in California it went down to 7.3/100k.
posted by jasper411 at 9:00 PM on October 29, 2017 [7 favorites]


Guys read the article linked, read this recent post, and check out the excellent Vox article posted by jasper411. It's nothing to do with doctor shortages or doctor pay or racist nursing textbooks or whatever else. It's primarily about the United States not valuing maternal health, women's health, or women generally, an issue which is compounded by a lack of evidenced based care and systemic racial injustice.
posted by supercrayon at 9:34 PM on October 29, 2017 [19 favorites]


The Indian Health Service has shorter wait times and better availability than any privately owned facility

And the TV in the waiting area has tips for "cookin' with commods"!

At least my IHS facility did last Thursday when I went to drop off my paperwork.
posted by elsietheeel at 9:47 PM on October 29, 2017 [1 favorite]


Absolutely, it’s a feature of analysing what the data tells you, having said that believing the data is important enough to capture wasn’t even on my radar before reading about the systems in the US, I mean come on! As a society we place an overwhelming emphasis on childbirth but we don’t capture MM or discuss each case and do a root cause analysis so we can avoid repeating that?
I suppose if you were to capture the data the rates in poor & WOC would be so unacceptable......nah.....who am I kidding?
posted by Wilder at 2:59 AM on October 30, 2017


I read both studies. I conclude, TX not Medicaid is the leading cause of maternal morbidity. It runs over the inexorable erosion of comprehensive clinical skill across the nation is. I haven't had an intelligent physical examination in years. The thing now is diagnostic tests (with "chaperone") to do diagnostic tests with new, improved equipment. Follow-up is email request to complete a satisfaction survey. Here's an orthopedic surgeon who sued (sotto voce) a (fancy) hospital for misdiagnosing preeclampsia he was helpless to prevent!

Under the circumstances, I think, the odds of a black woman surviving a TX pregnancy are fair. They aren't disproportionately enrolled in TX Medicaid either. I would guess, one third of each TX ethnic group is women enrolled in Medicaid or Medicare. In 2012 TXicaid enrolled 4,844,300, of which 17% black women, men, and children, or 820K of 3M or so. Like it or not, TX did not expand Medicaid. Yet Medicaid paid for a little over half of all births in TX.

The stats here and there gloss the deadliest conceits that Dr and Mrs Bloomstein represented. 42% of all maternal death occurred within 60 days of discharge. Cardiac arrest and "non-obstetric" hemorrhage (acute preeclampsia) stalking black women, was the top cause of death in the TX study. The remaining deaths researchers distributed between Neonatal Abstinence Syndrome, or opioid OD (cardiac arrest), and mental illness. They attribute that "risk" to 78% of Medicaid and 21% of private insurance cases, while the highest proportion of maternal death by suicide was among Latinas (30% of total deaths, 48% of total births, ~16% TX population).
posted by marycatherine at 3:58 AM on October 30, 2017


Guys read the article linked, read this recent post, and check out the excellent Vox article posted by jasper411. It's nothing to do with doctor shortages or doctor pay or racist nursing textbooks or whatever else. It's primarily about the United States not valuing maternal health, women's health, or women generally, an issue which is compounded by a lack of evidenced based care and systemic racial injustice.

I really agree. You don't get this shocking rise in mortality rate from an accumulation of racist person to person interactions, either, you explain them with systemic racism - policies that have the effect of placing poor women in worse health, of making sexual health resources difficult to access, and distancing them from adequate prenatal care, all of which create acute crises that are then exacerbated by substandard care.
posted by entropone at 5:58 AM on October 30, 2017 [3 favorites]


Increases in maternal mortality in this day and age are egregious, and the racial discrepancy is abhorrent. But this article and some of the comments here lack a bit of statistical rigor.

Newspapers love to do this thing where they report the risk change over time (or as a function of some other variable) in terms of multiples, without being explicit about the base risk. The base risk of maternal mortality in the US is .0175% (twice what it was 30 years ago but still incredibly low). Whenever we are talking about a situation with such a low base risk, tiny changes in absolute cases can lead to big percentage changes, and we have to keep that in mind when we throw around superlatives here.

The average maternal mortality rate for developed countries is 12 per 100,000 (with a CI of 11-14). The US rate is 17.5 per 100,000. No doubt higher. At least 1 or 2 deaths higher per 100,000.

Is this "as well as some of the developing economies, not as well as one of the worlds leading economies." Well, the lowest maternal mortality rate in the developing world is Eastern Asia, with an MMR of 27 per 100,000 (CI 23,33). I think it's a bit misleading then to say that the US has a much higher rate than any other developed nation than Mexico at an increase rate of about 2 per 100,000, and almost the same rate as a developing nation, where we trail the best countries by about 5 or 6 per 100,000.

Not to be a pedant about all of this but we would do well to be careful about the superlatives we use and how we report these risk rates. Someone is going to say I'm saying this isn't a problem - I'm not saying that, it is a problem, and any increase in MMR is completely bonkers and shameful. But we can hold that view and be careful about the actual numbers at the same time.
posted by Lutoslawski at 7:17 AM on October 30, 2017 [2 favorites]


Also, not many are usually aware that in the US we have a really great program as part of the HRSA called Maternal and Child Health, who have initiatives including Healthy Start: Eliminating Racial/Ethnic Disparities, which works on this very issue, and which was not mentioned in the article (disclosure is that some of my work is currently funded by MCH). This is a branch of our government that does great work and is a good place to look if you're interested in these types of initiatives and these issues. Of course, the future of this Bureau is likely uncertain.
posted by Lutoslawski at 7:33 AM on October 30, 2017


42% of all maternal death occurred within 60 days of discharge.

I wonder if some of this is about the rate of followup care?
posted by corb at 8:08 AM on October 30, 2017 [2 favorites]


Well-off black women have higher rates of maternal mortality than white women living in poverty, even when those black women have prenatal care, follow all medical advice, eat Instagram perfect prenatal diets, and have adequate post-natal care, and the white women have none of those resources.

When skye.dancer says that “Misogynoir is lethal”, that isn’t a dramatic statement for effect. It is literally true. Peer reviewed literature has been written about it. Every attempt to explain this problem with data has come up against the fact that measurable factors cannot explain it.

The lack of care for WoC is a huge problem that kills, but the biggest problem in this area appears to be allostatic load— living in a culture that hates you kills you, and it kills your babies, no matter how much education or money or medicine you have. Achieving equity in treatment and resources cannot eliminate the effects of allostatic load, because those effects are cumulative over the life course.
posted by a fiendish thingy at 1:21 PM on October 30, 2017 [5 favorites]


yes, corb. That is the inference expressed by researchers in the TX study. Correctives recommended mostly focus on pre- and post-partum mental health consultations which is kind of ironic considering how crucial monitoring symptomatic preeclampsia and gestational diabetes is to assuring successful pregnancy --very old school.

Meanwhile, conclusion to the stats report published by American College of Obstetricians and Gynecologists is all data collection error and technique --CA v. TX, specifically. Ima guess, 'cause I'm prejudiced, TX public health experts simply aren't.
posted by marycatherine at 7:13 PM on October 30, 2017


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