Madam Chair, I have an amendment at the desk. Madam Chair, first, let me start off by including in the Record a Harvard Public Health journal article, ``America Is Failing Its Black Mothers.'' America Is Failing Its Black Mothers For…
Madam Chair, I have an amendment at the desk.
Madam Chair, first, let me start off by including in the Record a Harvard Public Health journal article, ``America Is Failing Its Black Mothers.''
America Is Failing Its Black Mothers
For decades, Harvard Chan alumni have shed light on high
maternal mortality rates in African American women. Finally,
policymakers are beginning to pay attention.
Serena Williams knew her body well enough to listen when it
told her something was wrong. Winner of 23 Grand Slam singles
titles, she'd been playing tennis since age 3--as a
professional since 14. Along the way, she'd survived a life-
threatening blood clot in her lungs, bounced back from knee
injuries, and drowned out the voices of sports commentators
and fans who criticized her body and spewed racist epithets.
At 36, Williams was as powerful as ever. She could still
devastate opponents with the power of a serve once clocked at
128.6 miles per hour. But in September 2017, on the day after
delivering her baby, Olympia, by emergency C-section,
Williams lost her breath and recognized the warning signs of
a serious condition.
She walked out of her hospital room and approached a nurse,
Williams later told Vogue magazine. Gasping out her words,
she said that she feared another blood clot and needed a CT
scan and an IV of heparin, a blood thinner. The nurse
suggested that Williams' pain medication must be making her
confused. Williams insisted that something was wrong, and a
test was ordered--an ultrasound on her legs to address
swelling. When that turned up nothing, she was finally sent
for the lung CT. It found several blood clots. And, just as
Williams had suggested, heparin did the trick. She told
Vogue, ``I was like, listen to Dr. Williams!''
But her ordeal wasn't over. Severe coughing had opened her
C-section incision, and a subsequent surgery revealed a
hemorrhage at that site. When Williams was finally released
from the hospital, she was confined to her bed for six weeks.
Wanda Irving holds her granddaughter, Soleil, in front of a
portrait of Soleil's mother, Shalon Irving, at home in Sandy
Springs, Georgia. Wanda has been raising Soleil since
Shalon--an epidemiologist with the U.S. Centers for Disease
Control and Prevention--died in 2017 from complications of
hypertension a few weeks after giving birth.
Like Williams, Shalon Irving, an African American woman,
was 36 when she had her baby in 2017. An epidemiologist at
the U.S. Centers for Disease Control and Prevention (CDC),
she wrote in her Twitter bio, ``I see inequity wherever it
exists, call it by name, and work to eliminate it.''
Irving knew her pregnancy was risky. She had a clotting
disorder and a history of high blood pressure, but she also
had access to top-quality care and a strong support system of
family and friends. She was doing so well after the C-section
birth of her baby, Soleil, that her doctors consented to her
request to leave the hospital after just two nights (three or
four is typical). But after she returned home, things quickly
went downhill.
For the next three weeks, Irving made visit after visit to
her primary care providers, first for a painful hematoma
(blood trapped under layers of healing skin) at her incision,
then for spiking blood pressure, headaches and blurred
vision, swelling legs, and rapid weight gain. Her mother told
ProPublica that at these appointments, clinicians repeatedly
assured Irving that the symptoms were normal. She just needed
to wait it out. But hours after her last medical appointment,
Irving took a newly prescribed blood pressure medication,
collapsed, and died soon after at the hospital when her
family removed her from life support.
Viewed up close, the deaths of mothers like Irving are
devastating, private tragedies. But pull back, and a picture
emerges of a public health crisis that's been hiding in plain
sight for the last 30 years.
Following decades of decline, maternal deaths began to rise
in the United States around 1990--a significant departure
from the world's other affluent countries. By 2013, rates had
more than doubled. The CDC now estimates that 700 to 900 new
and expectant mothers die in the U.S. each year, and an
additional 500,000 women experience life-threatening
postpartum complications. More than half of these deaths and
near deaths are from preventable causes, and a
disproportionate number of the women suffering are black.
Put simply, for black women far more than for white women,
giving birth can amount to a death sentence. African American
women are three to four times more likely to die during or
after delivery than are white women. According to the World
Health Organization, their odds of surviving childbirth are
comparable to those of women in countries such as Mexico and
Uzbekistan, where significant proportions of the population
live in poverty.
Irving's friend Raegan McDonald-Mosley, chief medical
director for Planned Parenthood Federation of America, told
ProPublica, ``You can't educate your way out of this problem.
You can't health-care-access your way out of this problem.
There's something inherently wrong with the system that's not
valuing the lives of black women equally to white women.''
Lost mothers
Speaking at a symposium hosted by the Maternal Health Task
Force at the Harvard T.H. Chan School of Public Health in
September 2018, investigative reporter Nina Martin noted
telling commonalities in the stories she's gathered about
mothers who died. Once a baby is born, he or she becomes the
focus of medical attention. Mothers are monitored less, their
concerns are often dismissed, and they tend to be sent home
without adequate information about potentially concerning
symptoms. For African American mothers, the risks jump at
each stage of the labor, delivery, and postpartum process.
Neel Shah, an obstetrician-gynecologist at Beth Israel
Deaconess Medical Center in Boston and director of the
Delivery Decisions Initiative at Ariadne Labs, recalls being
struck by Martin's ProPublica-NPR series Lost Mothers, which
delved into the issue. ``The common thread is that when black
women expressed concern about their symptoms, clinicians were
more delayed and seemed to believe them less,'' he says.
``It's forced me to think more deeply about my own approach.
There is a very fine line between clinical intuition and
unconscious bias.''
For members of the public, the experiences of prominent
black women may prove to be a teachable moment. When pop
superstar Beyonce developed the hypertensive disorder pre-
eclampsia--which left untreated can kill a mother and her
baby--after delivering her twins by emergency C-section in
2017, Google searches related to the condition spiked.
According to the U.S. Agency for Healthcare Research and
Quality, pre-eclampsia--one of the leading causes of maternal
death--and eclampsia (seizures that develop after pre-
eclampsia) are 60 percent more common in African American
women than in white women, and also more severe. If it can
happen to Beyonce--an international star who presumably can
afford the highest-quality medical care--it can happen to
anyone.
Weathering report
Arline Geronimus, SD '85, has been talking about the
effects of racism on health for decades, even when others
haven't wanted to listen. Growing up in the 1960s in
Brookline, Massachusetts, Geronimus, who is white, absorbed
the messages of the Civil Rights movement and the
harrowing stories of her Jewish family's experiences in
czarist Russia. When she headed off to Princeton as an
undergraduate, she resolved to find a way to fight against
injustice. Her initial plan to become a civil rights
lawyer gave way when
she discovered the power and potential of public health
research.
Geronimus worked as a research assistant for a professor
studying teen pregnancy among poor urban residents, and, as a
volunteer at a Planned Parenthood clinic, witnessed close-up
the lives of pregnant black teens living in poverty in
Trenton, New Jersey. She felt a chasm open up between what
some of her white male professors were confidently
explicating about the lives of these adolescents and how the
young women themselves saw their lives.
According to the conventional wisdom at the time, Geronimus
says, teen pregnancy was the primary driver of maternal and
infant deaths and a host of multigenerational health and
social problems among low-income African Americans.
Researchers focused on this issue while ignoring broader
systemic factors.
Geronimus sought to connect the dots between the health
problems the girls experienced, like asthma and type 2
diabetes, and negative forces in their lives. She visited
them in their crumbling apartments and accompanied them to
medical appointments where doctors treated the girls like
props, without agency in their own care. And she noticed that
they seemed older, somehow, than girls the same age whom
Geronimus knew.
``That's when I got the fire in my belly,'' she says, her
voice rising. ``These young women had real, immediate needs
that those of us in the hallowed halls of Princeton could
have helped address. But we weren't seeing those urgent
needs. We just wanted to teach them about contraception.''
Geronimus came to the Harvard Chan School to learn how to
rigorously explore the ways that social disadvantage corrodes
health--a concept for which she coined the term
``weathering.'' Her adviser, Steven Gortrnaker, professor of
the practice of health sociology, provided data for her to
correlate infant mortality by maternal age. While most such
studies put mothers into broad categories of teen and not-
teen, Geronimus looked at the risks they faced at every age.
The results were surprising even to her.
White women in their 20s were more likely to give birth to
a healthy baby than those in their teens. But among black
women, the opposite was true: The older the mother, the
greater the risk of maternal and newborn health complications
and death. In public health, the condition of a baby is
considered a reliable proxy for the health of the mother.
Geronimus' data suggested that black women may be less
healthy at 25 than at 17.
``Being able to see those stark numbers was essential for
me,'' says Geronimus, who is now a professor of health
behavior and health education at the University of Michigan
School of Public Health and a member of the National Academy
of Medicine. And the implications were staggering. If young
black women were already showing signs of weathering, how
would that play out over the rest of their lives--and what
could be done to stop it?
Geronimus' questions were ahead of their time. The press
and the public--even other scientists--misinterpreted her
findings as a recommendation that black women have children
in their teens, she says, recalling with a sigh such clueless
headlines as, ``Researcher says let them have babies.''
In the 1970s, even researchers who broached the topic of
racial differences in health outcomes--and few did--focused
on small pieces of the puzzle. Some were looking at genetics,
others at behavioral and cultural differences or health care
access. ``No one wanted to look at what was wrong with how
our society works and how that can be expressed in the health
of different groups,'' Geronimus says. Over time, her ideas
would become harder to dismiss.
The tide began to turn in the early 1980s, when former
Health and Human Services Secretary Margaret Heckler convened
the first group of experts to conduct a comprehensive study
of the health status of minority populations. As the field of
social epidemiology took off, the Report of the Secretary's
Task Force on Black and Minority Health (also known as the
Heckler Report) brought Geronimus' animating questions into
mainstream debate.
Then, in 1993, researchers identified a physiological
mechanism that could finally explain weathering: allostatic
load. ``We as a species are designed to respond to threats to
life by having a physiological stress response,'' Geronimus
explains. ``When you face a literal life-or-death threat,
there is a short window of time during which you must escape
or be killed by the predator.'' Stress hormones cascade
through the body, sending blood flowing to the muscles and
the heart to help the body run faster and fight harder.
Molecules called pro-inflammatory cytokines are produced to
help heal any wounds that result.
These processes siphon energy from other bodily systems
that aren't enlisted in the fight-or-flight response,
including those that support healthy pregnancies. That's not
important if the threat is short term, because the body's
biochemical homeostasis quickly returns to normal. But for
people who face chronic threats and hardships--like
struggling to make ends meet on a minimum wage job or
witnessing racialized police brutality--the fight-or-flight
response may never abate. ``It's like facing tigers coming
from several directions every day,'' Geronimus says, and the
damage is compounded over time.
As a result, health risks rise at increasingly younger ages
for chronic conditions like hypertension and type 2 diabetes.
Depression and sleep deprivation become more common. People
are also more likely to engage in risky coping behaviors,
such as overeating, drinking, and smoking.
Geronimus' foundational work in the 1980s and 1990s has
been cited by David R. Williams, the Florence Sprague Norman
and Laura Smart Norman Professor of Public Health at the
Harvard Chan School, an internationally recognized expert in
the ways that racism and other social influences affect
health. His Everyday Discrimination Scale is one of the most
widely used measures of discrimination in health studies. It
includes questions that measure experiences such as being
treated with discourtesy, receiving poorer service than
others in restaurants or stores, or witnessing people act as
if they're afraid of you. As he explained in a 2016 TED MED
talk, ``This scale captures ways in which the dignity and the
respect of people who society does not value is chipped away
on a daily basis.''
Maternal Mortality in the U.S.: A Human Rights Crisis
Despite high-tech medical advances of the last century,
women around the world are still dying in pregnancy and
childbirth from age-old scourges such as hemorrhage and pre-
eclampsia and, increasingly, from complications related to
chronic diseases, obesity, and advanced maternal age.
In 2000, the global health and development community
acknowledged the need for action in Goal 5 of the U.N.
Millennium Development Goals, which aimed to reduce maternal
deaths by three-quarters in 15 years (it declined by 45
percent). While press and publicity around the push offered
harrowing stories, women reading these stories in the U.S.
may well have come away believing that it was a problem for
mothers in villages in Sierra Leone--but surely not in
Atlanta or Washington, D.C.
Starting in 2008, human rights groups around the world
began calling on the U.S. to do more to keep its mothers from
dying. The United Nations Committee on the Elimination of
Racial Discrimination (CERD) expressed concern about
inequities in maternal mortality and recommended that steps
be taken to improve access to maternal health care, family
planning, and sexuality education and information.
A 2012 Amnesty International report declared that these
steps weren't enough: ``Preventable maternal mortality can
result from or reflect violations of a variety of human
rights, including the right to life, the right to freedom
from discrimination, and the right to the highest attainable
standard of health.'' Having ratified two key international
treaties guaranteeing these rights, the authors wrote, the
U.S. government should be held accountable.
Four years later, representatives from the advocacy
organization SisterSong, the Center for Reproductive Rights,
and National Latina Institute for Reproductive Health issued
a report to CERD further exploring these issues. CERD adopted
the groups' recommendations, including addressing stereotypes
that promote discrimination in clinical settings and
standardizing data collection on maternal deaths. In 2015, an
advocacy organization called Black Mamas Matter emerged out
of this effort to keep pushing the agenda forward.
To the women leading the charge, one central fact was
clear: Racism is an undeniable thread running through the
stories of black mothers who die. But as Elizabeth Dawes Gay,
co-director of Black Mamas Matter and a public health
professional, wrote in The Nation, providers and researchers
often place ``the onus for large-scale change on individuals
rather than the systems that we know cause harm.''
Madam Chair, I rise today with an amendment to increase funding for the State Maternal Health Innovation Program by $7 million. This program is specifically tasked with reducing care gaps, maternal mortality, and disparities in maternal health.
The United States is the greatest country in the world with the most innovative healthcare system around. We continue to develop cutting- edge treatments that stretch the bounds of what is possible. Within the last two decades, we have mapped the human genome, conducted surgeries over the Internet, and grown organs out of stem cells. We have cured diseases and revolutionized treatments.
Despite all that progress, more of our mothers and mothers-to-be are dying today than at the turn of the century. Somehow, we have seen our maternal mortality rate increase over the past 25 years, and preventable near-deaths related to pregnancy have increased over 200 percent.
The statistics are shocking, and the reality for Black mothers is a crisis. Black mothers in Louisiana are now 4 times more likely to die than White mothers. The rate of Black maternal deaths is closer to the rates in developing countries than the nations we usually compare ourselves to.
With our vast resources and advanced technology, these deaths are unacceptable. This is a problem that demands
our immediate attention. That is why I am here today with this amendment.
With this increased funding, more States can implement programs to improve the care that mothers receive. More families can remain whole. More children can grow up with their mothers.
Madam Chair, I yield 1 minute to the gentlewoman from California (Ms. Lee).
Madam Speaker, if there are no other speakers, I am prepared to close.
Madam Speaker, let me just say, simply put, for Black women far more than for White women, giving birth can amount to a death sentence.
When Black women express concern about their symptoms, clinicians are more delayed and seem less likely to believe them. And the question becomes, as Harvard put it, whether it is clinical intuition versus unconscious bias.
So as we look around the country and we see the complications from motherhood for African American women, we can look at Serena Williams; we can look at Beyonce; we can look in my household; we can look at Ashley Mitchell, whose funeral I went to just this past weekend.
This is a crisis we have the ability overcome. We are America. We do great things when we put our mind to it, and this amendment simply asks this body to put our mind to maternal health, especially for African American women, but for all women in this country, to make sure that the best thing about womanhood, an ability to give birth, does not become a death sentence.
Madam Chair, I ask for everyone's support, and I yield back the balance of my time.