View pregnancy as ‘window to future health’ to lower risks for Black, indigenous women

Key takeaways:

• Black, Native American and Alaska Native women in the U.S. experience significantly worse maternal outcomes vs. white women.
• Systemic changes are needed to improve care before, during and after pregnancy.

DANA POINT, Calif. — Black and indigenous women in the U.S. experience “unacceptably poor” maternal health outcomes, including disproportionately high rates of mortality and morbidity with CVD as the leading cause, according to a speaker.

Each year, 1,205 women in the U.S. die from pregnancy-related complications, yet more than 80% of pregnancy-related deaths are preventable, Rachel M. Bond, MD, FACC, systems director of women’s heart health at Dignity Health in Arizona, said during a presentation at the Cardiometabolic Health Congress (CMHC) Women’s Cardiometabolic Health and Wellness Masterclass.

However, she said, the highest rates of maternal death happen disproportionately among women from underrepresented groups. Compared with white mothers, American Indian and Alaska Native women are twice as likely to die; Black women are three times more likely to die. The COVID-19 pandemic like worsened outcomes and further highlighted race disparities: From 2020 to 2021, maternal mortality rates doubled among American Indian and Alaska Native women compared with 2019, Bond said.

“But maternal mortality is just the tip of the iceberg,” Bond said during the presentation. “We know that there are so many more near-misses. For every mother who dies, there are about 75 to 100 who nearly die and experience severe maternal morbidity. It is important to highlight that Black women are twice as likely to experience these outcomes than white women. This is across all sociodemographic backgrounds.”

CVD and pregnancy-related deaths

Data show that, among non-Hispanic Black women, CV conditions such as embolism-thrombotic, cardiomyopathy and hypertensive disorders are leading cause of pregnancy-related deaths, Bond said.

“One may say that is not surprising, because pregnancy is sometimes nature’s first cardiac stress test,” Bond said. “Many times, when these women journey into pregnancy, the pregnancies are unintended. There are not many opportunities to undergo preconception care.”

Because many pregnancies are unintended, most people of reproductive age do not have ideal CV health, Bond said, coming into pregnancy with traditional risk factors such as type 2 diabetes, smoking, hypertension, dyslipidemia or obesity. Such risk factors are more common among women from underrepresented groups due to a lack of access to comprehensive care and other complex social determinants of health.

“We know American Indian women have a large prevalence of type 2 diabetes, about 72% in some communities, three times higher than white women,” Bond said. “There is greater nicotine exposure in this population and nearly half of all American Indian and Alaska Native women have obesity or overweight.”

Similarly, about half of Black women have obesity and the prevalence increases with age, Bond said. Black women also have the highest prevalence of hypertension in the world at 55.3%.

“Unfortunately, when we have these risk factors, they lead us to higher risk for adverse pregnancy outcomes,” Bond said. “This is why pregnancy is a window to one’s future CV health. When you have these risk factors and you are at higher risk for these adverse pregnancy outcomes, such a preterm delivery, hypertensive disorders of pregnancy, including preeclampsia, and gestational diabetes, we know this is not only impacting the pregnancy itself, but also the health of the women up to 20 years after these outcomes occur.”

Data also show that women who deliver their first child preterm, defined as before 37 weeks gestation, experience a 40% increased risk for CVD, Bond said. Women with a very preterm first birth, defined as before 32 weeks gestation, have double the risk for CVD, with 25% of this risk explained by hypertension, hypercholesterolemia, type 2 diabetes and change in BMI after pregnancy.

“These are risk factors that are not often screened but it is important that we educate our patients on their overall risk,” Bond said.

‘Sound solutions’ to improve outcomes

To improve generational health, clinicians should ensure management along all stages of maternal health, including before, during and after pregnancy, Bond said. Preconception and even “pre-preconception” care, beginning in childhood and early adolescence, can address health problems, plan for potential problems and ensure early prenatal care.

“Think about this across the life course,” Bond said. “Instill the values of healthy eating [and] exercise as early as possible. Talk about independent reproductive risks that indicate future CV health.”

Additionally, the “critical first year” after delivery also offers clinicians an opportunity to diagnose preventable conditions early, Bond said, adding that every clinician must ask women about pregnancy history.

Bond said the interconception period should also be a key area of focus, with providers working with women to optimize health between pregnancies to lower risks for hypertension, hyperlipidemia and gestational diabetes.

However, although following guidance that improves cardiometabolic health is helpful, systemwide solutions that target root causes are needed, Bond said. Data from the March of Dimes show that 2.2 million women of childbearing age live in U.S. counties that are maternity care “deserts,” with no obstetric clinician, no hospital and no birthing center. Similarly, approximately 16.8 million Black Americans live in U.S. counties with little to no access to a CV specialist.

“We know that the reason we are seeing these disparities is largely not related to the individual, it is more rooted in the system,” Bond said. “The higher risk faced by Black women when it comes to maternal health spans income, education and ideal CV health.”

Systems solutions should include a thorough review of maternal mortality and maternal morbidity cases, standardization of care across communities, promoting safe birthing spaces via access to contraceptive methods, using available geo-mapping data on disparities to focus public health campaigns, and supporting programming that emphasize primary care, disease prevention and the inclusion of psychosocial screenings.

“The maternal health continuum is not specifically during pregnancy,” Bond said. “It is before it. It is after it. It is ongoing.”

At the individual level, clinicians must do four things with all patients, Bond said: Stop, look, listen and believe.

“We will stop blaming the victims, denying that implicit bias exists as it pertains to sex, gender, race and ethnicity,” Bond said. “We will look patients in the eye and look for opportunities to empower evidence-based practices. We will listen without judgment, with empathy. We will believe that racism is inaction in the form of need, and we will believe her at all costs,” Bond said.

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