Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
A Case Report
A Dedication
About Our Fellows
About Ourselves
About Professor Js Bajaj
Abstract
Abstract Article
Abstracts
Abstracts From Papers
Aero Medical Society
Aeromedical Assessment
Aeromedical Decision Making
Aeromedical Evaluation
Aircraft Accident Report
Article
Aviation Physiology
Aviation Quiz
Book Review
Book Reviews
Bulletin
Bye-Laws
Case Report
Case Reports
Case Series
Case Study
Civil Aerospace Medicine
Civil Aviation Medicine
Clinical Aerospace Medicine
Clinical Aviation Medicine
Clinical Information
Clinical Medicine
Clinical Series
COMMENTARY | PERINATAL HIV TRANSMISSION
Concept Paper
Contemporary Issue
Contemporary issues
Cumulative Index
Current Issue
Director General Armed Forces Medical Services
Editorial
Exploring Space
Field Experience
Field Report
Field Study
Field Survey
Field Trials
Flight Trials
Guest Editorial
Guest Lecture
In Memoriam
Inaugural Address
Internet For The "Internaut"
Journal Scan
Know your President
Lecture
Letter to Editor
Letter to the Editor
LETTER TO THE EDITOR | COVID-19 TEST
Letters to the Editor
Message From Our Patron
Methods in Aerospace Medicine
Methods in Medicine
News Of The Members
Notice
Notice To Contributors
OBITUARY
Om Satya Mehra Award 1997
Oration
Orginal Article
Original Article
Original Article (Field Study)
ORIGINAL ARTICLE | CAFFEINE AND CHILDHOOD OBESITY
ORIGINAL ARTICLE | DEPRESSION & HIV
ORIGINAL ARTICLE | DIETARY MICRONUTRIENTS AND HIV
ORIGINAL ARTICLE | HIV INFECTION
ORIGINAL ARTICLE | HIV SCREENING
ORIGINAL ARTICLE | HIV/AIDS IN ECUADOR
ORIGINAL ARTICLE | OXYTOCIN VS MISOPROSTOL IN PPH
ORIGINAL ARTICLE | REPRODUCTIVE HEALTH
Original Research
Our New President
Perspective
Presidential Address
Questionnaire Study
Quiz
Retrospective Study
Review Article
Short Article
Short Communication
Short Note
SHORT RESEARCH COMMUNICATION
SHORT RESEARCH COMMUNICATION | COVID AND MENTAL HEALTH
SHORT RESEARCH COMMUNICATION | COVID MCH RESEARCH AGENDA
SHORT RESEARCH COMMUNICATION | COVID-19 AND CHILD VACCINATION
SHORT RESEARCH COMMUNICATION | COVID-19 AND MATERNAL MORTALITY
SHORT RESEARCH COMMUNICATION | COVID-19 AND REMOTE WORKERS
SHORT RESEARCH COMMUNICATION | SINGLETONS, TWINS, MULTIPLE BIRTHS
SHORT RESEARCH COMMUNICATION | SURVEILLANCE SYSTEM FOR COVID-19
Society Calender
Society News
Symosium
Symposium
Teaching File
Teaching Series
Technical Communication
Technical Note
Technical Report
The Aviation Medicine Quiz
The Fellowship
Welcome Address
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
A Case Report
A Dedication
About Our Fellows
About Ourselves
About Professor Js Bajaj
Abstract
Abstract Article
Abstracts
Abstracts From Papers
Aero Medical Society
Aeromedical Assessment
Aeromedical Decision Making
Aeromedical Evaluation
Aircraft Accident Report
Article
Aviation Physiology
Aviation Quiz
Book Review
Book Reviews
Bulletin
Bye-Laws
Case Report
Case Reports
Case Series
Case Study
Civil Aerospace Medicine
Civil Aviation Medicine
Clinical Aerospace Medicine
Clinical Aviation Medicine
Clinical Information
Clinical Medicine
Clinical Series
COMMENTARY | PERINATAL HIV TRANSMISSION
Concept Paper
Contemporary Issue
Contemporary issues
Cumulative Index
Current Issue
Director General Armed Forces Medical Services
Editorial
Exploring Space
Field Experience
Field Report
Field Study
Field Survey
Field Trials
Flight Trials
Guest Editorial
Guest Lecture
In Memoriam
Inaugural Address
Internet For The "Internaut"
Journal Scan
Know your President
Lecture
Letter to Editor
Letter to the Editor
LETTER TO THE EDITOR | COVID-19 TEST
Letters to the Editor
Message From Our Patron
Methods in Aerospace Medicine
Methods in Medicine
News Of The Members
Notice
Notice To Contributors
OBITUARY
Om Satya Mehra Award 1997
Oration
Orginal Article
Original Article
Original Article (Field Study)
ORIGINAL ARTICLE | CAFFEINE AND CHILDHOOD OBESITY
ORIGINAL ARTICLE | DEPRESSION & HIV
ORIGINAL ARTICLE | DIETARY MICRONUTRIENTS AND HIV
ORIGINAL ARTICLE | HIV INFECTION
ORIGINAL ARTICLE | HIV SCREENING
ORIGINAL ARTICLE | HIV/AIDS IN ECUADOR
ORIGINAL ARTICLE | OXYTOCIN VS MISOPROSTOL IN PPH
ORIGINAL ARTICLE | REPRODUCTIVE HEALTH
Original Research
Our New President
Perspective
Presidential Address
Questionnaire Study
Quiz
Retrospective Study
Review Article
Short Article
Short Communication
Short Note
SHORT RESEARCH COMMUNICATION
SHORT RESEARCH COMMUNICATION | COVID AND MENTAL HEALTH
SHORT RESEARCH COMMUNICATION | COVID MCH RESEARCH AGENDA
SHORT RESEARCH COMMUNICATION | COVID-19 AND CHILD VACCINATION
SHORT RESEARCH COMMUNICATION | COVID-19 AND MATERNAL MORTALITY
SHORT RESEARCH COMMUNICATION | COVID-19 AND REMOTE WORKERS
SHORT RESEARCH COMMUNICATION | SINGLETONS, TWINS, MULTIPLE BIRTHS
SHORT RESEARCH COMMUNICATION | SURVEILLANCE SYSTEM FOR COVID-19
Society Calender
Society News
Symosium
Symposium
Teaching File
Teaching Series
Technical Communication
Technical Note
Technical Report
The Aviation Medicine Quiz
The Fellowship
Welcome Address
View/Download PDF

Translate this page into:

SHORT RESEARCH COMMUNICATION | COVID-19 AND MATERNAL MORTALITY
9 (
3
); 386-389
doi:
10.21106/ijma.405

Expected Surge in Maternal Mortality and Severe Morbidity among African-Americans in the Era of COVID-19 Pandemic

College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, TX, USA
Department of Family and Community Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
Corresponding author email: kadegoke@adelphi.edu
Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Prior to the COVID-19 pandemic, African-American mothers were three times as likely to die from pregnancy-related causes compared to white mothers. The impact of the pandemic among African-Americans could further worsen the racial disparities in maternal mortality (MM) and severe maternal morbidity (SMM). This study aimed to create a theoretical framework delineating the contributors to an expected rise in maternal mortality (MM) and severe maternal morbidity (SMM) among African-Americans in the era of the COVID-19 pandemic due to preliminary studies suggesting heightened vulnerability of African-Americans to the virus as well as its adverse health effects. Rapid searches were conducted in PubMed and Google to identify published articles on the health determinants of MM and SMM that have been or likely to be disproportionately affected by the pandemic in African-Americans. We identified socioeconomic and health trends determinants that may contribute to future adverse maternal health outcomes. There is a need to intensify advocacy, implement culturally acceptable programs, and formulate policies to address social determinants of health.

Keywords

COVID-19
Maternal mortality
Severe maternal morbidity
African-Americans

1. Introduction

Globally, millions of people have been infected with the novel coronavirus disease 2019 (COVID-19). In the United States (US), African-American people are being hospitalized and dying in disproportionately greater numbers due to the COVID-19 pandemic. African-Americans comprise less than 13% of the population but account for 33.1% of hospitalized COVID-19 patients.1 This unequal burden of the disease could partially be explained by the higher prevalence of underlying chronic medical conditions such as hypertension, diabetes, and obesity among African-Americans. Prior to the pandemic, African-American mothers were three times as likely to die from pregnancy-related causes compared to white mothers.2 The current burden of both chronic diseases and COVID-19 pandemic among African-Americans could further worsen the racial disparities in maternal mortality (MM) and severe maternal morbidity (SMM). The purpose of this paper was to create a theoretical framework delineating the contributors to an expected rise in MM and SMM among African-Americans in the era of the COVID-19 pandemic due to preliminary studies suggesting heightened vulnerability of African-Americans to the virus as well as its adverse health effects.1,3 We also present policy recommendations to address the anticipated widening of the existing maternal health disparity.

2. Methods

Rapid searches were conducted in PubMed and Google to identify published articles on the select health determinants of MM and SMM that have been or likely to be disproportionately affected by the pandemic in African-Americans. The following keywords were used separately and in combination: “maternal mortality”, “severe maternal morbidity”, “race/ethnicity”, “black or African-American”, “determinants”, “disparity” and “COVID-19”. Since this was a rapid mini-review, and due to the fast turnover of COVID-19 publications, it would be misleading and inappropriate to provide retrieval numbers. The theoretical framework for this study was based on a population health determinants model.4 The determinants of population health are commonly classified as either proximal or distal. Proximal factors act directly to cause the outcome, while distal determinants are further back in the causal chain and indirectly influence health by acting on the more proximal factors, their interrelated mechanisms, and distributions.4,5 The identified determinants from our searches were classified as proximal or distal determinants, and a conceptual framework to explain the expected rise in MM and SMM in African-Americans due to the pandemic was created.

3. Results

Six articles were synthesized in this brief review. The identified proximal determinants are lower insurance coverage, reduced access to or utilization of reproductive and maternal health services, and an increase in the prevalence of chronic health conditions such as diabetes, hypertension, and obesity. The distal determinants include higher unemployment, heightened fear of the virus, travel difficulty, and shelter-in-place restrictions. Figure 1 describes the proposed theoretical framework for a projected increase in MM and SMM in African American women as a consequence of the COVID-19 pandemic. It also highlights the link between the identified proximal and distal determinants and the outcomes.

Figure 1
A theoretical framework to explain a projected increase in maternal mortality and severe maternal morbidity in US African American women in the era of COVID-19 Pandemic

The economic crisis, due to the ongoing pandemic, has led to a higher unemployment rate in African-Americans. From April to May 2020, the unemployment rate rose from 16.4 to 16.5% in African-American women but decreased from 15.0% to 13.1% in white women.6 Among African-American women, this may result in differential loss of insurance coverage and the inability to pay for health services. Lack of health insurance or insufficient healthcare access correlates negatively with the use and quality of maternal health services and potentially better maternal health outcomes.7

Compounding reduced health care access is the government-imposed movement and shelter-in-place restrictions, heightened fear of the virus, and travel difficulty due to reliance on public transport, which all affects African-Americans disproportionately. About 19% of African-Americans compared to only 4.6% of whites live in homes in which no one owns a car.8 The highlighted distal determinants may lead to underutilization of reproductive and maternal health services, resulting in reduced preconception and prenatal visits and missed postpartum visits. Abortion and contraceptive services to prevent unwanted or high-risk pregnancies may also be underutilized. Inadequate prenatal care is associated with adverse pregnancy outcomes.7 Additionally, preconception and postpartum care are essential for monitoring the health of women with chronic illness, linking vulnerable women with the health system and reducing SMM and MM.9

A recent study estimated that 31%, 17%, and 4.9% of the attributable increase in maternal mortality were due to the proportion of obese women of childbearing age, the proportion of births to women with diabetes, and births to women attending fewer than ten prenatal visits respectively. 7 These determinants could be affected negatively during the pandemic. For instance, the prevalence of obesity might increase because of shelter-at-home, while diabetes may be undiagnosed or untreated because of insufficient healthcare access. Further, elevated BMI also increases the risk of chronic health conditions, including diabetes mellitus and hypertension.7 African-American women already have a higher prevalence of obesity and may be disproportionately affected during this crisis. As evident from previous research, small changes in body weight in relatively short time periods can become permanent and lead to substantial weight gain over time. 10 Considering the surge of COVID-19 cases in the US due to the reopening of states, the stay-at-home order could be extended and may last several months. As a result, extended home confinement due to COVID-19 could result in significant body weight gain, with women with overweight/obesity being at the greatest risk for permanent change.11

4. Discussion and Global Health Implications

In the coming months, the US may expect to see a substantial increase in pregnancy and childbirth-related complications and deaths among African-American women. The significant changes in socioeconomic factors and health trends because of COVID-19 may play an important role. African American women constitute a population with social vulnerabilities, and to mitigate the inevitable rise in maternal mortality and morbidity, it is necessary to target the proximal and distal risk factors noted in this study.

Given the historical context of systemic racism among African-Americans, there is a need to intensify advocacy, implement culturally acceptable intervention programs, and formulate policies to address social determinants of health and make equitable social justice a reality. Globally, to sustain the gains in maternal health achieved in the past decades, country-level assessments of the pandemic-related altered risk factors that may affect maternal health, particularly among high-risk populations, are warranted and appropriate interventions implemented.

Compliance with Ethical Standards

Conflicts of Interest: The authors declare no conflict of interest.

Funding/Support: The publication of this article was partially supported by the Global Health and Education Projects, Inc. (GHEP) through the Emerging Scholars Grant Program (ESGP). The information, contents, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by ESGP or GHEP.

Ethics Approval: This study was based on existign literature.

References

  1. , , , . Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 states, March 1-30 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):458-464.
    [Google Scholar]
  2. , , , , , , , . Pregnancy-related mortality in the United States 2003-2016:Age, race, and place of death. Am J Obstet Gynecol. 2020;222(5):489.e1-489.e8.
    [Google Scholar]
  3. , , . Social Vulnerability and Racial Inequality in COVID-19 Deaths in Chicago. Health Educ Behav. 2020;47(4):509-513. doi:10.1177/1090198120929677
    [Google Scholar]
  4. , , , , . Health system outcomes and determinants amenable to public health in industrialized countries:A pooled, cross-sectional time series analysis. BMC Public Health. 2005;5 81-2458-5-81
    [Google Scholar]
  5. . The World Health Report 2002:Reducing risks, promoting healthy life. https://www.who.int/whr/2002/en/whr02_en.pdf?ua=1
  6. . . Employment status of the civilian population by race, sex, and age. https://www.bls.gov/news.release/empsit.t02.htm
  7. , , , . Population-level factors associated with maternal mortality in the united states 1997-2012. BMC Public Health. 2018;18(1) 1007-018-5935-2
    [Google Scholar]
  8. , , . Socioeconomic differences in household automobile ownership rates:implications for evacuation policy. . Paper presented at:Berkeley Symposium on Real Estate, Catastrophic Risk, and Public Policy;March 22-23. https://www.berkeley.edu/news/media/releases/2006/03/23_carownership.shtml
    [Google Scholar]
  9. , . Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61(2):387-399.
    [Google Scholar]
  10. , . The effect of holiday weight gain on body weight. Physiol Behav. 2014;134:66-69.
    [Google Scholar]
  11. , , . COVID-19 related home confinement in adults:Weight gain risks and opportunities. Obesity (Silver Spring) 2020
    [Google Scholar]
Show Sections