"If they were White and Insured, Would they have Died?"Roundup
tags: racism, Texas, womens history, medical history, medical racism, Maternal Mortality
Udodiri R. Okwandu is a doctoral candidate in the History of Science Department and Presidential Scholar at Harvard University. Broadly, her research examines how scientific and medical disciplines facilitate the production of hierarchies of race, gender, and class in the United States from the late 19th century to the present.
In December 2022 – a few days shy of the new year – the Texas Maternal Mortality and Morbidity Review Committee (MMMRC) and Department of State Health Services released a joint Biennial Report on maternal mortality and morbidity rates in the state. They use term “maternal mortality” to describe the death of a childbearing person while pregnant or in the year following the end of a pregnancy from any cause related to or aggravated by the pregnancy. Meanwhile, “maternal morbidity” refers to any health condition attributed to and/or exacerbated by pregnancy and childbirth that negatively impacts the childbearing person’s well-being.
This report, long overdue, revealed what many had long known: that negative maternal health outcomes were on the rise, with Black parents experiencing disproportionately high levels of harm and death.
The MMMRC was established in 2013 by Senate Bill 495, 83rd Legislature, Regular Session to address a longstanding problem in the state of Texas: disproportionately high rates of pregnancy- and childbirth-related illness and death and racial disparities in maternal mortality and morbidity. In the year that the committee was formed, Black women constituted 31% of maternal deaths even though they made up only 11% of those giving birth. The Texas Health and Safety Code, Section 34.015 required that the MMMRC and the Department of State Health Services submit a joint report on the findings by September 1st of each even-numbered year. As a result, the MMMRC had a legal obligation to publish a report before or by September 1, 2022.
Yet in the months leading up to the overdue 2022 release, the report elicited significant controversy. After the Committee failed to release the report by the September 1, 2022 deadline, The Society for Maternal-Fetal Medicine – a non-profit organization dedicated to improving maternal and child outcomes – threatened to sue the state for refusing to release vital information to the public that could address Texas’ longstanding maternal mortality crisis. Two months later, the Committee’s pre-release warning that the report would reveal disturbing racial and class disparities elicited additional outrage given the state’s present assault on abortion rights, which has already proven to disproportionately impact low-income women of color.
Unfortunately, these concerns did not prove to be unfounded. The report’s results were startling: of the 118 pregnancy-associated deaths reviewed by the MMMRC, 40% were pregnancy-related (i.e., the deaths were explicitly tied to complications arising from pregnancy itself) and 36% were pregnancy-associated. In fact, 90% of pregnancy-related deaths were found to be preventable. This means that “there was at least some chance of averting the death by one or more feasible changes to the circumstances of the patient, provider, facility, systems, or community factors contributing to the death.”  Further, Black childbearing people and individuals who lacked private insurance disproportionately died from or experienced severe complications during pregnancy.  According to the MMMRC, these deaths result in 6,162 years of potential life lost and have left approximately 184 children affected by their mothers’ deaths. 
As a historian of race and medicine, I was disturbed but – unfortunately – not surprised. An honest examination of the historical record shows how rampant disparities and inequities in maternal health outcomes are due to systemic racism and classism. Systemic racism and classism refer to the complex interactions of large-scale systems, practices, and beliefs that systematically disadvantage racial and ethnic minorities and members of the working class. In the U.S., systemic racism and classism have been critical to the historical formation of not only obstetrics but also American medicine and the healthcare system more broadly. For example, the belief that Black people have inferior, different bodies, and psyches – which emerged in the 18th and 19th centuries – was a foundational, widely-held belief held by members of the white professional medical academy. While this belief has been challenged, it continues to persist, manifesting as rampant racial bias and discrimination amongst providers that, ultimately, impacts the provision of care. In addition, a capitalistic-driven healthcare system continues to drive unequal access to healthcare, particularly among the working class.