A Call to Action: Cardiovascular-Related Maternal Mortality: Inequities in Black, Indigenous and Persons of Color

Pregnancy-related mortality has been steadily increasing in the United States, with cardiovascular disease (CVD) leading as the major cause of maternal mortality.¹ Black and Indigenous (American Indian/Alaska Native) women suffer the greatest disparities in maternal mortality and postpartum disease progression, largely due to increased risk for the onset and progression of CVD during and following pregnancy.² The most recent statistics (2014–2017) of the pregnancy-related mortality ratio by race/ethnicity show that non-Hispanic Black women experience 41.7 deaths per 100,000 live births as compared to 13.4 deaths per 100,000 in non-Hispanic White women,³ representing nearly a 4-fold higher risk of death.^4,5 Indigenous women in the United States experience 29.7 deaths per 100,000, representing over 2-fold higher risk of death compared to the non-Hispanic White referent group.¹

The causes of CVD pregnancy-related mortality vary by race and ethnicity with a greater proportion of cardiomyopathy and hypertensive disorders of pregnancy in both Black women (14.2% and 8.2% respectively) and American Indian/Alaska Native women (14.5% and 12.8% respectively).¹ Comparative rates in non-Hispanic White women are 10.5% for cardiomyopathy and 6.7% for hypertensive disorders of pregnancy.¹ The causes for these inequities are multifactorial, but largely point to social determinants, structural racism, and the intersection of gender and race on health outcomes.⁶

Many recommendations and reports have recently been published that highlight the critical need for comprehensive, systemic solutions to address the realities that Black, Indigenous and Persons of Color encounter within social systems which serve as the root causes of maternal health and health care disparities.^7–9 The Black Maternal Health Momnibus Act of 2021, sponsored by the Black Maternal Health Caucus Members and intended to address maternal mortality and racial and ethnic disparities in maternal health outcomes was unveiled in February 2021. It builds on existing legislation to comprehensively address every dimension of the maternal health crisis in America. The Black Maternal Health Momnibus Act of 2021 includes 12 standalone bills which will:

1. Make critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.

2. Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity.

3. Comprehensively study the unique maternal health risks facing pregnant and postpartum veterans and support VA maternity care coordination programs.

4. Grow and diversify the perinatal workforce to ensure that every mom in America receives culturally congruent maternity care and support.

5. Improve data collection processes and quality measures to better understand the causes of the maternal health crisis in the United States and inform solutions to address it.

6. Support moms with maternal mental health conditions and substance use disorders.

7. Improve maternal health care and support for incarcerated moms.

8. Invest in digital tools like telehealth to improve maternal health outcomes in underserved areas.

9. Promote innovative payment models to incentivize high-quality maternity care and non-clinical perinatal support.

10. Invest in federal programs to address the unique risks for and effects of COVID-19 during and after pregnancy and to advance respectful maternity care in future public health emergencies.

11. Invest in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies.

12. Promote maternal vaccinations to protect the health and safety of moms and babies.¹⁰

All health providers have an important role in addressing Black and Indigenous maternal mortality and morbidity, and nurses are uniquely positioned within local and federal governments, professional/advocacy organizations, health care systems, academic institutions, and communities to contribute to addressing systemic and structural root causes. Nurses can lead change to improve maternal health care delivery and care coordination, expand tailored health education, examine multi-factorial causes and solutions, and advocate for change through policy and legislation at organizational, local and federal government levels.¹¹ Furthermore, nurses who specialize in cardiovascular care, CVD prevention, and management have especially distinctive expertise to collaborate with women’s health and primary care providers to assure comprehensive CVD risk assessment, disease management, and lifetime follow-up.

The United States is long overdue for a paradigm shift in maternal health, away from a focus on individual behaviors and socioeconomic status and instead, to focus on comprehensive and systemic approaches that address the social and structural issues underlying maternal health inequities.¹² Together, we can decrease overall maternal mortality and eliminate the maternal health and health care inequities that disproportionately burden Black, Indigenous, and Persons of Color.