Keywords
disparity - COVID-19 - race - maternal mortality
The disproportionate number of coronavirus disease 2019 (COVID-19)-related deaths
suffered by minorities has been widely reported, and it mirrors what is known about
maternal mortality. Accordingly, COVID-19 infections may marginally increase disparities
in maternal mortality. However, even if no women were infected, the COVID-19 pandemic
could still exacerbate disparities in maternal outcomes. As such, it highlights where
much of the solution to disparities must lie.
Historically, efforts to reduce maternal mortality have focused on creating safer
inpatient experiences. By developing algorithms, encouraging teamwork and drills and
creating simulations and regionalization, the treatment of hemorrhage, hypertension,
deep venous thrombosis, and sepsis has improved. However, a careful look at deaths
and serious morbidities in 2020 makes the singular focus on inpatient, that is, downstream
events hard to justify. In reality, the attention paid to events in the hospital is
in large part because that is where physicians practice. It is not because the etiology
and earlier opportunities to intercede do not exist elsewhere. The breach between
upstream (in community) events that seed morbidity and downstream (in hospital) interventions
that try to reverse the course of disease, has grown through the years as the gap
between rich and poor has grown, and as maternity services in minority communities
have closed.[1] COVID-19 is both a biologic threat, and another challenge to the social determinants
of health that already disfavor poor and minority women. COVID 19-based fear of hospitals,
and hospitals' adoption of protocols that reduce the number of provider-patient contacts
during the prenatal period,[2] have led to diminished opportunities for downstream “saves,” and underscore the
need for upstream interventions.
Our awareness of nonbiologic contributors to morbidly has grown rapidly over the last
decades. The terms “structural racism,” “implicit bias,” and “social determinants
of health” appear much more often in the literature than they did in previous generations.
While a provider may not hear those particular words on rounds, if they work in underserved
communities, they will hear terms that should raise their specter and help providers
to recognize the link between the terms they do hear and adverse events. Every time
a patient is called “noncompliant” or “difficult” one should interrogate the circumstances,
and consider the possibility that there are issues that affluent individuals do not
confront, and which may lead less privileged women to be labeled “noncompliant.” Will
they lose their placement in a homeless shelter if they do not sign out of the hospital
at a certain point to re-establish their residence? Can they afford the bus fares
to get to the clinic? And if they finally get to the clinic, are they told to come
back at a different time if they are late? Are they “difficult” because their experiences
with the health care system have been marked by treatment that was rude, indifferent,
or racially insensitive? All of these challenges have been exacerbated by the pandemic.
The ability to access healthy food; afford housing; avoid contagion on public transport
or in their buildings' small elevators, even to maintain equanimity and avoid weathering
in the face of real or perceived microaggressions is undermined by a disease that
preferentially infects those whose lives are spent in crowded apartments, and who
rely on public transportation to get to low paying but essential jobs.
Even prior to the pandemic, it was hard to ignore the contributions of these problems
to morbid outcomes. Hospitals were never, and will never, be able to provide the full
sanctuary they should until there is an understanding of the factors that underpin
the risks whose consequences are seen full-blown in emergency departments and labor
and delivery suites. Those factors begin at a remove of both space and time from the
hospital. For example, when reviewing the death of a woman who succumbs to status
asthmaticus, it is important to consider that asthma is not randomly distributed across
geographic areas. Locations with more pollutants have higher rates of asthma. Communities
with more pollutants tend to be poorer communities, often communities of color.
Segregation itself is the residue of affirmative acts designed to relegate certain
groups to particular communities and to make it difficult for them either to improve
the environment or to leave it. Among the factors that have contributed to the current
pattern of color-coded neighborhoods is redlining.[3] The vestiges of these practices are still felt in these communities, and the continued
segregation of these communities is not merely the passive persistence of acts perpetrated
generations ago. Residential segregation continues to this day,[4] and environmental risk factors in poorer communities, such as traffic, air, and
noise pollution haven been shown to have a deleterious effect on perinatal outcomes
including increased rates of premature birth, stillbirth, and low birthweight.[5] Other risk factors, for example, obesity and diabetes related to fewer green spaces
for exercise and food deserts are the same factors that may accelerate the progression
from COVID-19 infection to death from COVID-19.
The COVID-19 pandemic did not create these upstream injuries, but it has brought them
to national attention and has exacerbated them. Women may be scared of the crowded
buses that they use to go to clinics, and they may be uncomfortable with the new technology
platforms being used to replace in-person visits. Indeed surviving relatives have
already voiced complaints, not yet fully vetted, that these COVID 19-necessitated
changes have contributed to maternal deaths.[6] Whether these issues are widespread or not, it is clear that more than ever physicians
have to link into community organizations so patients are assisted in navigating complex
system and in stabilizing their social circumstances, which in turn will allow them
to follow medical advice and address illness before they reach an irreversible stage.[7] The key attribute of the professional in these linkages will not be scholarship
or technical skill; there should be the assumption that those will be present. Rather
it is a humility that will allow them to learn from the women they serve. William
Osler said, “Just listen to the patient, he will tell you the diagnosis.” The same
is true of communities; they know the issues that thwart the best intended, constructed,
and implemented inpatient processes. The health care team must be expanded to include
representatives from those communities, individuals who can act as medical Sherpas,
and guide women through the medial thicket that often frustrates the best intended
but under-resourced woman.
When obstetricians prepare to care for a woman with a complicated cardiac disease,
they recognize that medicine cannot be practiced in silos, and highly functioning
programs will organize multidisciplinary meetings to assure that everyone is prepared.
Similarly, the hospital itself is a silo, and there are outside agents who must play
key roles if physicians are to assure patients the best possible outcomes. There are
opportunities. Community-based organizations, including legal professionals, health-home
coordinators, and advocacy groups, surround almost every hospital and can be willing
partners with interested departments. The effort needed to forge these links may seem
herculean. But, COVID-19 has reminded us that physicians are capable of herculean
efforts. If we can battle a viral pandemic, we can confront a social one as well.
COVID-19 has made it clearer than ever that it is time to step out of the footprint
of our institutions and recognize that there are upstream opportunities to prevent
downstream tragedies.
