# data[].attributes.body
Maternal Mortality is the death of a woman during pregnancy or within 42 days of termination of pregnancy, from causes related to or aggravated by the pregnancy or its management, excluding accidental or incidental causes.

Although everyone is affected by Maternal Mortality, Black Women are at much higher risk. (Detailed Evaluation of Changes in Data Collection Methods, 2019)

# data[].attributes.attachment_link.readable_text
Background and Process

Maternal mortality is an important health indicator, and correctly identifying and reporting maternal deaths has been a longstanding challenge.

A maternal death is defined as, "the death of a woman while pregnant or within 42 days of termination of pregnancy," but excludes those from accidental or incidental causes.

Official statistics are obtained through death certificates completed by physicians and reported to states. To promote standardization, the National Center for Health Statistics (NCHS) periodically organizes a national consensus process that makes recommendations to states on the content of birth and death certificates.

Responding to research showing that maternal deaths were undercounted on death certificates and that states used noncomparable methods, in 2003, this consensus process recommended that all states add a standardized checkbox to improve the identification of maternal deaths. Physicians were instructed to check a box for a known pregnancy in defined timeframes before death.

Vital registration systems are controlled individually by each state, and the standardized checkbox was implemented as funding, technology, and state laws allowed. The last state added the checkbox to the death record form in 2017.

As state systems diverged, the comparability of data diminished to the point where in 2007, NCHS suspended the publication of national maternal mortality data.

Vital Statistics Reporting Guidance No. 4, A Reference Guide for Certification of Deaths Associated With Pregnancy on Death Certificates [PDF - 4 MB] , provides physicians, medical examiners, coroners, and other medical certifiers with specific recommendations and examples of documenting different types of deaths associated with pregnancy, to improve consistency and accuracy in reporting.

Evaluation of the Impact on Maternal Mortality Rates (MMRs)

With states now using more comparable approaches, NCHS undertook a rigorous evaluation of maternal death reporting.

The new checkbox, as intended, substantially increased the identification of maternal deaths. The addition of the checkbox led to capturing twice the rate of maternal deaths through death certificates.

If all states added the checkbox at once, there would have been a large, one-time increase in the reported rate. However, since the checkbox was added one state at a time, over an extended period, assessing the real trends in maternal mortality over time has been a challenge.

Two NCHS reports capture the result of a rigorous evaluation by NCHS: "Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths [PDF - 1 MB] " describes the changes in maternal death rates due to the inclusion of the checkbox. "The Impact of the Pregnancy Checkbox and Misclassification on Maternal Mortality Trends in the United States, 1999-2017 [PDF - 6 MB] ," uses a set of sophisticated statistical models to look at trends over this period to better understand the impact of the gradual adoption of the checkbox on national statistics.

A separate report, "Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018 [PDF - 1 MB] " includes the 2018 MMRs and discusses new coding procedures.

What NCHS Found

The understanding of the trend in maternal mortality changed significantly with these new studies. In short, using more comparable data across states, NCHS found that the increase in maternal mortality in the United States is not likely due to a true increase in the underlying extent of maternal mortality. Rather, the majority of the observed increase in the MMR is attributed to changes in data collection methods (i.e., the gradual adoption of the checkbox). Based on the pre-2003 coding method, the MMR was 8.9 in 2002 and 8.7 in 2018. (NVSR Vol. 69, No. 2, Table E).

The understanding of this trend comes from looking at this in two different ways, and the congruence of these two different approaches strengthens our confidence in the findings. First, NCHS looked at direct counts from certificates, taking into account the addition of the checkbox over time. Second, NCHS developed a sophisticated model of the data to test two different scenarios: What would the data have looked like if no state had used a checkbox, and what if all states had implemented a checkbox at the same time? In both cases, NCHS found that the MMR did not change significantly over this period.

NCHS also found that while the addition of the checkbox allowed more pregnancies to be identified, it also likely introduced errors and overcounting with increasing age. For example, in deaths to women over age 44, NCHS found the rates were as much as 124.1 times those of younger women, and that in many of these cases, there was no accompanying cause-of-death information that supported the conclusion that the death was likely related to pregnancy.

For more information, see Implementation of New Coding Methods and the 2018 Maternal Mortality Reports.

# data[].attributes.attachment_link.title
NVSS - Maternal Mortality - Evaluation of Changes

# data[].attributes.body
Decrease the number of Maternal Mortalities among Black Mothers due to Maternal Health Issues in the San Francisco/Bay Area in 3 years.

Decrease the number of Infant Mortalities due to Maternal Health Issues in the San Francisco/Bay Area in 3 years.

# data[].attributes.body
SHE MATTERS (Supporting Health, Equity, and Maternal Advocacy Through Empowered Resources & Support)

# data[].attributes.body
San Francisco does not meet the national Healthy People objective for maternal mortality of no more than 3.3 deaths per 100,000 live births.

Each year, in San Francisco, about 11 woman dies from complications of pregnancy or childbirth (Maternal and Infant Mortality, SFHip).

# data[].attributes.attachment_link.readable_text
What is it?

Maternal death is defined as the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication. Pregnancy complications may include any chain of events initiated by pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy [1, 2]. The pregnancy-related mortality ratio is the number of pregnancy-related deaths for every 100,000 live births [2].

Infant death is the death of an infant before his or her first birthday [3]. The infant death rate is the number of infant deaths for every 1,000 live births [3].

Maternal and sudden unexpected infant deaths are considered sentinel events [4]. The U.S. government's Healthy People targets aim for no more than 3.3 maternal deaths per 100,000 live births [5] and no more than​ 6.0 infant deaths per live births [6].

Why is it important for health?

The pregnancy-related mortality ratio and infant death rate are often used as indicators of the nation's health [2, 3]. Factors that affect the health of the entire population can affect mortality among pregnant and postpartum women and infants.

What is the status in San Francisco?

Over the 10 year period 2007-2017, there were 10 maternal deaths due to pregnancy or childbirth. Relative to the 89,594 live births during the decade, the estimated pregnancy-related mortality ratio was 11.2 maternal deaths per 100,000 births. The top 3 causes of maternal death were embolism, infection, and chronic disease, including cancers and hypertension.

Figure 1 describes trends in infant death in San Francisco. Over the past decade, local infant death rates have consistently been lower than statewide and national rates, and below the Healthy People 2020 target of 6.0 infant deaths per live births [6]. For infants born between 2012-2016, there were about 24 infant deaths per year. The 5-year infant death rate was 2.7 infant deaths per 1,000 births (see Table 1). The top 3 causes of infant death were low birth weight, SUID, and birth trauma. The majority of infant deaths occurred within 7 days of birth.

# data[].attributes.attachment_link.description
Maternal death is defined as the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication. Pregnancy complications may include any chain of events initiated by pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy [1, 2].

# data[].attributes.headline
Addressing Racism and Discrimination in Healthcare Settings

# data[].attributes.subject
Addressing Racism and Discrimination in Healthcare Settings

# data[].attributes.body
Short Term: Increase in the # of health care workers who know the elements of cultural competency to more effectively take care of their patients by 9 months. (Knowledge)

Short Term: Increasing the # of people working in a hospital setting and diversifying the work place so that provider bias decreases by 6 months. (Circumstances)

# data[].attributes.body
Black Women living in San Francisco who are expecting, currently pregnant, and trying to get pregnant.

Healthcare Professionals who serve Women of Color and Expecting Mothers

# data[].attributes.headline
Maternal Mortality Devastates Black Women in the San Francisco/Bay Area

# data[].attributes.subject
Maternal Mortality Devastates Black Women in the San Francisco/Bay Area

# data[].attributes.body
According to CDC data in 2021, Black mothers’ have the highest maternal mortality rate, at 40.8 deaths per 100,000 live births.

Black/African American mothers had about 4 out of100 births, but experienced 5 out of 10 maternal deaths, and 15 out of 100 infant deaths.

(Black Maternal Health in the U.S., 2023)

(Maternal and Infant Mortality, SFHip)

# data[].attributes.headline
Working Together to Reduce Black Maternal Mortality

# data[].attributes.subject
Working Together to Reduce Black Maternal Mortality

# data[].attributes.body
Black Women are 3X more likely to die from pregnancy-related issues than White women are due to variations in quality healthcare and underlying chronic health conditions.

Healthcare providers can ask questions about their patients, help their patients understand urgent maternal warning signs, and provide their patients with quality care.

Hospitals and healthcare systems can help improve quality of prenatal and postpartum care.

(CDC, Working Together to Reduce Black Maternal Mortality)

# data[].attributes.attachment_link.title
Working Together to Reduce Black Maternal Mortality

# data[].attributes.attachment_link.description
Learn about working together to reduce Black maternal mortality.

# data[].attributes.headline
Program Activities Phase 1: Program Development (Months 1-3)

# data[].attributes.subject
Program Activities Phase 1: Program Development (Months 1-3)

# data[].attributes.body
Hire Staff for the Program.

Find 10 Healthcare Professionals to lead workshops.

Find accessible locations where we can hold training sessions and activities.

Purchase necessary materials to conduct activities.

Develop a curriculum to train healthcare professionals on cultural competency.

Develop a Social Media campaign to spread the word about our program, this could include flyers posted throughout the city to those without internet access.

Develop an online resource, a website, that allows us to provide information for pregnancy, birthing, and maternal resources.

# data[].attributes.body
Knowledge of preconception/pregnancy health is important for a successful pregnancy because women need to be able to make informed decisions about their health and pregnancy. A lack of knowledge can also lead to inadequate care, and can result in pregnancy complications.

Knowing specific pregnancy milestones, or having an understanding of initial health condition can play a role in pregnancy outcomes, and this lack of education plays a role in maternal health mortality rates amongst black women.

Having an understanding on how stress plays a role in pregnancies is essential to a successful pregnancy, as well as alcohol intake, whether they are a current or former smoker, and nutritional and occupational status are important components that can determine the success of the pregnancy.

(Njoku, et al., 2023)

# data[].attributes.headline
Lack of Access to Quality and Timely Prenatal Care Resources 

# data[].attributes.subject
Lack of Access to Quality and Timely Prenatal Care Resources 

# data[].attributes.body
Medium Term:

Increase in the # of Pregnant Black Women in SF/Bay Area Who Have Access to Timely and Quality Prenatal Care Resources in 12 Months.(circumstances)

Short Term:

Increase in the # of Pregnant Black Women in SF/Bay Area Who Know Where To Access Prenatal Resources Within 3 Months.(Knowledge)

Short Term:

Increase in the # of Pregnant Black Women in SF/Bay Area Who Believe They Can Reach Out To Their HealthCare Providers With A Positive Experience Within 6 Months.(attitude)

# data[].attributes.headline
Community Cultural Wealth for Black Women

# data[].attributes.subject
Community Cultural Wealth for Black Women

# data[].attributes.body
When creating this Public Health program we utilized Tara Yosso's Community Cultural Wealth theory. This framework allows us to see the inequities and biases that Black Women face within the healthcare field by honoring and building upon the cultural wealth this demographic possesses. They understand the best what they experience when accessing health care resources and can aid other women through a peer-to-peer program using their own experiences to make others better.

# data[].attributes.headline
Improper Diagnosis and Lack of Context Due to Mistrust

# data[].attributes.subject
Improper Diagnosis and Lack of Context Due to Mistrust

# data[].attributes.body
There is a reluctance amongst the community to be treated by healthcare professionals due to the racism and mistreatment of the healthcare industry. This reluctance can lead to improper diagnoses of fatal conditions such as preeclampsia, perpartum cadiomyopathy(weakening of the heart muscle after child birth), postpartum hemorrhage, hypertension, and etc, all common misdiagnosed or under-diagnosed conditions. All of the risks due to these conditions can be reduced through thorough medical diagnosis, which can be established through a relationship of trust between health care provider and patient.

This mistrust in healthcare leads to a lack of open communication between healthcare providers and black women, which worsens their case as there may not be sufficient information to determine a proper and accurate diagnosis.

Factors such as ignoring and withholding diagnoses, lack of appropriate referrals, and poor documentation and communication can endanger Black women’s lives.

(Njoku, et al., 2023)

# data[].attributes.body
Medium Term:

Increase in the # of Pregnant Black Women in SF/Bay Area Who Have Access to Supportive Groups, Family Members, and Friends Who Are Supporting Them Through This Journey Within 12 Months. (Behaviour)

Short Term:

Increase in the # of Pregnant Black Women in SF/Bay Area Area Who Believe They Have Access to Support Systems Online Within 3 Months. (Attitude)

# data[].attributes.headline
Program Activities Phase 2: Program Implementation (Months 4-21)

# data[].attributes.subject
Program Activities Phase 2: Program Implementation (Months 4-21)

# data[].attributes.body
Maternal Health Training for Black Mothers:

Participants will collaborate with Doulas and Midwives through a series of health education classes and courses that meet 3 hours a day, once a week for 6 months to learn more about their pregnancies.

Training Topics: Pregnancy risks, maternal mortality rates, managing health during pregnancy, navigating the healthcare system, and pospartum care

Completion of course material that end with group discussions facilitated by instructors to evaluate understanding of subject matter

Each week will be a different topic

5 cohorts of 20 participants that rotate through different training topics

Black Birth Matters:

Doulas and Midwives will undergo training over the course of 3 months; each training session will be 3-4 hours long and occur 2-3 times a month. This training will involve the development of culturally competent and sensitive healthcare practices in order to design effective coursework materials as well as create inclusive environments for the participants involved.

20 Participants per group; 5 groups will be served during this training

Training approach

Complete coursework to demonstrate adequate understanding

Collaborate with midwives and doulas

Training Topics

Culturally sensitive care, social determinants, crash course of the history regarding maternal mortality rates

Peer Support Group:

-Gather participants from Maternal Health Training for Black Moters to form peer support groups. These support groups will act as a resource for participants to facilitate group conversations and to create a community. They will essentially bond through group activities that stimulate discussion surrounding potential mental health issues can arise due to pregnancy. Groups will usually consist of 15 participants, but will meet 3-4 times a week for 1 hr sessions.

# data[].attributes.headline
Black Women are Disproportionately Affected by Health Inequities.  

# data[].attributes.subject
Black Women are Disproportionately Affected by Health Inequities.  

# data[].attributes.body
Some Things That Affect the Quality of Care in a Health Care Setting for Black Women is:

Pre-existing conditions like preeclampsia, postpartum hemorrhage, and blood clots are more likely to occur in Black Women.

Lack of health insurance

Lack of culturally competent care

Maternal health policies

Racism and bias in healthcare settings.

(Winny & Bervell, 2023)

Redlining (Montalmant et al., 2023)

Structural racism (Njoku, et al., 2023)

This information is important as we can address these specific topics when improving healthcare experiences for Black mothers in the SF/Bay Area. These factors contribute to Maternal Mortality and increase the likelihood of Black Mothers looking into healthcare.

# data[].attributes.attachment_link.provider_name
Johns Hopkins Bloomberg School of Public Health

# data[].attributes.attachment_link.title
Solving the Black Maternal Health Crisis | Johns Hopkins Bloomberg School of Public Health

# data[].attributes.attachment_link.description
Change at every level-from federal policy to individual action-can support Black birthing people in the U.S.

# data[].attributes.body
Medium Term:

Increase in the # of Pregnant Black Women in SF/Bay Area attending prenatal and postpartum appointments from their healthcare providers in 1 year. (Behavior)

Short Term:

Increase in the # of Pregnant Black Women in the SF/Bay Area who know about their pregnancy (natal health, their initial health during pregnancy, pregnancy milestones, etc.) in 6 months.  (Knowledge)

Short Term:

Increase the # of Pregnant Black Women in SF/Bay Area that believe they can manage their health during pregnancy in 6 months. (Attitude)

# data[].attributes.headline
Program Activities Phase 3: Closing (Months 22-24)

# data[].attributes.subject
Program Activities Phase 3: Closing (Months 22-24)

# data[].attributes.body
Hold SHE MATTERS party to celebrate the participants journey throughout this training

Hold acknowledgement ceremony for healthcare professionals

Conduct evaluation activities

Promote highlights on social media

Develop final report about the SHE MATTERS campaign

# data[].attributes.headline
Racism, Bias and Discrimination in Healthcare Settings

# data[].attributes.subject
Racism, Bias and Discrimination in Healthcare Settings

# data[].attributes.body
Historic redlining policies pushed people of color out of wealthier neighborhoods with better healthcare access. Less access to high quality healthcare facilities can lead to delayed or inadequate prenatal care, which affects maternal and infant health.

Having symptoms dismissed, pain undertreated compared to white patients, referred less frequently for specialty care compared to white patients are all forms of racial discrimination experienced by Black patients in healthcare settings.

Black mothers may also be subjected to unnecessary and invasive medical procedures, such as C-sections, based on healthcare providers biases and assumptions.

(Tulane University, 2023)

# data[].attributes.body
10 trained MHTBM healthcare professionals

1 curriculum to train MHTBM healthcare professionals

1 MHBTM training curriculum

20 program participants per session trained in MHTBM

100 social media posts as part of the SHE MATTERS campaign

# data[].attributes.headline
Systemic Racism and its Effect on Health Outcomes for Black Mothers

# data[].attributes.subject
Systemic Racism and its Effect on Health Outcomes for Black Mothers

# data[].attributes.body
Black women living in the US are more susceptible to diseases and complications before, during, and after pregnancy due to the effects of systemic racism.

(Hunt, 2021)

Black mothers experience a higher level of suspicion by healthcare providers, which can lead to delays in diagnosis and treatment and contributes to poor maternal health outcomes. This suspicion is often based on implicit biases and stereotypes that are rooted in systemic racism. (Tulane University, 2023)

Hospitals serving primarily Black patients had higher rates of maternal complications as they performed worse on 12 of 15 birth outcomes compared to hospitals primarily serving white patients (Frank et al., 2020)

# data[].attributes.body
Impacts on their families and friends which can lead to infant mortality, poverty, and long-term health issues.

Families and Friends are losing loved-ones that have significant impact on their lives. This can affects the Mental Health of everyone who was in connection with these women.

The high cost in economic structure for black, low-income communities and the healthcare system.

This tragedy, leads to death, cutting the lives of these women short.

(Montalmant et al., 2023)

# data[].attributes.attachment_link.readable_text
Data: California Department of Public Health. Chart: Alice Feng/Axios

April is National Minority Health Month, and each year, one week is dedicated to education and awareness around Black maternal health.

Driving the news: San Francisco is home to some of the country's most sought-after physicians and medical establishments, but when it comes to maternal deaths, racial inequities remain.

State of play: Black women in the United States die at rates three times higher than white women.

San Francisco's overall maternal mortality rate has been lower than the national figure, but the disproportionate impact on Black women is just as prevalent.

Between 2007 and 2016, Black mothers had four out of 100 births but made up half of all maternal deaths in the city, according to a report by the San Francisco Health Improvement Partnership.

Between the lines: Systemic racism like redlining and segregation havelong determined the kind of care a Black patient gets.

What they're saying: When Black women are asked what they envision as their perfect doctor, many respond that they "just want to be treated like a human being," Linda Jones, a doula and co-founder of the Bay Area-based collective Black Women Birthing Justice, told Axios.

"In the past and even now, Black women who speak up for themselves get labeled noncompliant or angry," she said. "But we have to teach people how to work within the system ... and help them understand how they're supposed to be treated."

What to watch: The conversation around how to better serve pregnant Black people is starting to shift to center on the need for safety and security.

San Francisco is piloting a program to provide a monthly income supplement of $1,000 to roughly 150 Black and Pacific Islander participants throughout pregnancy and their baby's first six months.

At the onset of the pandemic, the volunteer-run group One Love Black Community began delivering boxes of diapers, fresh produce, and other necessities to expecting and new Black parents.

Meanwhile, more Black women are turning to doulas who can serve as trusted advisers in hospital settings, or other forms of non-clinical care like home births.

The bottom line: To address longstanding racial inequities, the U.S. will need to focus on "the ways in which our society is structured around racism that makes Black mothers vulnerable to adverse health outcomes," epidemiologist Shawnita Sealy-Jefferson warned in a 2022 study.

# data[].attributes.attachment_link.title
The state of Black maternal health in the Bay Area

# data[].attributes.attachment_link.description
Across America, Black women die at rates three times higher than white women.

# data[].attributes.body
https://publichealth.tulane.edu/blog/black-maternal-health-racial-disparities/#:~:text=Understanding%20the%20Black%20Maternal%20Mortality%20Rate%20The,collectively%20as%20the%20social%20determinants%20of%20health).

https://www.sf.gov/perinatal-equity-initiative#

https://globalhealthsciences.ucsf.edu/black-maternal-mortality-a-human-rights-crisis/

https://sfhip.org/chna/community-health-data/maternal-and-infant-mortality/

https://pmc.ncbi.nlm.nih.gov/articles/PMC9914526/

https://publichealth.jhu.edu/2023/solving-the-black-maternal-health-crisis#:~:text=Black%20birthing%20people%20are%20also,birth%20and%20low%

https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/

https://www.cdc.gov/womens-health/features/maternal-mortality.html#:~:text=Black%20women%20are%20three%20times,%2C%20physical%2C%20and%20emotional%20health.

https://sfhip.org/chna/community-health-data/maternal-and-infant-mortality/

https://mjgh.library.mcgill.ca/article/view/1322/1380

https://sfhip.org/chna/community-health-data/maternal-and-infant-mortality/

https://www.sf.gov/perinatal-equity-initiative

Hunt, J. (2021). Maternal Mortality among Black Women in the United States. Ballard Brief. https://ballardbrief.byu.edu/issue-briefs/maternal-mortality-among-black-women-in-the-united-states

Tulane University. (2023, June 20). Black maternal health in the U.S. Publichealth.tulane.edu. https://publichealth.tulane.edu/blog/black-maternal-health-racial-disparities/

‌

Black Babies who BLOOM | UCSF Benioff Children’s Hospitals Foundation. (n.d.). Give.ucsfbenioffchildrens.org. https://give.ucsfbenioffchildrens.org/stories/bloom-black-baby-equity-clinic

‌

https://publichealth.jhu.edu/2023/solving-the-black-maternal-health-crisis#:~:text=Black%20birthing%20people%20are%20also,birth%20and%20low%20birth%20weight

https://www.cdc.gov/nchs/maternal-mortality/evaluation.htm#:~:text=Maternal%20mortality%20is%20an%20important,from%20accidental%20or%20incidental%20causes.

https://doi.org/10.1007/s40615-023-01816-x

# data[].attributes.attachment_link.title
The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature - Journal of Racial and Ethnic Health Disparities

# data[].attributes.attachment_link.description
Background The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women. Methods A literature review was conducted to examine the racial disparities in the United States’ MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014. Result Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women. Conclusions The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system.