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Melissa Harris-Perry: In the United States, Black women are more than three times as likely as their white counterparts to die from pregnancy-related causes.

Last month, a report published by the CDC showed that this disturbing maternal health crisis had gotten worse during the pandemic. Overall, maternal mortality rates rose 14% from 2019 to 2020. It's an increase attributable primarily to rates for Black and Hispanic women.

We should also note that while past CDC data did show that Indigenous women were more than twice as likely as white women to die from pregnancy-related causes, this latest round of CDC data doesn't include information on Indigenous communities at all.

Now, some states are trying to find a solution to this crisis. For example, last year, Illinois became the first State to expand postpartum Medicaid coverage from 60 days after birth to a full year. Given that Black women have higher mortality risk, even at middle and high incomes, it's clear we need a far more complete overhaul of the American maternal health system.

Monica Rose McLemore: My name is Monica Rose McLemore and I'm an Associate Professor in the Family Healthcare Nursing Department at the University of California, San Francisco.

Melissa Harris-Perry: Professor McLemore has been working on the issue of maternal and child health for decades, and sounding the alarm about just how serious the situation is. I asked if she was surprised by the increase in pregnancy-related deaths for Black mothers during the pandemic.

Monica Rose McLemore: No. I bristle sometimes when people call me an oracle, but I will point the listeners to a piece I published on March 28th of 2020, in Scientific American, which was entitled The Pandemic is No Reason to Abandon Pregnant People. At the time I wrote that piece, I didn't realize how prescient it was going to be in terms of really predicting that Black pregnant-capable people were going to bear the brunt of the harms from COVID-19.

I want to contextualize these statistics for the listeners, just so they get a real sense of how to think about them and how to interpret them. These are counts, and we count the number of pregnancy-associated deaths by deaths per 100,000. The reason that we do that is these are small numbers and we've known that the maternal death rate in the United States has been rising for the last four to five years.

In 2016, for all maternal deaths, they were about 19 per 100,000. In 2019, it rose to 20 deaths per 100,000. This is everybody. In 2020, we just saw it's 24 deaths per 100,000. Now, this is 861 deaths, so the numbers are relatively small and rare, which is why we calculate them out per 100,000. When you think about it, the deaths for Black people were already 44 deaths per 100,000, so twice the number in 2019, and in 2020, they were 55 deaths per 100,000. Compare it to the 24 deaths per 100,000 for everyone.

The average is really high in these numbers. Black deaths from pregnancy-related causes in these statistics is now three times higher for Black people. That's why those numbers are so alarming.

Melissa Harris-Perry: As you were saying the numbers, the rates, I was thinking, "Wait a minute, that's not just a proportionate, everyone leveled up," or in this case, leveled down in terms of rate but there was actually an exponential growth, a relative growth in that gap.

Monica Rose McLemore: Yes. For white people, it stayed the same. That we went from double the number of deaths to triple the number of deaths during the pandemic should not be surprising to anyone because it was predicted, not just by me but by a whole lot of other people. These counts that come from the National Center for Health Statistics, they're just that. They don't pontificate or make any extension to the causes of these deaths. They're just counts.

What we already knew from other research and other triangulated data, that COVID-19 was going to be exacerbated in people who had chronic conditions like hypertension and diabetes, and we already know that Black people are overrepresented in those chronic conditions, not because they're Black but because of structural racism, because of inability to have access to wealth and capital and food and clean water and decent environment.

We already knew that chronic conditions were expected to exacerbate COVID-19. Black people are overrepresented in chronic conditions because of structural racism and particularly, how that's operationalized in healthcare. It shouldn't be surprising to people that we saw a tripling of Black maternal deaths in 2020 associated with the COVID-19 pandemic.

Melissa Harris-Perry: Even if it was not a clear surprise, I suppose one of the things I feel like I noticed within the public sphere was greater conversation about it, greater awareness of it. Even the fact that there was a White House symposium addressing this, which I think was a first time at that level of policymaking and acknowledgment of the racial gap in maternal health. Even as we were publicly acknowledging this thing that you and other researchers have known for quite some time, how is it that that gap grows and those numbers grow, at the same time, there seems to finally be attention?

Monica Rose McLemore: Let's add even more attention. In 2020, we had a first-ever presidential proclamation of the Declaration of Black Maternal Health Awareness Week, which is April 11th through April 18th. It was started by the Black Mamas Matter Alliance. The Vice-President put forward a maternal morbidity and mortality crisis day and called to action.

We had the Momnibus, which has been introduced. It was first introduced in 2020 and got pulled. It died on the House floor because of the COVID-19 pandemic, introduced by the Black Maternal Caucus, led by Representative Alma Adams from North Carolina and Rep Lauren Underwood from Chicago. It was reintroduced January 3rd, right before the insurrection. It went from being 9 bills to protect maternal health across the spectrum to being 12 because they included maternal vaccinations and COVID-19.

This comprehensive bill would have done something about these increases in maternal deaths, had been languishing in Congress because they got tied into the Build Back Better bill. Having dollars and humans and space and awareness, it's languishing because the legislation has not passed. We actually know what to do to reduce maternal morbidity and mortality. We know what the strategies are.

We knew these deaths were preventable in the same way we knew COVID-19 deaths were preventable if we appropriately married public health mitigation strategies along with clinical health services provision. The other thing that these statistics don't reflect-- Again, for the listeners, childbirth prior to COVID-19 was the number one reason why people in the United States were being admitted to healthcare and hospital institutions because we have, approximately, 4-million births a year in the United States. Number one reason--

Melissa Harris-Perry: Wait, wait. Slow down, slow down. Say that one again. That one I didn't know.

Monica Rose McLemore: Prior to COVID-19, pregnancy and childbirth were the number one reasons why people in the United States were admitted to hospitals and healthcare institutions, because we have an estimate of 4 million births per year. Only 2% of births happen outside of hospitals and healthcare institutions like at birth centers or home births, so 98% of births in the United States happen in hospitals and healthcare institutions. Prior to COVID-19, it was the number one reason why people were admitted to hospitals and healthcare institutions.

Melissa Harris-Perry: Basically, everybody in the hospital during the-- Not everyone but just an overwhelming proportion during the pandemic are people giving birth or people with COVID-19?

Monica Rose McLemore: Yes.

Melissa Harris-Perry: Or both?

Monica Rose McLemore: Yes. Again, the national health statistics were deaths. It says nothing about long COVID. It says nothing about having had COVID and recovered. We have pregnancy registries including the ones-- Full disclosure, that I'm associated with at the University of California, San Francisco, where we've been tracking persons from the beginning of the pandemic who were pregnant at the time and had COVID. We were looking at numbers of deaths and numbers of morbidity and mortality.

Looking at symptomology, we found that preterm birth also increased, so it wasn't just maternal deaths. It's also all the other known factors that were associated with infectious disease during pregnancy that we've been monitoring for years. Yes, the statistics and counts are horrible in terms of what we saw from the report from the National Center for Health Statistics last week with the 861 deaths, but those counts are not even inclusive of the other negatives sequelae that happen when you have infectious diseases and pregnancy together. It didn't even capture the increase in preterm birth. We reported on that in The Lancet, the 13% increase in preterm birth.

We really need to talk about these statistics in the context of not only were pregnant people not protected, similarly to flattening the curve on the backs of the essential workers. We didn't prioritize the right individuals to be able to receive those public health mitigation strategies and that we didn't prioritize protecting pregnant-capable people.

Melissa Harris-Perry: Two more of these numbers I want you to break down for us. One is how race intersects with age as a Black woman well over 40. Also, however, no longer pregnancy capable, but well over 40, when I look at that category, those numbers are absolutely astonishing. How is it that age intersects here?

Monica Rose McLemore: We call people who have pregnancies over 35 advanced maternal age.

Melissa Harris-Perry: You all call them geriatric. I remember it because was written on the file, geriatric pregnancy, and I had many feelings about that, let me tell you.

Monica Rose McLemore: That drives me up a tree, but the formal clinical term is advanced maternal age. That is because epidemiologically when we look at all the pregnancies that are reported in the United States, there are age groupings that occur where we look at, again, chronic disease, chronic illnesses, and other comorbidities that complicate pregnancies, and there was a arbitrary age that was determined based on population-level statistics that over 35 was advanced maternal health.

Prior to the pandemic, we already knew that people who were of advanced maternal age were already going to be more likely, again, to experience chronic conditions that complicate pregnancy.

When you look at the raw statistics of all maternal deaths and you look at them by age, it doesn't look as though they've increased. However, when you look by age and when you look by race, and this is another argument for the need for disaggregated statistics, by race, by ethnicity, by age, by all of these different factors so that we can really hone in on who has the greatest burden. That's where you really see the people over age 40 bearing the brunt of COVID-19, chronic conditions, all colliding together in the context of pregnancy and resulting in increased mortality.

Melissa Harris-Perry: Let's talk about Hispanic and Latina people capable of birth and what happened with those numbers. Maybe also start by walking back, because I think sometimes we presume that Latinx health and Black health are exactly next to each other, but that is often actually not the case and it looks like there were some very particular effects that happened here.

Monica Rose McLemore: Yes. There's been a lot of discussion and a lot of conversation just really quickly about the Latina or Hispanic paradox that more recent immigrants who come to the United States, we've seen this epidemiologically. Now, there definitely is regional variation in this, but for more recent immigrants who come to the United States, they seem to tend to have better health outcomes and that the longer that they stay in the United States, their health outcomes deteriorate, and people have tried to tabby that to the adoption of the American diet or cultural factors in terms of assimilation. I personally think they start to become as exposed to over racism as the rest of us who've been here all lives, but that's all different discussion.

In the data from the National Health Statistics, we saw that pregnancy-related deaths per 100,000 climbed in Black people, again, from 2019, from 44 to 55 among Black people, but it went from 13 to 18 among Hispanics.

The reason that matters is, interestingly enough, when you look at Hispanic individuals, their birth outcomes are actually better than anybody's if you break it out by nativity, because the 2020 rates among whites were 19 deaths per 100,000. Hispanics went from 13 to 18. They're still under in terms of deaths. They're still under white people in these statistics.

It's a mixed picture in terms of who and they were overrepresented in essential workers. It's this mixed bag and it's hard to interpret without other kinds of research studies and registry data to be able to really tease out what's going on.

The other piece of this is that within the age categories, because Hispanic people tend to have births earlier and younger, it really debunks this notion around the stigma that we've had around teen pregnancy, because people are really starting to hypothesize that if you do have your children younger, you actually, well, not young kids, but younger, you actually may have superior health outcomes, both for you and baby, depending on where across that reproductive spectrum your pregnancies occur.

It's more complicated than we've always thought about in terms of how we set up health services provision and how we do public health for families. This is why reproductive justice is just so important and that we use that to really infuse our thinking around who is protected? Who is vaccinated? Who is able to really, really have the workplace protections that's necessary in order to have healthy pregnancies and to have healthy outcomes, and who's been able to access comprehensive reproductive healthcare during a global pandemic?

Melissa Harris-Perry: Can I ask you about a group that was simply left out from these statistics, and that is Indigenous women? I went, I looked, I was like, "Hey, I'm a [unintelligible 00:15:05] I don't see it." What is going on with that?

Monica Rose McLemore: There have been many, many brilliant people and epidemiologists, Abigail Echo-Hawk is really, really good at clearly articulating this way better than I can. That native indigenous people are traditionally and historically excluded because of what I think is a poor scientific excuse, that their numbers are too small to be reported. It really has to do with the fact that because maternal deaths impact a community, and it's one of the reasons why statistically, we report them out per 100,000 that we don't want people and their deaths to be disclosed because that's confidential information.

To me, I think that's a lazy statistic, especially being a laboratory scientist and knowing that we could account to small numbers-- When we have genome projects, we will have an n of 1, a sample size of one person, but we'll look at a thousand genes and we figure out statistical methods to be able to account for that. I don't understand why we keep arguing that the numbers of native indigenous individuals, especially pregnant people, are too small for us to do any kind of analytics in terms of understanding just the basic counts.

I actually think we need some new statistical methods to be able to make sure not only are they included in these data, but we also know that deaths in pregnancy are in extreme undercount, and we actually do have regional counts and not national ones.

I think that there are ways for us to think about pooling data, whether it's across traditional tribal lands or reservations, there are ways for us to be able to do that. Native scholars have been working on this and we need to lift up their methods such that they can be included in these counts as well.

Melissa Harris-Perry: Dr. Monica McLemore is Associate Professor of Family Healthcare Nursing at the University of California, San Francisco, and always teaching me something new about methodology. Thank you, Monica.

Monica Rose McLemore: Thank you for having me.

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