Federal health officials yesterday reported that the death rate for pregnant women in the District is nearly the worst in the nation, reflecting a racial disparity in health status that has perplexed scientists for decades.
In the 10 years ending in 1996, the District had 22.8 maternal deaths for every 100,000 live births -- nearly twice that of the second-highest jurisdiction, Mississippi. Maryland's overall rate was 9.1 and Virginia's 5.8. The national rate was 7.7, and New Hampshire had the lowest rate, 1.9.
Experts consider it unfair to compare statistics on the District, a small and entirely urban jurisdiction, with data from states that have urban, rural and suburban populations. Yet the District fares poorly in the U.S. Centers for Disease Control analysis even when its black population is compared with black populations in the other jurisdictions. The District's African American maternal mortality rate of 25.7 surpassed the national African American rate of 19.6.
Only New York and Kansas had higher death rates for black pregnant women. The New York City health department yesterday said that its 1997 maternal mortality rate for African Americans was 33 deaths for every 100,000 live births, compared with an overall rate of 14.
The report was the first ever to provide a state-by-state comparison of the numbers of women who died during pregnancy or within six weeks of childbirth or abortion, said Lynne Wilcox, director of reproductive health at the CDC.
The leading causes of pregnancy-related death are hemorrhage, high blood pressure and blood vessel blockage. District officials said about 23 pregnant women died of such causes in the decade studied. Wilcox said the disparity between blacks and whites cannot be fully explained by differences in access to medical care.
"People have spent a long time looking at gaps in infant mortality, but they've not specifically looked at gaps between white and African American women in maternal mortality and complications of pregnancy," Wilcox said. "We're calling for monitoring these deaths more closely and researching why these differences in experiences might be happening."
A small but growing number of jurisdictions have maternal mortality review committees to determine the cause of every pregnant woman's death, she said.
The District spends millions on prenatal care for women, but Ronald David, medical director of the agency that runs D.C. General Hospital and 12 community clinics, said the solution is vastly more complex than merely inviting impoverished women to use free health services.
Many black women, he said, suffer so much social alienation that they simply withdraw and refuse to trust health care. These are the women who never see a doctor until they go into labor, he said.
"There is enough prenatal care available," he said. "I wonder if it has meaning for those who don't avail themselves of it. To the extent that they don't find it meaningful, they don't want to participate or don't believe in its value."
District Health Department officials quibbled with the accuracy of Wilcox's numbers, saying late yesterday that their calculations give the city a lower overall rate of 21.9 deaths for every 100,000 live births for the same 10-year period.
The data, published in today's edition of CDC's Morbidity and Mortality Weekly Report, is further evidence of the dismal health status of African Americans in the District.
The life expectancy of black men in D.C. is at levels similar to those in developing countries, and death rates from preventable causes, including heart disease, HIV/AIDS, stroke and diabetes, are much higher than national averages. Moreover, rates of teen pregnancy, homicide and drug abuse also are higher than national averages.
District officials said the city's overall maternal mortality ranking reflects the fact that 78 percent of all the children born in the District are delivered by black women -- far more than the national average of 16 percent.
Wykiki Alston, 27, of Southeast Washington, has seen maternal health issues from both sides. She had no medical treatment during her first pregnancy in 1991 and nearly bled to death. Doctors performed an emergency Caesarean section and saved her life and that of her daughter, JazMyn. Two years later Alston had another girl, and now she is nine weeks pregnant.
Alston recently began working as a nurse's aide at a Virginia nursing home, but she won't qualify for employer-sponsored health insurance until August. In the meantime she is continuing prenatal care at the Washington Free Clinic.
"If you're unable to get the care you need or can't afford it, then this contributes a lot of stress on you and your child," she said. "A lot of people don't know about free clinics and how to take care of themselves. That's why a lot of mothers and children end up dead."
A growing body of research suggests that a relentless flow of stress hormones in response to difficult living or working conditions takes a physical toll that could explain the racial disparities.
"When we're encountering stresses all day everyday, we are experiencing high levels of the stress hormones, and that disregulates major body systems," said Nancy E. Adler, a psychiatry and pediatrics professor at the University of California at San Francisco who studies socioeconomic factors in health.
Persistent high levels of those hormones have been shown to damage the brain and increase the risk of cardiovascular and immune system problems, high blood pressure and even excess body fat, she said.
"For women in extreme poverty," she said, "the adversities of their life take a toll, and it's reflected in things like this."
Staff writer Stacey Pamela Patton contributed to this report.
Maternal Deaths High in District
From 1987 to 1996, the District had the highest maternal mortality rate in the nation: 22.8 deaths for every 100,000 live births. This is three times the national rate.
Maternal Mortality Rates (MMR), 1987 to 1996:
State Total MMR Pct. of births State
MMR Black White to black women ranking
D.C. 22.8 25.7 * 77.7% 1st
Maryland 9.11 5.9 6.1 31.5 11th
Virginia 5.8 12.0 3.8 23.8 34th
U.S. 7.7 19.6 5.3 16.0
*Percentage estimates for states with fewer than seven maternal deaths for 1987-1996 are considered unreliable.
SOURCE: Morbidity and Mortality Weekly Report