During my last semester at UMD, one of the courses I took was entitled Race Relations in the US and France. This course was originally supposed to be connected to a study abroad trip to Paris, but due to the ongoing pandemic, we were unable to do so. However, we still had the opportunity to learn a lot about race relations in Paris through podcasts and lectures from professors at the American University in Paris. I was really interested in this course because for the majority of my undergraduate career I have focused a lot on American race relations, but I had not had the opportunity to expand my understanding of race relations internationally. As the final project for this class, we had to conduct a social science research project comparing racial disparities in France and in the U.S. I decided to center my project on Black maternal mortality rates in France and in America. Below, please find my final research paper.
Black Maternal Mortality Rates in France and the United States
Racial disparities with healthcare have been a prevalent ongoing issue disproportionately affecting African Americans for generations. One facet of racial disparities in healthcare is that Black American women are more likely than White American women to have complications with birth such as death and infant mortality. This has become such a noticeable discrepancy that the U.S. House of Representatives Committee on Oversight and Reform had a hearing on May 6th, 2021 entitled “Birthing While Black: Examining America’s Black Maternal Health Crisis” where they discussed national racial differences in healthcare from a historical and medical lens. As a sociology major interested in race relations in the United States, this problem has been of great interest of me. Additionally, my status as a Black woman makes this issue personal for me as I could unfortunately be one of the women in the statistics. Recently, data has become more widespread about disparities specifically for Black women and maternal mortality rates. Since there are notable differences in racial perception and healthcare in France in contrast to the United States, my research project will study if Black maternal mortality rates are similar or different in both countries. This is really important research because Black women and their newborn babies are dying at much higher rates than White women when giving birth. If we compare these two countries and find differences in the Black maternal mortality rates, then we can better determine what changes need to be made to improve the issue. However, if both countries seem to have similar somber statistics, then we can go from there to figure out what is similarly going wrong and how to fix it. Overall, the outcome of this research could lead to higher survival rates of Black mothers and their infant children after childbirth.
According to “Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries” published by the Common Wealth Fund written by Roosa Tikkanen, Munira Z. Gunja, Molly FitzGerald, and Laurie Zephyrin, “in 2018, there were 17 maternal deaths for every 100,000 live births in the U.S. – a ratio more than double that of most other high-income countries (Tikkanen et. Al, 1).” Utilizing Organization for Economic Co-operation and Development (OECD) data, the authors show that the United States is leading the “first-world” countries in maternal mortality rates with Canada and France trailing behind at 8.7 maternal deaths for every 100,000 live births. This academic journal explains that maternal mortality can be constituted by three things: a pregnancy-associated death where a woman dies while pregnant or within one year of the end of the pregnancy, a pregnancy-related death which is similar to a pregnancy-associated death except the cause of death was from a chain of events initiated by pregnancy, and finally maternal mortality which is defined as death while pregnant or within 42 days of the end of a pregnancy. Pregnancy-related death was created by the Center for Disease Control and Prevention (CDC) and is only used in the United States while maternal mortality is used by the World Health Organization (WHO). In the United States, 31% of maternal deaths occur during the pregnancy, 17% during the day of delivery and 52% occur within a year postpartum. Unfortunately, according to a CDC article entitled “Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths”, they found that, “Black, American Indian, and Alaska Native women are two-three times more likely to die from pregnancy related causes than White women (CDC, 1).” More specifically, the Commonwealth Fund found that in 2018, the number of deaths per 100,000 births for Black women was 37.1% while it was 14.7% for White mothers. The CDC says that there have been racial and ethnic disparities in maternal mortality rates and that most of these deaths are preventable. There is a lot of data that covers race related maternal mortality rates within the United States but is hard to come by for the same data for France. Interestingly, a lot of the maternal mortality rate data is viewed from a nationality and immigration standpoint instead of a racial standpoint. In the United States, data is separated by African American, White, Asian American, Hispanic, etc. but according to “Can Excess Maternal Mortality Among Women of Foreign Nationality be Explained by Suboptimal Obstetric Care?” by M Philibert, C Deneuz-Tharaux, and M-H Bouvier-Colle, “in France, the only variable available is the current nationality of the mother (Philibert, et al, 1).” In 2000-2002, these researchers found that the maternal mortality rate for women with French nationality was 6.8 per 100,000 livebirths while it was 14.9 for women of non-European nationality. They first separated their data from the National Expert Committee on Maternal Mortality by French versus foreign and then further separated it by French, other European, North African, sub-Saharan African, and other (which would be North and South American and Asian). After doing data analysis, the authors concluded that, “after taking individual characteristics into account, the excess risk of postpartum maternal death for women of foreign—compared with French—nationality persists. This excess risk is especially important for some nationalities (sub‐Saharan Africa, Asia, North and South America) and for some causes of death (hypertensive disorders and infections). In these same subgroups of nationality and of cause of death, quality of care received by women who died was less often optimal for foreign compared with French women. The existence of an overall excess risk of postpartum maternal death for women of foreign nationalities is consistent with other European studies (Philibert, 1).” This study points to the less optimal quality of care that foreign pregnant women receive as the main reason why maternal mortality rates were highest for women from sub-Saharan Africa, but also acknowledges that there were some limitations in their study because they were unable to look at education and socioeconomic status and they might have missed people due to language barriers and non-response rates. It is important to include data on socioeconomic status and education levels because as mentioned in “Race and Class in African-American Politics” by Michael C. Dawson, “the ‘overdeterminancy of race… particularly in the United States’ has led many researchers and activists to ignore how class and gender divisions within race shape reality differently and ignores nonracial forms of oppression (Dawson, 46).”
“Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries” says that “some experts note that ‘high income countries with the lowest intervention rates, best outcomes, and lowest costs have integrated midwifery-led care’ into their health systems (Tikkanen et. Al, 1).” In comparison to other countries, the United States maternity workforce is opposite to patient needs and has more OB-GYN’s than midwives per 1,000 births. The U.S. typically has 11 OB-GYN’s and 4 midwives per 1,000 live births while France also has 11 OB-GYN’s and 30 midwives. This article states that, “in some countries, women can choose their maternity care provider, as both midwife and obstetrician care services are covered by universal health insurance…in the U.S., midwife services are not uniformly covered by private insurance plans (Tikkanen et. Al, 1).” Postpartum home visits by a midwife or nurse have been connected with improved outcomes, however the United States is the only country of other leading countries such as France, Canada, Australia, Switzerland, the United Kingdom, etc. that does not cover postpartum home visits by national insurance. Specifically, in France a new mother will get postpartum home visits within 24 hours after discharge and will get one to three visits from the midwife. Conversely, in the United States these visits are varied depending on individual insurance and are not done by a midwife. Additionally, the United States is the only high-income country that does not guarantee paid leave to mothers after childbirth. France offers at least 42 weeks of paid maternity leave and Norway has the most at 91 weeks of paid maternity leave.
All of this background information has led me to the hypothesis that Black women in France are going to have lower maternal and infant mortality rates than Black women in the United States. I think that the rates will be lower in France for two reasons. The first reason why it would be lower is because race is perceived differently in France than in the United States and for a very long time, French people tried hard to not focus on race as much. This means that there would be less of a racial difference in maternal mortality rates because there may be much less racial bias within their healthcare system. However, I think that since ethnic divides are focused more on immigration status than race in France, there is a chance that immigrant women in general have higher mortality rates than native French women. As mentioned in “Etre Francais, Cela se Merite” by Rogers Brubaker, “the French debate on citizenship has centered on North African, especially Algerian immigrants (Brubaker, 139).” In comparison to the United States, I believe that while there may still be a disparity in France it will be less prominent than how it is in the United States. Additionally, there is the possibility that it might be reported as lower than it could be in reality because since they do not focus on race nearly as much as we do in the United States, so they probably do not normally conduct that type of research. The second reason it would be lower is because France has a universal healthcare system where access to healthcare is nationalized so the kind of care you receive is not based entirely on your occupation or how much money you make. In the United States our healthcare system is based off of what job you have and how great your insurance coverage is, so there is a possibility that Americans are not receiving the same standard of care as those in France. The American healthcare system leads to unfair disadvantages with coverage and accessibility. If you are poor or do not have insurance coverage in the United States, it is likely that you will probably receive bad or no care whereas that is not necessarily a factor for French people. Interestingly, the Commonwealth Fund found that, “these disparities are not unique to the U.S… in the U.K., which has universal health coverage, maternal deaths were five times more common among Black women… and two times more common among Asian women (Tikkanen et. Al, 1).” So, there is a possibility that having universal health care does not change some of the jarring racial disparities in maternal death rates. However, even though France and the U.K. have similar healthcare coverage, they could still differ from the U.K just because of the difference in racial perceptions and identity in France. In the United States, we focus a lot on our racial differences, and we have been collecting race-related data for a very long time, so we have a lot of data to reference in particular with racial differences in maternal mortality rates which may not be as common in France. Additionally, in the United States we do have a lot of documented instances where there has been racial bias and discrimination within healthcare so that could affect the kind of care that Black women get. France has a different way of looking at race, so there may be less implicit biases in healthcare and treatment than what Black women experience in the U.S. Unfortunately, it has been reported that many Black women living in the United States have their medical concerns ignored or overlooked because of stereotypes that Black women are stronger and just a general lack of trust and care for Black women. This may not be the case in France because of their hyper focus on being colorblind and not seeing race first and foremost.
The most effective way to research this issue would be to collect data from hospitals in both France and the United States about Black maternal mortality rates. To do this, I could randomly select five hospitals in both countries and collect data on maternal and infant mortality rates for all races of women. It is important to study women of all races because I will be comparing Black women to White women to see if there are any tangible differences and then I will take that information and compare it across both countries. This study would last for 10 years just to see if there are any valid trends. Not only would I document how many women and infants died, I would also document their education level, immigration status, socioeconomic status, how many women had complications but survived, an explanation for what caused their complications or death, how long it took them to receive care, and if they felt like the care was satisfactory. In order to make this research project ethical, it would be important to ask each woman entering the hospital for pregnancy related issues for informed consent about the research project and ensure that their identity will remain anonymous. This additional information could help create a positive health policy recommendation that could help reduce the amounts of maternal and infant mortality rates. If we are able to see what some of the confounding issues are in connection with what might have caused the complications or death, then we should be able to address them more specifically. I think that this a really good research design because it will be based off of randomly selected hospitals within both countries so if there are similarities across each nation then the research that was conducted could be widely applicable. Furthermore, this research is extremely important because it has not really been done before in France.
The key takeaway of my research project is to find out differences in maternal mortality rates in France and the United States to see if the racial disparities in the United States are apparent in France. Through outside research sources, it has been made clear that though there is a significant lack of racial data in maternal mortality rates in France, there is evidence that there are disparities for non-native French women. My proposed research project would help bridge the gap of all of the missing data surrounding this issue. Preliminary research shows that France has differing healthcare structures that may improve their general rates in comparison with the United States, but there is still work to be done to discover how accessibility may differ by race/nationality. In order to fix this issue, the CDC recommends that hospitals in the United States should, “Implement standardized protocols in quality improvement initiatives, especially among facilities that serve disproportionately affected communities [and] identify and address implicit bias in healthcare that would likely improve patient-provider interactions, health communication, and health outcomes (CDC, 1).” However, the Commonwealth Fund believes that the best way to solve maternal mortality rates would be to increase midwifery care, insurance coverage, postpartum care, paid leave, and to focus on racial disparities. Hopefully this research project can support those policy recommendations and can be implemented to improve maternal mortality rates across both countries for all women.
References:
Brubaker, Rogers. Citizenship and Nationhood in France and Germany. ACLS History E-Book Project, 2005.
Dawson, Michael C. “Behind the Mule.” 1995, doi:10.1515/9780691212982.
“Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.” Maternal Mortality Maternity Care US Compared 10 Other Countries | Commonwealth Fund, www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.
Philibert, M, et al. “OBGYN.” Obstetrics and Gynecology, John Wiley & Sons, Ltd, 15 Sept. 2008, obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2008.01860.x?saml_referrer.
“Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 6 Sept. 2019, www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html.