In her latest column, Adjunct Associate Professor Lesley Russell delves into recent, worrying developments in the United States, with a focus on maternal mortality and growing restrictions on abortion.
She also reports on new research documenting the failure of high-income countries – including Australia – to ensure that all citizens have safe drinking water and sanitation services. The authors lay the blame squarely on racism, social exclusion and discrimination.
Lesley Russell writes:
If you follow me on Twitter, then you will know that I am currently at our Colorado home, enjoying the wonderful mountain scenery and lots of skiing and snowshoeing. This also means that I’m getting lots of United States news – and some of this, especially around issues of healthcare, is pretty grim.
We can stand back and watch, appalled, as right-wing politicians seem determined to take the United States back to the 19th century with ongoing attacks on women’s reproductive rights and vaccinations, the loosening of child labour laws, the banning of library books, the undermining of federal agencies charged with regulating medicines, and more.
But these actions serve as warning signs to Australians that, without careful attention to the guardrails of democracy and equality, these issues could easily arrive on our shores.
Shocking new data
The United States has long had a reputation as a singularly dangerous place for new mothers compared to other wealthy nations.
In contrast to most other wealthy nations (like Australia), maternal mortality has steadily risen in the US for decades. High rates of chronic conditions like diabetes and obesity, a larger proportion of mothers giving birth via caesarean section, a lack of universal healthcare, shortages of maternity care providers and a lack of paid maternity leave are among the factors that have been suggested as contributing towards the increase.
Maternal death rates are consistently higher among Black women, who also face systemic racism, lower life expectancy, and have disproportionately higher levels of conditions like heart disease and diabetes.
There is a good summary of key US data on health and healthcare by race and ethnicity on the Kaiser Family Foundation website.
A new report from the Centers for Disease Control and Prevention (CDC) highlights how that situation has worsened during the pandemic and how the sudden spike in maternal mortality has hit Black families the hardest.
The overall maternal mortality rate (MMR) for 2021 was 32.9 maternal deaths per 100,000 live births, up from 23.8 in 2020 and 20.1 in 2019. Black women, who had a mortality rate of 69.9 deaths per 100,000 live births, disproportionately shouldered this burden, dying at 2.6 times the rate of white women.
OECD data show that in 2020 Australia reported just two maternal deaths per 100,000 live births, although the Australian Institute of Health and Welfare reported the 2020 MMR as 5.5 pr 100,000 live births. This discrepancy might be explained as the difference between direct deaths and indirect deaths (see figure from AIHW below).
Aboriginal and Torres Strait Islander women, especially those living in remote areas, are at three times greater risk for dying during childbirth. Recent publications (see, for example, here and here) highlight that it is paramount that maternity services partner with First Nations communities to implement trusted and culturally secure maternity and birthing programs that respond to the needs of local communities.
Culturally safe maternity care provision to Aboriginal and Torres Strait Islander women was identified as a priority area in Woman-centred care: strategic directions for Australian maternity services, endorsed by COAG in March 2019.
The Federal Government last year announced $22.5 million for the advancement of Waminda’s Birthing on Country Centre of Excellence on the south coast of NSW. 
See also this Croakey article, reporting on results from the Birthing in Our Community study: First Nations midwives’ leadership and care are central for improving outcomes.
You can read more about the US data and the possible ways the COVID-19 pandemic may have affected MMRs (together with some good graphic representations of the data) here.
On top of this awful situation, a second CDC report, published in Pediatrics, finds a 15 percent increase in sudden unexpected infant deaths (SUIDS – note that this a somewhat broader category than SIDS) among babies of all races from 2019 to 2020, making SUIDS the third-leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth.
Again, there was a striking racial disparity: in 2020 Black babies (214 deaths per 100,000 live births) died of SUIDS at almost three times the rate of White infants (75.6 deaths per 100,000 live births). The rate for American Indian / Alaskan Native infants was 205 deaths per 100,000 live births.
The overall rise in SUIDS rates in 2020 are attributed to diagnostic shifting — or reclassifying the cause of death. But the rise in sleep-related deaths also coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities.
An opinion piece which accompanied the Pediatrics paper sees the increasing disparities in infant deaths as reflecting societal failures.
The PBS NewsHour had an excellent report on these two papers. You can read the transcript here.
A paper published in January in BMJ Global Health found that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity.
Taken together, the data seem to suggest that the adverse impacts on maternal and infant mortality during the pandemic may be due to a combination of direct infections with the SARS-CoV-2 virus, delays in seeking medical care, and the societal and financial impacts of the pandemic.
There are fears that the US situation is likely to get worse. Experts have warned maternal death rates could be pushed even higher following recent rollbacks of abortion access after the Supreme Court overturned Roe v Wade.
Restricting abortions
The above statement is a perfect (or should I say extremely disturbing?) segue into looking at what is happening with abortion and women’s reproductive health in the United States. This is an issue that is constantly in the news here.
Across the nation women and their healthcare providers are grappling with the fallout from the overturning of Roe v Wade, which had enshrined the federal right to abortion. Abortion is now banned in at least 13 states and is very difficult to access in many others.
See my summary of the issues in an article written for Croakey Health Media in June last year.
Conservative lawmakers are acting in the face of public opinion, which generally supports legalised abortion and does so overwhelmingly when a pregnancy endangers the woman’s life.
All eyes are currently on Texas, a Republican state which has some of the most stringent bans on abortion procedures, including the ability to prosecute people who assist a woman to access an abortion. The situation is well-summarised here.
Texas, like most states with bans, does allow exceptions when a physician determines there is risk of “substantial” harm to a pregnant woman, but the legal language around this is (perhaps deliberately) very vague. The potential for prison sentences of up to 99 years, US$100,000 fines and the loss of medical licenses has scared doctors into not providing abortions even in cases where the law would seem to allow them.
Now five women are suing the state, following excruciating experiences of life-threatening situations to themselves and their foetuses that made abortion a medical necessity they were unable to access.
The fear is that women will have to die before these needed safety requirements will be clarified.
See also: Tennessee must change its abortion law – written by a doctor who specialises in high risk pregnancies.
The second reason to watch what is happening in Texas is a wrongful death lawsuit filed by a Texas man against three women who allegedly helped his ex-wife obtain abortion pills and terminate her pregnancy.
“Under the law of Texas, a person who assists a pregnant woman in obtaining a self-managed abortion has committed the crime of murder and can be sued for wrongful death,” the lawsuit argues.
This is the first case of its kind to be brought under the new laws that would potentially see legal action against even the taxi driver who drove a woman seeking advice about pregnancy termination to a medical appointment.
It gets worse. See also: 21 South Carolina GOP Lawmakers Propose Death Penalty for Women Who Have Abortions.
And the third reason eyes are on Texas is another legal case, this time involving the approval and sale of mifepristone, one of two drugs used for medical abortions (mifespristone is also known as RU486). This case argues that mifepristone was improperly approved two decades ago by the Food and Drug Administration (FDA) (the drug has been available in the US for more than 20 years, and even longer in Europe).
The judge hearing this case is very conservative and almost certain to rule against the FDA; it is expected this case will ultimately end up in the US Supreme Court.
The attack on mifepristone is problematic for a variety of reasons: it is part of an effort to ban medical abortions in states where surgical abortions are already banned; it is also part of an effort by conservatives to undermine federal regulatory agencies, even those responsible for the quality and safety of medicines and vaccines.
National pharmacy chains like Walgrens have announced they will not dispense mifepristone in the 21 states where Republican attorneys general have threatened legal action.
Wyoming has already acted to outlaw medical abortion.
It is quite possible that, in the face of a preliminary ruling from the Texas judge ordering the FDA to withdraw its approval of mifepristone (this ruling is expected any day), the FDA may act to reconsider the safety of the drug and/or the manufacturers may withdraw sales. This could lead to international supply problems.
As an aside, it is possible to achieve medical abortions using only misoprostol; this is safe and effective but has more side effects. The misoprostol-only regime has not been approved by the FDA (perhaps this is why abortion opponents have not gone after it or it might be because this drug is also used to treat gastric ulcers), but it is widely used in Europe.
The NPS MedicineWise consumer guide for the use of these drugs in Australia is available here.
The White House has spoken out on the mifepristone lawsuit, saying that decisions on medication safety and use should be made by the FDA, not the courts.
There is one piece of good news among all this worrying gloom: last week the all-Republican North Dakota Supreme Court ruled, in a unanimous decision, that its state constitution protects abortion “where it is necessary to preserve her life or health,” blocking a ban that criminalised such procedures. It’s the first decision of its kind in the wake of the overturning of Roe v Wade, but hopefully not the last.
One final comment on this topic and its wide-ranging impact: last week was Match Day, when Americans who have finished their undergraduate medical education found out where they will do their residency program. Match 2023 applicants have compiled their match and rank lists with the knowledge that the US no longer protects the constitutional right to abortion.
In a survey of more than 2,000 current and future doctors, 82.3 percent said they would prefer to work or train in states with preserved abortion access and 76.4 percent would not even apply to states with legal consequences for providing abortion care. In other words, many qualified candidates would no longer even consider working or training in more than half of US states.
The irony is that the Republican-governed (red) states that are enacting tough abortion bans are the same states that have poorer health status and many medically-underserved areas. Their healthcare problems are compounding.
Australia among high-income countries failing on safe drinking water
A review just published in The Lancet Global Health looks at the failure of high-income countries – including Australia – to ensure that all citizens have safe drinking water and sanitation services. It lays the blame squarely on racism, social exclusion and discrimination.
The international cohort of authors cite several case studies:
- Communities of colour in North Carolina (US) which are excluded from municipal incorporation
- Roma communities in Europe
- People experiencing homelessness in California (US)
- Migrant populations in US and Europe
- Indigenous communities in central and northern Australia.
They write about the problems facing these Indigenous communities. “The challenges faced by these communities are exacerbated by low-quality housing, crowding, obstacles to good governance, environmental vulnerabilities compounded by climate change, and absence of political and economic visibility that limits effective advocacy for change. These communities share commonalities with other Indigenous populations in the USA and Canada, where the legacies of colonialism, genocide, exclusion, and oppression have resulted in generally poor governance and barriers to accessing resources.”
The paper makes recommendations to governments and policy makers:
- Recognise the problem
- Take responsibility for providing services to all, proactively reducing persistent disparities
- Collect specific, representative, disaggregated data on access to and quality of water and sanitation services and their attributable disease burden
- Develop new approaches to water and sanitation service delivery (ie upend financing models that rely on market forces and full-cost pricing to ratepayers).
It concludes that: “High-income countries should move towards sustainable models of infrastructure development and reimagine the relationships among water, sanitation, public health, and the environment, in which justice and substantive equality are central.”
I wrote about the problems of unsafe drinking water in remote Australian communities for the 21 November 2022 issue of The Health Wrap.
The best of Croakey
Do make sure you read Marie McInerny’s excellent assessment of the Close the Gap Campaign 2023 report: How young Aboriginal and Torres Strait Islander people are driving positive change.
The full report is available here.
The good news story
I was excited and fascinated by an article in Inside Story on the work that has been done to develop a dictionary for the Gija language spoken by the people of the East Kimberley.
This opens a window on their sophisticated culture. To quote the author of this article:
This is not simply an etymological project, translating vocabulary and explaining meaning; in many respects, it allows Gija speakers – and learners – to see themselves and their culture in a linguistic mirror.
It reflects and documents the sophisticated worldview, developed over eons, that enabled Gija society to thrive in one of the most severe environments in Australia.”
Perspectives
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
