Much has been written in the literature of public health about America’s shocking maternal mortality rate. Occasionally media reports the alarming rate when there is a hook. Advocates concerned with women and health illuminate the problem in reports and at conferences. But in light of the SCOTUS Dobbs decision on abortion, new urgency arose in addressing U.S. maternal mortality and its causes because of the link between reproductive rights and the persistence of inherent racial issues in women’s healthcare.

It is disturbing and illuminating to note the World Health Organization's maternal mortality rate rankings. The U.S. is 55th in the list of industrialized nations at nearly 24 deaths per 100,000 live births. A 2022 study found that women in this country face the highest rates of preventable problems and mortality when compared with women in 10 other wealthy nations, and that rate continues to go up. The race disparity in maternal mortality is additionally alarming. Black women die at a rate of 55.3 deaths per 100,000 live births, more than 50 percent higher than white women.

That’s one reason Rep. Alma Adams (D-NC) and several colleagues in the House introduced a bill earlier this year to specifically address the high rate of stillbirths, which Black women and other women of color are twice as likely to experience as white women. Targeted legislative like that is critical to changing the public health landscape when it comes to pregnancy outcomes and the health of women and children.

So are campaigns like the “Hear Her” initiative at the Centers for Disease Prevention and Control (CDC), designed to address the fact that women are often not heard, believed, or viewed as reliable when they present relevant histories or symptoms. That problem is worse for Black women too. Research shows that women of color are more likely to be described negatively in notes and reports and recent studies reveal that doctors are most likely to use “stigmatizing language” in their notes about patients of color, referring to them as “noncompliant, challenging or resisting,” as research at the University of Chicago revealed.

That’s why the all-out attempt to end abortion nationally, ignoring 50 years of precedent regarding a woman’s right to privacy, reproductive healthcare and choice was such a travesty, exacerbating the already shameful maternal morbidity and mortality data which serves as an indicator of continuing racism in this country.

Black women and their sisters of color are likely to suffer enormously from the consequences of state-ordered pregnancy in the states that cling to misogynistic, racist policies, and not only in terms of their health or possible survival. They will also be affected economically in dramatic ways. A Forbes report suggests they will be deprived of education that can lift them out of poverty, and they will be targets of aggressive invasions of privacy through data searches that enable the over-policing of their reproductive habits and practices. Depending on where they live, they may be subject to fertility and period-tracking apps used by police according to their zip code because they are deemed to reside in high .abortion areas.

In her monumental work resulting in the 1619 Project documenting the history of broad-reaching racism in this country, Nicole Hannah-Jones provides a historical perspective essential to understanding the confluence of maternal mortality, the abortion crisis we now face, and unrelenting racism. Her book provides vital context regarding the connection between those three issues.

The title of both the project and book derives from the origins of slavery in America, dating back to 1619 with much of the book’s relevance focusing on the period of Reconstruction following the Civil War, when a key question arose. What would white America do with black people post slavery? Where would formerly enslaved people fit in a paid workforce? How would former slaves be treated if they were free Americans? What would be done about their education or healthcare?

Southern Democrats resisted these considerations mightily, especially when reformers like Rebecca Lee Crumpler, the first black woman doctor in America, laid bare the burdens of being black in a country unwilling to facilitate freedom for former slaves.

Because of that resistance, the National Medical Association formed by black doctors in 1895 called for a national health care system - which went nowhere until the idea became a states’ rights issue during WWII when President Truman called for an expanded hospital system that predictably led to segregation and the denial of healthcare for black people. Later, insurance-based healthcare presented a further hurdle, while medical schools excluded black physicians and medicine became a for-profit, unregulated system. All of this has led to present-day lack of equitable, affordable, accessible healthcare if you are black or poor.

In the midterm election, five states had abortion on the ballot and in all five, voters supported the right to choose. Three of them guaranteed the right to abortion in their constitutions. That is a huge relief to women in the five states, but it remains to be seen how women of color will fare.

In Nicole Hannah-Jones’ words, “…arguments about socialized medicine, equity and human rights…echo down to the present day.” Her book reveals the connections that make women of color exceptionally vulnerable even in this moment, and reminds us that there is still work to be done.

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Elayne Clift writes about women, health, and social issues from Brattelboro, Vt.

A mother watches her seven-year-old child die in excruciating pain from a ruptured appendix in their car waiting for access to the emergency room. A family member sees their 44-year-old relative succumb to a heart attack waiting for a bed in the Cardiac Care Unit. A woman suffering from high blood pressure during pregnancy awaits admission while in premature labor.

These actual examples underscore the reality of people unable to access crucial healthcare because of a crisis that has been exacerbated by people who refuse to be vaccinated. Not only are extremely ill patients dying in parking lots. Hospitals are also suffering shortages of beds, staff, and equipment, especially in ICUs, and flying patients out of state for care, while leaving others in need of urgent care literally out in the cold.

It’s an unimaginable, horrific scene to contemplate.

A friend of the man waiting for cardiac care put it this way. “Car accidents happen. Heart attacks happen. Trauma happens and there may not be care for you in the hospital if we can’t do something to get this under control.” The fact is, it’s been getting harder to control.

It is not just a terrifying experience for people waiting for care. It’s also difficult to imagine what it must be like for exhausted doctors, nurses and other healthcare professionals. What must it be like as a nurse holding the hand of a young patient who might be succumbing to Covid or setting up a Zoom call so someone on a ventilator can wheeze out a farewell to loved ones? Consider the emotional toll it takes being on a team that must declare one patient worthy of trying to save and another not quite so worthy. It’s a deeply depressing situation to ask anyone to endure.

The burnout rate among health workers since the Covid pandemic skyrocketed initially, and again with the Delta variant, has resulted in a significant number of nurses leaving or considering leaving the field. A report issued by The Washington Post/Kaiser Family Foundation in June “found that 26% of health care workers in hospitals are angry and 29% have considered leaving the medical field. These are the warning signs of a smoldering epidemic of burnout among front-line medical professionals.”

In the midst of the current crisis, the idea of rationing healthcare, which several hospitals have been forced to do or to contemplate by triaging who will live and who will die, begs for attention. Rationing care, often applied during wartime, should not mean that people of any age living with a pandemic must have their lives cut short because others refuse to comply with lifesaving mandates or masking requirements and end up occupying all available beds.

We may never know exactly how many people in this country died from Covid-19 but many compounding variables must be considered, from lack of health insurance to increased vulnerability to poverty. It’s likely that deaths from rationed care will likely not be among them.

In 2010, an Institute of Medicine committee defined the term “crisis standards of care,” calling it “a substantial change in usual healthcare operations and the level of care it is possible to deliver which is made necessary by a pervasive (e.g., pandemic) or catastrophic (e.g., earthquake) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternative care facility operations.”

I wonder if the crafters of that statement were thinking about rationed care during a pandemic resulting in numerous tragic deaths because some people behaved irresponsibly when they wrote that definition, given that they emphasized that “in order to ensure that patients receive the best possible care in a catastrophic event, the nation needs a robust system to guide the public, healthcare professionals and institutions, and governmental entities at all levels.”

To achieve that objective, the committee cited the important of “Fairness – standards that are …recognized as fair by all those affected by them…”, and “Equitable processes – processes and procedures for ensuring the decisions and implementation of standards are made equitability…”

The Hippocratic Oath, the basis for medical ethics, no longer required of graduating medical students by many medical schools, does not actually contain the phrase “First, do no harm.” Nevertheless, medical students, some of whom write their own Oaths, as well as doctors and other healthcare providers, are deeply dedicated to their commitment to providing compassionate care and healing practices for all those in need.

That’s why I believe 20 percent of hospital beds, ICU or otherwise, should be allocated to unvaccinated patients suffering from Covid, while 80 percent of all beds and resources be available to anyone requiring care at any level in order that their lives or health not be held hostage to those who have made choices that are not only deeply selfish but dramatically dangerous.

That seems more “fair and equitable” to me than people having to die in hospital parking lots. It also might just be the way to “get this under control.”