THE TELOMERE CONNECTION
In the early 2000s, research on telomeres—protective caps on chromosomes—provided further evidence that weathering is not merely a metaphor but a biological reality. Each time cells divide, telomeres get a little shorter. They eventually reach a point where they can’t divide anymore and die. Allostatic load causes cells to divide faster to keep repairing themselves. The result is earlier deterioration of organs and tissues—essentially, premature aging.
“This is what I’ve been talking about all along,” Geronimus says. “Weathering is a biological response to social factors—a product of your lived experience and how that impacts you physiologically. But now, I can describe this even more specifically, in terms of physiological mechanisms. The emerging science gives the concept of weathering a kind of substance or credibility, which has allowed more people to be open to it.”
Geronimus has incorporated the study of allostatic load and telomere length into her own work. She recently led a study of telomere length in Detroit among low-income individuals of multiple races and ethnicities. The results suggested that community and kin networks may be more protective for health than income and education.
Indeed, in this study population, poor white individuals actually experienced more weathering than poor minority populations, and Hispanics with more education experienced more weathering than those with less education. Social isolation and feeling estranged from one’s community, whether because of occupational or educational differences, along with everyday exposure to discrimination in new, predominantly white, middle-class contexts—in popular lingo, being “othered”—may explain these outcomes, Geronimus says.
She hopes to dig further into this line of inquiry, to find out which social stressors matter the most for health, how they can be disrupted, and how the scientific findings can be turned into policy. “If someone is experiencing weathering because of the discrimination they face in their lives,” she says, “the solution is not just to tell them to get more exercise.”
That Geronimus’ ideas have become mainstream in the field was evident at the 23rd Annual HeLa Women’s Health Symposium, held in September 2018 at Morehouse School of Medicine, in Atlanta. This year’s event focused on maternal health disparities, and Geronimus’ findings bubbled up in the talks of many speakers. Researchers and advocates said that a key part of reducing maternal deaths was addressing the societal conditions that affect women’s health throughout their lives, like housing, air quality, and nutrition. One of those speakers was a fellow Harvard Chan alumna and a public health professional who was in a position to make a difference.
FINDING STORIES IN STATISTICS
When she was growing up in a military family in California’s San Fernando Valley, Wanda Barfield, MPH ’90, a rear admiral in the U.S. Public Health Service and director of the Division of Reproductive Health at the CDC, was the kind of kid who would tend to an injured squirrel that fell out of a palm tree. She could never turn away a creature in distress, she says, and often had a stray dog or cat at home under her care. Veterinary medicine seemed like an obvious career path, but as an undergraduate at the University of California–Irvine, she learned about another vulnerable population in need of her big heart.
Black babies were twice as likely to die within their first year as white babies, Barfield read in the Heckler Report. That insight was life-changing.
Barfield, who is African American, had grown up largely protected from the harsh realities of U.S. health inequities. Her dad was in the Navy’s submarine service, a job that came with secure housing and high-quality, accessible health care for his family. Reading the government report completely altered her perspective, and volunteering in a neonatal intensive care unit (NICU) sealed the deal. “I knew I wanted to care for babies and somehow close the gap,” she says. “As I started learning more about working in the NICU, I realized that a baby’s health is related to the health of the mother, and that the health of the mother is related to her community and to the circumstances of her life. I learned that the social determinants of health mattered in very real and concrete ways.”
Barfield entered Harvard Medical School in 1985, one of just 24 students selected to participate in a new approach to medical education focused on problem solving and early patient interaction. Encouraged to take time off before her last year of medical school to earn an MPH at the Harvard Chan School, Barfield researched infant health outcomes in military families. Overall, African American babies in this population were healthier compared with babies in the general African American population, and their birth weights were higher.
One factor that may have made a difference: better access to care, which included more frequent prenatal visits. But Barfield notes that access is just a small piece of the overall health care women receive. More women are going into pregnancy with diabetes, hypertension, and overweight, she says, and these can threaten pregnancy.
But health care is not just a matter of scheduling an appointment. Mary Wesley, DrPH ’18, an epidemiologist and health services consultant working with the Mississippi State Department of Health, organized data from a series of focus groups held with mothers across the state in 2013. Some women reported that they avoided prenatal care because of the way they were treated by providers. These women, many of whom were low-income or lived in rural areas, wanted more education about caring for themselves and their babies but were limited in their choice of providers. If they felt disrespected or unheard in the examining room, there was nowhere else to go.
The CDC currently collects the death certificates of all women who died during pregnancy or within a year of pregnancy. The information is voluntarily provided by the health departments in all 50 states, New York City, and Washington, D.C. But the information is limited, and there is no national standard.
Barfield and others in the field are pushing for wider adoption of Maternal Mortality Review Committees (MMRCs), now operating in about 30 states. Every time a mother dies, these volunteer expert panels meet to review official data as well as other information about the mother’s life, such as media stories or her social media postings. The goal is to identify what went wrong and to develop guidelines for action. In Georgia, for example, where the country’s maternal death rates are highest, the committee has found records of women who developed hypertension during pregnancy and didn’t receive medication soon enough, women who died waiting for unavailable ambulances, and women whose providers didn’t understand warning signs that led to a hemorrhage, just to name a few gaps in the system. “We need these stories to save women’s lives,” Barfield says.
Data that Barfield and her colleagues at the CDC are gathering through a new system called MMRIA (Maternal Mortality Review Information Application)—pronounced “Maria”—may help identify other under-recognized barriers to safe delivery. MMRIA pulls stories together and looks for trends. In its first report, published in January 2018, data from nine states found that the reasons women died varied by race. White mothers were less likely to have died from pre-eclampsia than black mothers, and more likely to have died from mental health issues, including postpartum depression and drug addiction. Barfield hopes to find out whether these results are true across a broader population and is working on expanding the system. Ideally, MMRCs will amass more fine-grained information about the conditions of lost mothers’ lives, so that researchers can understand how to stop these untimely, heartbreaking—and largely preventable—deaths.
“A maternal death is more than just a number or part of a count,” says Barfield. “It is a tragedy that leaves a hole in a family. It is a story that often includes missed opportunities, both inside and outside of the hospital. It’s important to find out why women are dying so we can prevent the circumstances leading to their death.”
Will this growing body of data attesting to black women’s increased risk of death during and after childbirth shape policymaking? Researchers want to see a broad range of changes in health care culture, in public health information gathering, and in society at large. As Neel Shah and Boston University’s Eugene Declercq noted in an August 2018 editorial in STAT, maternal deaths are a “canary in the coal mine for women’s health.” Shah added in a recent interview: “Efforts by clinicians and hospitals to improve maternity care are essential. But we can’t solve the problem of maternal deaths unless we acknowledge that women’s health isn’t something to be concerned about only during pregnancy and then disregarded after the baby is born.”
In 2017, Shah started a national March for Moms to raise public awareness around maternal health. Through his work with Ariadne Labs, he is piloting new approaches to the birth process that ensure that mothers are empowered to make decisions about their care, including a labor and delivery planning whiteboard that helps track mothers’ preferences, health conditions, and birth progress. He says that work is under way on a program to improve community support for mothers during the critical first year after childbirth by galvanizing city governments to coordinate and develop resources.
Along similar lines, the Mississippi State Department of Health offers programs that address issues of quality in care that moms referred to in the focus group discussions, says Mary Wesley. One example is the department’s Perinatal High Risk Management/Infant Services System, a multidisciplinary case management program for Medicaid-eligible, high-risk pregnant and postpartum women and their babies less than 1 year old. The program includes enhanced services with home visits, health education, and psychosocial support for nutritional and mental health needs.
Arline Geronimus takes a wider view of the issue, arguing that the solution to racial inequities in maternal mortality is to change the way society works. In the near term, she says, race should regularly be taken into consideration during prenatal risk screenings, because even younger black women could be at increased risk of pregnancy complications. Risk status by maternal age should be reappraised in context, as well. While most women in their 20s and early 30s are considered low-risk, black women may be weathered and biologically older than their chronological age, she said, which makes them more subject to health complications at younger ages.
This is true even among highly educated or professional women, such as Serena Williams or Shalon Irving. The danger of failing to recognize the effects of weathering in black women of higher socioeconomic position can be compounded. That’s because the U.S. lacks policies that support women who want both careers and parenthood, a gap that can lead professional women to postpone childbearing until their late 30s or 40s. According to Geronimus, “As a group, black mothers in their mid- to late 30s have five times the maternal mortality rate of black teen mothers, although the older mothers generally have greater educational or economic resources and access to health care.”
Ana Langer, professor of the practice of public health and coordinator of the School’s Women and Health Initiative, points out that the 2010 Amnesty International report Deadly Delivery: The Maternal Health Care Crisis in the USA, contained a shocking fact: Most women in the U.S. weren’t dying during childbirth because of the complexity of their health conditions, but because of the barriers they faced in accessing high-quality maternal care—particularly those who were poor or faced racial discrimination.
In general, maternal mortality in the U.S. receives scant attention, Langer adds, in part because there are relatively few deaths each year compared with other conditions, and also because there are no important business opportunities related to conditions that don’t require sophisticated drugs or technologies. But she bluntly suggests an additional reason: “Women—particularly those who are most vulnerable due to their race, age, or socioeconomic status—receive less attention overall for their health issues, compared to men. On a positive note, the attention on gender and sex gaps and social determinants of health in research and care is rapidly increasing. This is the time to build on this growing momentum to increase the efforts to improve maternal health in the U.S.”
In an April 2018 Rewire News story, Elizabeth Dawes Gay, of Black Mamas Matter, directly addressed the racial disparities element in maternal mortality: “Those of us who want to stop black mamas from dying unnecessarily have to name racism as an important factor in black maternal health outcomes and address it through strategic policy change and culture shifts. This requires us to step outside of a framework that only looks at health care and consider the full scope of factors and policies that influence the black American experience. It requires us to examine and dismantle oppressive and discriminatory policies. And it requires us to acknowledge black people as fully human and deserving of fair and equal treatment and act on that belief.”
As Linda Blount, of the Black Women’s Health Imperative, noted during the Morehouse symposium, “Race is not a risk factor. It is the lived experience of being a black woman in this society that is the risk factor.”
Serena Williams understands that. She told the BBC that she had received excellent care overall for her postpartum complications. But then she pulled back the lens. “Imagine all the other women,” she said, who “go through that without the same health care, without the same response.”
Amy Roeder is associate editor of Harvard Public Health.
Photos: Getty Images, Becky Harlan/NPR, Brian Lillie/University of Michigan, U.S. Centers for Disease Control and Prevention
Illustrations: Benjamin S. Wallace/Harvard Chan School