This month The Pharmacologist features the final two policy briefs written by participants of the 2024 ASPET Washington Fellows program. These topics present compelling arguments for policy improvements on an issue of personal importance to each Fellow. The policy briefs below discuss racial disparities in maternal mortality and increased PFAS regulations in consumer products.
Addressing the Divide: Examining Racial Disparities in Maternal Mortality
By Tamara Morris, Louisiana State University Health Sciences Center
Executive Summary
Maternal mortality rates in the United States exhibit a troubling racial disparity, with Black and Native American women experiencing significantly higher risks compared to their White counterparts. This policy brief addresses the underlying causes contributing to this disparity including discrimination and receiving lower quality of care. This policy brief proposes targeted interventions to mitigate maternal mortality rates among minority populations such as supporting Medicaid expansion and implementing implicit bias training. It is critical that policies be implemented to help decrease the high mortality rate of Black and Native American women.
Introduction
There is a disproportionately higher risk of maternal mortality when it comes to race. According to the CDC, Black women are two to three times as likely to die due to pregnancy or childbirth than White women.1 In addition, Native American women or Alaskan Native (NAAN) maternal mortality rate is also concerningly high. NAAN women’s mortality rate is twice as high as White women.2 In 2021, the mortality rate for Black women was 69.9 deaths per 100,000 live births compared to 26.6 deaths per 1000,000 live births for White women.1 This disparity deserves policy intervention to ensure quality maternal health for all women.
What Causes Maternal Mortality?
Health Conditions
The main cause of maternal mortality differs by race. Cardiac and coronary issues were the main cause of maternal mortality among Black women3, mental health issues, including suicides and overdose/ poisonings related to substance use disorder were the main cause of mortality for White, Hispanic, and AIAN women.3–4 In addition, hemorrhage was the main cause of maternal mortality in Asian women.3 Other causes include but are not limited to, infections, hypertensive disorders, and complications during delivery (such as obstructed labor).
Discrimination
Other contributing factors to the large disparities in outcomes include systemic racism and discrimination. Women of color are more likely to experience discrimination during health services. One study reported that 22 percent of Black women and 29 percent of Native American women have stated that they have experienced discrimination when going to a doctor or health clinic.5 In addition, 12 percent of Black women and 27 percent of Native American women have stated that they avoid going to doctors out of concern that they would be discriminated against.5 Black and Native women have said that they experienced mistreatment from their medical professionals which included being shouted at, scolded, ignored, getting refused help, and incredibly delayed responses to requests for help.6 Due to mental health being a common cause of maternal mortality, especially in AIAN women, increased discrimination from healthcare providers is a major concern for pregnant women.
Not Always an Issue of Status
Socioeconomic status and increased education do not shield Black and Native American women from increased maternal mortality rates. For example, regardless of educational status Black women remain at risk. Studies found that even in Black women with college degrees pregnancy-related mortality rates were five times as high as White women with a similar education background.7 The National Academy of Medicine (NAM) stated that people of color receive lower quality health care even controlling for insurance status, income, age, and severity of conditions.8 NAM found that Black patients are more likely to receive less desirable treatments. Black patients with heart disease are more likely to receive older, cheaper, and more conservative treatments than White individuals with heart disease. NAM also found that Black women are less likely to receive coronary bypass operations and angiography. In addition, after surgery, they are likely to be discharged earlier than White patients.
Eighty Percent of Pregnancy-Related Deaths are Preventable
According to data from Maternal Mortality Review Committees (MMRCs), four in five pregnancy-related deaths are preventable.9 Surprisingly, 93% of deaths in AIAN women were determined to be preventable. The fact that a large number of these deaths can be avoided identifies a need to make the necessary changes so that we can see a decrease in maternal deaths. Implementing strategies that include widening insurance coverage, preventing barriers to transportation to care, and providing post-partum support will aid in reducing pregnancy-related deaths.
Policy Recommendations
- Support Medicaid Expansion. In many states, Medicaid coverage ends 60 days postpartum. However, according to the CDC, 53% of pregnancy-related deaths occurred 7–365 days postpartum.10 Therefore, extending postpartum medical coverage can be highly beneficial in reducing maternal deaths. Six states also limit the number of postpartum doctor visits that will be covered under insurance.11 Increased Medicaid expansion helps ensure access to healthcare services including prenatal care, childbirth, and postpartum care. States where Medicaid expansion is implemented have lower maternal mortality than nonexpansion states; this highlights the benefit of supporting Medicaid expansion as a method to help reduce maternal mortality rates.12
- Implement Implicit Bias Training. Healthcare professionals should be mandated to attend implicit bias training sessions as part of their professional development. This will help address the issue and consequences of implicit biases to ensure that all patients are treated equally and fairly. By incorporating comprehensive training modules that raise awareness of unconscious biases and their consequences, healthcare providers can also develop the necessary skills to recognize and mitigate biased decision-making processes. Such training should encompass cultural competency, empathy-building exercises, and strategies for promoting equitable care delivery. Implicit bias training can help reduce disparities in maternal mortality rates and improve outcomes for Black and Native American women.
Conclusion
In conclusion, addressing racial disparities in maternal mortality demands urgent and targeted action. Black and Native American women are disproportionately affected by higher mortality rates compared to their white counterparts. Root causes such as discrimination in healthcare services, regardless of socioeconomic status or educational attainment, highlight systemic issues that must be addressed. The policy recommendations outlined in this brief offer tangible steps toward reducing maternal mortality rates among minority populations, including extending postpartum medical coverage and implementing implicit bias training for healthcare professionals. By committing to these interventions, we can strive towards a future where every woman, regardless of race or ethnicity, receives the care and support she deserves during pregnancy and childbirth.
Are ‘Forever Chemicals’ a Forever Problem? A Call for Increased PFAS Regulations in Consumer Products
By Hannah Work, PhD, Cogent Biosciences
What are ‘Forever Chemicals’?
Per- and poly-fluorinated alkyl substances, abbreviated as PFAS, are a family of synthetic chemicals that contain chains of strong carbon-fluorine bonds. These strong bonds make PFAS extraordinarily hard to break down: they take hundreds of years to naturally degrade, hence the nickname ‘forever chemicals.’ Since their introduction in the 1940s, PFAS have been used in an increasingly wide range of consumer and institutional products, including waterproof clothing, non-stick pans, stain-resistant carpeting and furniture, cosmetic products, fire-fighting foams, artificial turf, refrigerants, food-handling materials, and more.1,2
Routes of PFAS Exposure
Everyone, regardless of age, location, or profession, use and interact with PFAS on a daily basis through consumer products or sometimes through our occupation (i.e. factory workers, firefighters, etc.). In addition to our general interactions through these products, we are also unintentionally exposed to PFAS. Consumer products can shed PFAS chemicals onto surfaces in our homes and into the food we eat. For instance, babies and infants crawling and maybe chewing on stain-resistant carpeting containing PFAS can be a significant source of exposure for them.
However, one of the most significant routes of exposure is in our drinking water. For decades, companies have dumped PFAS directly into the natural environment, including soil, groundwater, rivers, and aquifers, leading downstream to drinking water contamination across the United States since PFAS cannot break down naturally.3 From public water system testing by the Environmental Protection Agency (EPA), we’ve discovered that all 50 states have PFAS contamination at over 5,000 water sites,4 and it has contaminated the tap water of at least 200 million people in 33 states and Puerto Rico.5 Additionally, food products, such as milk and fish, can become contaminated if livestock consume contaminated water supplies. PFAS chemicals are universally detected in fish and wildlife due to PFAS disposal into the environment.3
As a consequence, we unintentionally consume PFAS. According to a report by the Center for Disease Control, PFAS chemicals have been found in the blood of roughly 97% of Americans.2
What Risks do PFAS Chemicals Pose?
There are thousands of PFAS chemicals in commercial use, and almost all of them are lacking toxicological data. The limited data we do have suggests that exposure to PFAS is highly associated with many detrimental health effects, including disruption of the hormonal system and increases in the following: cholesterol levels, weight gain and retention, ulcerative colitis, thyroid disease, testicular and kidney cancer, reduced immune response to vaccines, pregnancy-induced hypertension and preeclampsia, low birth weight, birth defects, and delayed development.2,6
What are the Regulations for PFAS and are They Enough?
Due to the probable link of PFAS exposure to adverse health effects, the EPA has recently (April 2024) identified six PFAS chemicals—PFOA, PFOS, PFBS, PFNA, PFHxS, and GenX—that will now be regulated in drinking water as part of their National Primary Drinking Water Regulation. This ruling establishes legally enforceable levels of the identified PFAS chemicals and is expected to reduce PFAS exposure for approximately 100 million Americans.7 Water systems that currently exceed the drinking water standard will have to switch to uncontaminated source waters or install treatment to assure their water complies with EPA’s PFAS standard within the next five years.
While this is an incredible stride towards PFAS exposure reduction, these six PFAS chemicals will still be used in consumer products, so human exposure is still possible. Additionally, there are more than 10,000 different kinds of PFAS chemicals listed on the Toxic Substances Control Act Chemical Substance Inventory that have been previously or are currently used in products and are discharged into the environment, and new PFAS chemicals are continuously being developed. While we may limit exposure by these 6 PFAS chemicals, there are still many others we could be exposed to in drinking water with unknown health effects.
There is a lot of responsibility placed on the EPA to prove that harm is occurring once a chemical is already out and exposed to humans and the environment. And afterwards, more responsibility is placed on the EPA to regulate the chemicals. While the new National Primary Drinking Water Regulation is a great effort to reduce PFAS exposure to humans, it is still (quite literally) a downstream effort—cleaning up a problem after contamination and health issues are identified. More responsibility should be placed upstream of the issue. The companies and manufacturers who are disposing PFAS into the environment should be more strictly regulated.
Policy Recommendations
While the EPA has already begun initiatives to reduce PFAS exposure via their PFAS Strategic Roadmap,8 provided below are additional policy recommendations that other agencies, such as the Consumer Product Safety Commission (CPSC),9 should consider to further reduce PFAS usage in consumer products and their subsequent exposure.
- CPSC should include PFAS chemicals as hazardous substances under the Federal Hazardous Substances Act and regulate their usage. There may not be great alternatives for some products, like fire-fighting foams and other non-consumer applications, but for consumer products that the public regularly uses, if PFAS is used, it should be mandated that the company report its usage and necessity for the product under the Consumer Product Safety Act. Only PFAS uses that are deemed necessary, in which the benefit of PFAS in a product outweighs the potential exposure risks, should be approved for mass market. All others that do not meet this health/safety standard should be rejected or banned.
- The CPSC should require PFAS labeling on consumer products to help people limit and reduce their PFAS exposure. This may even sway companies to find and use PFAS alternatives to avoid such labeling standards.
These efforts could help reduce and restrict PFAS usage, and thus reduce PFAS exposure in humans and the environment. Federal agencies, like the EPA and CPSC, should work together to reduce all PFAS exposure until any are deemed relatively safe, not continue exposing people until they are deemed unsafe.