Chaniece White WallaceThe first thing you notice about Chaniece White Wallace, M.D., in photos is her smile. It’s a radiant sunbeam illuminating the frame. It certainly brightened every patient room she entered.

And Wallace had plenty of reasons to smile. The Mobile native was following her passion to provide care to underserved communities and address the health disparities they face. She was the first in her family to graduate from college, and she shone brightly in the UAB School of Medicine’s Class of 2017, where she became a strong patient advocate who provided care with kindness and empathy. By the fall of 2020, she was chief resident in Pediatrics at the Indiana University School of Medicine. Ahead of her lay a career as a primary care physician for children—and motherhood.

Wallace and her husband, Anthony, eagerly anticipated the birth of Charlotte, their first child. But last October, just a few weeks before her due date, Wallace developed a headache and didn’t feel well—which led to an emergency cesarean section. Two days after the birth of her beautiful baby girl, Wallace tragically passed away. The 30-year-old died from preeclampsia, a condition in which pregnant women suddenly develop high blood pressure that endangers their kidneys, liver, brain, and other organs.

Little Charlotte Wallace’s amazing mother is one of approximately 700 women in the United States who die each year from pregnancy or related complications. Chaniece Wallace’s passing also highlights a startling racial gap: Black/African American women are three times more likely to die from a pregnancy-related cause than White women, according to the Centers for Disease Control and Prevention (CDC). The divide endures—and even widens—among Black women of different ages and education levels, no matter where they live.

Each loss shatters another family, another community, another dream for the future. But why, in 21st-century America, do Black/African American women face a magnified risk of maternal mortality?

The Data Behind the Numbers

The first step to answering that question is understanding the scope of the problem. And that’s not as simple as you might think.

In Alabama and throughout the U.S., death certificates include a “pregnancy checkbox” to identify deaths that occur while a woman is pregnant, during childbirth, or within a year of pregnancy. That data then informs a variety of reports, including one last year from the CDC that ranks Alabama third highest among the states in maternal death rates. Women in Alabama, it stated, die from pregnancy and related complications at more than twice the national rate.

Rachel SinkeyThe numbers need a closer look, says Rachel Sinkey, M.D., assistant professor in the UAB Department of Obstetrics and Gynecology. For example, “a woman who dies in an automobile accident 11 months after delivery is classified as a maternal death,” she explains. “Women who die of drug overdose up to 365 days postpartum are also classified as maternal deaths.” The CDC generally labels these as pregnancy-associated deaths—in which pregnancy did not lead to death—as opposed to pregnancy-related deaths.

Three years ago, Sinkey “saw an opportunity to partner with the Alabama Department of Public Health (ADPH) to provide critically important data to better understand opportunities for improvement in our state.” She joined forces with Grace Thomas, M.D., the ADPH Assistant State Health Officer, and nearly 50 experts—clinicians, scientists, public health professionals, and others representing multiple disciplines—to launch the Alabama Maternal Mortality Review Committee (AL-MMRC). Sinkey chairs the group, which closely examines each maternal death to learn about causes and contributing factors.

In its first report, the AL-MMRC found a pregnancy-related mortality ratio of 22 deaths per 100,000 live births. A little less than a third of the women were pregnant at the time of death, another 30.8 percent died within 42 days of giving birth, and 38.4 percent died between 43 and 365 days after delivery. Cardiovascular-related conditions, such as cardiomyopathy, were the leading causes of pregnancy-related deaths, followed by hemorrhage, amniotic fluid embolism, blood disorders, cerebrovascular accidents, infection, mental health conditions, and preeclampsia and eclampsia (seizures related to high blood pressure).

While cardiovascular conditions top the list for both Black/African American and White women nationwide, the CDC reports that Black/African American mothers commonly die from cardiomyopathy, medical comorbidities, and blood clots.

“The deaths can occur suddenly,” Sinkey says. “Many are unpredictable and occur under emergent conditions. Many of the babies survive, but some do not.”

Studying Potential Solutions

The AL-MMRC determined that 70 percent of the pregnancy-related and pregnancy-associated deaths in 2016 were preventable (meaning there was either a “good chance” or “some chance” to prevent the death). That is an arresting number, but it also includes a glimmer of hope that lifesaving solutions could make a significant impact.

Alan TitaAlan Tita, M.D., Ph.D., “came to Alabama because UAB provided opportunities to do something about this problem, both locally and globally, in an impactful way,” he says. Tita, the John C. Hauth, M.D., Endowed Professor of Obstetrics and Gynecology and vice chair for Research, was recently named the associate dean for Global and Women’s Health at the School of Medicine. He grew up in the African country of Cameroon, where his mother provided nursing and midwifery services. There he “witnessed firsthand the excessive toll of maternal mortality in underserved settings.”

At UAB, Tita directs the Center for Women’s Reproductive Health (CWRH), which is home to a multidisciplinary team of researchers who are leading efforts to understand and discover solutions for major causes of maternal mortality. The center is also part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine (MFM) Units Network, and is a universitywide interdisciplinary research center, meaning it leverages partnerships across UAB to improve the health of women across their lifespans as well as the health of their offspring.

“Our center’s coordinating expertise and resources provide a platform to facilitate and spearhead initiatives to reduce maternal mortality,” says Tita.

As an example of this coordination, scientists from the CWRH and UAB’s Hypertension Research Center are investigating the benefits and safety of using medication to treat mild chronic hypertension in pregnant women. The CDC reports that Black/African American women are 60 percent more likely to have high blood pressure than non-Hispanic White women, and they are less likely to have their blood pressure under control. Hypertension is linked with preeclampsia and placental separation that triggers bleeding, as well as preterm birth and stroke. The UAB study will gauge the potential impact of medications on both mothers and their babies, says Tita, the project’s principal investigator and director. “Specifically, while we know chronic hypertension adversely affects the baby’s growth, there are concerns that treatment of hypertension may also impair the baby’s growth,” he explains. “It’s a catch-22, and we need answers.”

CWRH scientists also are investigating a treatment that could lower the risk of postpartum hemorrhage in women undergoing a cesarean delivery. Another trial will determine if a single oral dose of the antibiotic azithromycin during labor can reduce bacterial infection risk among moms and babies in seven low-and middle-income countries. (The World Health Organization reports that infections like sepsis during and immediately following pregnancy account for approximately 10 percent of worldwide maternal deaths and 16 percent of newborn deaths.) Two more studies—one in partnership with the CDC and another with the NICHD MFM Units Network—are investigating COVID-19’s impact during and after pregnancy. The center is also participating in the Pfizer COVID-19 vaccine trial in pregnancy. The results could help shape public health and clinical guidance.

Bringing Care Closer

One problem in addressing the disparity in maternal mortality is that it builds upon other gaping disparities. Research has shown that Blacks/African Americans are more likely than Whites to die from heart disease and to have hypertension, diabetes, and obesity. Finding care for these and other chronic conditions—and for pregnancy itself—is a challenge when there is no doctor to treat them, and when patients do not have the resources or the ability to travel long distances to receive regular care. In 2019, the ADPH found that only 16 of Alabama’s 54 counties that are considered rural had hospitals providing obstetrical services. Seven of Alabama’s counties have no hospitals at all. And mothers throughout the state could benefit from additional OB-GYN specialists, family practice physicians providing obstetrical care, nurse practitioners, and certified nurse midwives, notes the AL-MMRC.

Brian Casey“Lack of access to care is a common factor associated with maternal mortality,” says Brian Casey, M.D., professor and director of the Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology. “This is why telemedicine offers such promise.” UAB MFM specialists, patients, clinic sites, and health departments across Alabama link up to conduct video visits to support patients with high-risk pregnancies. The experts provide “education, clinical services such as monitoring of blood pressure and blood sugar in women with diabetes, and remote access to fetal ultrasound expertise.”

But even telemedicine bumps into barriers, Casey notes. Broadband Internet service may not be available in rural and underserved areas, digital literacy may be lower, and clinics may not have specialized equipment that allows specialists to monitor blood pressure or fetal status remotely. “Also, public and private health insurers’ insistence on videoconferencing rather than telephonic visits to qualify for reimbursement runs the risk of increasing disparity in women who don’t have access to smartphones, computers, or tablets necessary for such visits,” Casey says. Luisa Wetta, M.D., an associate professor of Maternal-Fetal Medicine, and Sinkey are leading efforts to evaluate processes and devices that could overcome some barriers, he explains.

Building Bridges Across the Gap

Medical student Abigayle Kraus knows that bridging gaps in care sometimes requires a one-on-one approach. “Listening to mothers today will improve the lives and care of mothers tomorrow,” says Kraus, a 2020 Alabama Schweitzer Fellow.

For her Schweitzer Fellowship project, Kraus targeted cardiomyopathy as a cause of maternal mortality by shedding light on the postpartum challenges of women with heart failure. She developed a survey asking new mothers about their needs and the treatment obstacles they face in the first year after delivery. Then she guided the women toward resources and support based upon their individual responses. Kraus says she treasures the personal relationships she built with many participants. “I feel honored that these extremely busy and extraordinarily strong women have given me insight into the struggles they have faced and that they have allowed me to aid in solving these problems,” she says.

Kraus hopes her research will lay the foundation for policy and program changes that benefit Alabama moms. The AL-MMRC already is championing some changes, such as the expansion of Medicaid coverage for up to a year after delivery, along with better provider reimbursement. “If a patient has heart disease but loses insurance three months postpartum, then she may die because of a lack of access to care,” Sinkey says.

Addressing education also has the potential to make a big difference, notes the AL-MMRC: Rewriting patient materials in plain language could help expectant mothers more clearly understand high-risk medical conditions, the importance of follow-up visits with care providers, and actions to mitigate risk, such as quitting smoking. Likewise, better education tailored to health professionals, particularly those who are not OB-GYN specialists, could help them spot warning signs early and identify when to make referrals.

Reasons for Hope

Despite rising numbers for maternal mortality in Alabama and other states, the UAB specialists remain optimistic.

Sinkey says the upward trajectory may, ironically, reflect Alabama’s efforts to do a better job of documenting cases. “With the advent of the AL-MMRC, surveillance of maternal deaths has vastly improved,” she explains. “We look forward to future reports to better understand trends.”

“We have begun the hard process of assessing maternal deaths for accuracy and identifying the cause and the potential preventability of each case,” Casey adds. “And we are organizing efforts to address the most common factors associated with racial and other socioeconomic disparities in maternal mortality.

“The women of Alabama deserve our very best,” Casey says. “We can and must do better.”

By Charles Buchanan, illustration by Kate Green

Become a Supporter

To honor Dr. Wallace’s life and legacy while paving the way for future medical students, and with the blessing of Anthony Wallace, the School of Medicine is working to establish the Chaniece White Wallace, M.D., Memorial Endowed Scholarship. Visit go.uab.edu/cwallacescholarship to learn more about the scholarship’s intended impact and gift matching opportunities, including a Dean’s Office match for gifts received through September 30, 2021.

To learn more about the research, clinical, and training missions of the UAB Center for Women’s Reproductive Health, or to make a gift online, visit uab.edu/medicine/cwrh, or contact Erica Hollins at 205-996-6839, elhollins@uabmc.edu.