US Olympian Tori Bowie’s Death Underscores Maternal Mortality Crisis in the United States
SPH’s Lois McCloskey on what’s behind the increase in deaths and what needs to be done to improve pregnancy outcomes
The recent death of track star Tori Bowie, a sprinter who earned three medals in the 2016 Rio Olympics and was once the fastest woman in the world, has once again focused attention on the high rates of maternal death in the United States—especially among Black women. Bowie, 32, and eight months pregnant, was found dead in her Florida home in May. An autopsy report released earlier this month revealed she died from complications of childbirth, including respiratory distress and eclampsia, a disorder related to high blood pressure in pregnancy. Her baby also died.
The United States has the highest maternal mortality rate among high-income countries, and the crisis is getting worse. The number of maternal deaths rose from 17.4 per 100,000 live births in 2018 to 32.9 in 2021. That rate is driven by the deaths of Black women, who are 2.6 times more likely to die from pregnancy-related causes in the United States than are white women, according to the Centers for Disease Control and Prevention.
Lois McCloskey, a clinical professor and interim chair of community health sciences at the School of Public Health and director of SPH’s Center of Excellence in Maternal & Child Health, has devoted her career to improving healthcare for women and their babies. BU Today spoke with McCloskey about the state of maternal healthcare in the United States, steps that need to be taken to improve pregnancy outcomes, and the role racism plays in racial health disparities.
with Lois McCloskey
BU Today: What was your reaction when you heard the news that Tori Bowie had died from pregnancy complications?
McCloskey: I just felt heartsick. My initial reaction was to want to read about what happened—with a sinking feeling that her death was going to be another example of the lack of listening to Black women during and after childbirth. I dug into details a little bit and learned that, in fact, her death happened while she was alone. The other thing that struck me is that there seem to have been multiple factors that led to such a tragic ending—factors that could have been intervened upon.
BU Today: You have long been interested in ending racial disparities in the health of women and their babies. What does research tell us about why these disparities exist?
McCloskey: For some time, researchers have been realizing that these disparities don’t go away when you control for factors like people’s income, people’s social standing, or employment, and so there’s something deeper at play. Researchers have begun to dig into the causes of stress among Black and indigenous women that exceed those of white women. The continual experience of racism—both deeply rooted, historic, structural racism and the interpersonal racism that is still so prevalent within healthcare and in our society—is toxic, even deadly. In essence, the research tells us that racism has enduring biological effects, and they are magnified during pregnancy, which itself is a stress test for things like metabolic and cardiac health. And the effects are carried across generations.
BU Today: The US high maternal mortality rates—especially among Black women—have received significant media attention in recent years. Has this attention brought about any positive change?
McCloskey: Increased attention is always a good thing, but it takes time to turn that attention into action and more money—and of course, the political will has to be there. The increased attention began around 2017, and political change is slow, as we well know. I have, though, seen some really wonderful things that make me hopeful. The most important of these is the amazing growth and support of Black-led, community-based organizations at the forefront of activism for higher investment in maternal health. We also have more men and women of color in key policymaking positions. For example, the [US House of Representatives] Black Maternal Health Caucus has sponsored a federal bill called the Black Maternal Health Momnibus Act—still pending—that includes 13 different pieces of legislation devoted to things like the social determinants that underlie poor outcomes in maternal health, innovative payment models, care for those with mental health conditions and substance use disorder, and extending care across the postpartum period, when a lot of the preventable deaths are occurring. So, there are signs of hope, both in community activism and in policy.
BU Today: Assuming the bill passes, what more do you think needs to be done, beyond what’s included in the Momnibus Act?
There are big-picture, long-term things that must happen for purposes of maternal mortality, and for every other health inequity that we see, and those have to do with addressing the root causes of structural racism. In the shorter term, we need to end the disrespect that continues to occur when Black and Indigenous people walk into healthcare settings. A lot of institutions have begun conducting implicit bias training, but that’s too little, too late. We need deep changes in the training of health professionals that’s longitudinal—far beyond these one-offs. Antiracism needs to be front and center in the education of our providers.
We also need to change the face of providers in primary care and especially, in OB-GYN. We need more BIPOC clinicians. We know that when people are cared for by providers who look like them, and can truly understand their lived experience, understanding and trust can grow, and there is evidence of improved outcomes.
BU Today: Recent research shows that many women experience serious complications months after giving birth, highlighting the need for better and longer postpartum care. Tell us about the advocacy work you’ve done around improving postpartum care.
I coled a national initiative that was supported by the National Institutes of Health (NIH) and a funder called PCORI. We called it Bridging the Chasm between Pregnancy and Health over the Life Course. The purpose of the initiative was to bring together diverse stakeholders to create a national agenda to address the racism and fragmentation in the care of pregnant people long into their futures. We created an agenda that includes policies such as the expansion of Medicaid coverage for pregnant people all the way to one year. It includes high-touch models of care that include “bridge people” from communities—like doulas and community health workers—to accompany people across the chasm between pregnancy and ongoing primary care. It includes ways that we can preserve and elevate people’s narratives in their medical records, so that primary care providers who are often unaware of pregnancy complications can be sure to follow up. There’s a reimagined research agenda and a call for training of medical providers in antiracism.
BU Today: Have you seen forward movement in any of these areas?
About 15 states, including Massachusetts, have either active or pending legislation to require Medicaid to cover doula care, so there’s action at the state level for doulas who will help women navigate pregnancy and the postpartum year. The American Rescue Plan Act gave the option to all states to expand Medicaid coverage from 60 days to one year after pregnancy. That’s a huge leap. So far, 38 states have implemented that expansion.
I’m not seeing enough investment in the training of medical providers that would be meaningful, lasting, sustainable. And the most stubborn one to change is the actual structure of our healthcare system, moving from the silos of different specialties like OB-GYN and primary care to a more comprehensive, coherent, seamless system where providers are communicating with one another across specialties and where care is continuous. Fragmented healthcare is dangerous for all of us, but especially for birthing people.
BU Today: You currently lead SPH’s Center of Excellence in Maternal & Child Health (MCH), which aims to educate a diverse MCH workforce. Tell me about the work you’re doing on that front.
The Center of Excellence in Maternal & Child Health at SPH is supported by the Health Resources & Services Administration and one of our goals, as you said, is to diversify the public health workforce. To do that, we have a special initiative called the Diversity Scholars Leaders Program. We select scholars from underrepresented communities as they enter their maternal and child health studies at SPH and offer tuition assistance. We also offer, perhaps most importantly, intensified mentoring by both a faculty member of color and also by a field mentor, someone who shares their background and their professional interests and is there for them throughout the year and a half or two years that they’re navigating SPH, a predominantly white institution.
We’re also collaborating with HBCUs—historically Black colleges and universities—that are interested in improving their maternal and child health education pathway and research. In November, we convened an all-day working session with representatives from 12 HBCUs and two predominantly white schools of public health, BU and Harvard. During the session, we got to know one another and then shared our education priorities and our research priorities, which then led to some promising collaborations.
BU Today: Is there anything else you’d like to say on the topic of maternal health?
I would elevate Massachusetts. Massachusetts was wise enough to form a Special Commission on Racial Inequities in Maternal Health, led largely by BIPOC individuals, including State Senator Liz Miranda (D-2nd Suffolk). Some of the key recommendations from the commission are now in an omnibus bill pending before the state legislature. This is one more example of how important state legislatures are, with such divisive federal lawmaking and especially in the post-Dobbs era. It’s another example of Massachusetts’ role as a leader in reproductive healthcare.
This conversation was edited for length and clarity.
Corinne Steinbrenner can be reached at firstname.lastname@example.org.