Most people were shocked when 30-year-old Dr. Chaniece Wallace, a chief piediatric resident at the Indiana School of Medicine, died on October 26, 2020, shortly after giving birth to her daughter. Conventional wisdom suggests that in the United States women don’t die from problems associated with childbirth. This is especially true for those like Dr. Wallace, who have access to good medical care.
While I have no information on Dr. Wallace’s health status, her untimely death highlighted a long-standing problem in the American healthcare system. Although maternal mortality rates have been dropping in most places around the world, over the past three decades the number of pregnancy-related deaths in America has been rising steadily.
It’s sad to say but the United States has the highest maternal mortality rate in the Western world. Moreover, racialized women (this includes Black and indigenous women) are almost three times more likely to die from pregnancy complication than white women. The United States also has the highest rate of infant mortality in the industrialized world. Not surprisingly, the greatest percentage of infant deaths are babies born to racialized women.
Since an infant’s health is closely connected with that of its mother, these statistics raise an obvious question: Are the number of women experiencing pregnancy-related deaths and the number of newborns that don’t survive long enough to celebrate their first birthday connected in any way? The answer is yes. Both can be linked with socioeconomic inequality.
Fitting this puzzle together involves another marker: Low birthweight (LBW; when a baby weighs less than 5 pounds 8 ounces), which directly links a mother’s health with the health of her baby. In the United States LBW is associated with socioeconomic inequality so it’s not surprising that African-American infants are about twice as likely to be born with LBW than non-Hispanic white infants. Low birth weight is not necessarily a product of poverty --- it can result from premature or multiple births, for instance. However, when a fetus fails to grow at a normal rate it often reflects a failure to thrive, which can be linked to factors like poor nutrition and chronic stress. This condition is known as fetal growth restriction and it is a risk factor for the development of chronic illness as an adult.
Thanks to the science of epigenetics, we are seeing how the effects of hardscrabble lives are passed on like a biological memory, handed down through the generations. Social inequities extract a toll on women’s bodies. Poor nutrition plays a key role in the eventual outcomes and its effects take hold at both an individual and collective level.
When malnutrition is prolonged over several generations, diseases begin to show up as historical phenomena. Examples include the Stroke Belt in the American South and runaway rates of diabetes in previously nonindustrialized nations with long histories of poorly nourished people, such as India and China. Over the long term it has undermined women’s ability to have healthy pregnancies and give birth to robust infants.
Consider that females are born with their lifetime supply of eggs. That means a pregnant woman’s eggs were formed while she was still a fetus in her mother’s womb. Those eggs reflect the quality of her mother’s diet and life history. If her mother was malnourished and/or belongs to a group that has been historically disadvantaged, those experiences will have left a biological imprint on her and also on the eggs she passes on to her female baby. In other words, a baby’s grandmother plays an active role in their lifelong health. This is an area of research known as transgenerational inheritance .
Dr. David Barker, a British epidemiologist, got the ball rolling on the first stage of this science, now known as The Developmental Origins of Health and Disease, in the early 1970’s. Dr. Barker’s interest was piqued when he noticed that heart disease, then believed to be associated with affluence, was much more prevalent in more impoverished areas of the country. He also found that in Britain the most reliable predictor of stroke rates in any location was the maternal mortality rate 70 years earlier.
His gut instinct, now supported by a substantial body of research, was that many chronic illnesses can be traced back to fetal development in the womb.
By 1986, when he published his findings in The Lancet, he had identified low birth weight as a marker linked with a raft of chronic diseases as an adult, including high blood pressure, type-2 diabetes and cardiovascular disease.
A developing fetus draws on the nourishment provided in utero like a plant soaks up minerals from the soil. If soil is not cared for, over time its quality declines, as does its ability to sustain healthy plants. We know from studying developing countries, that the effects of malnutrition are multigenerational.
Simply stated, a mother’s nutritional status at the onset of pregnancy reflects the experience of previous generations. Once pregnant, an undernourished woman will not be able to provide her fetus with the nutrients it needs to develop optimally. And, if she belongs to a group that has been historically disadvantaged, she is not likely to have stored enough nutritional reserves for the fetus to draw on. This sets the stage for the likelihood of delivering a baby with low birth weight, extending the cycle of chronic illness.
Experts now consider the health care costs associated with treating our so-called “epidemics” of chronic disease to be unsustainable. That’s one reason why in hard economic terms, maternal health matters. We now know that in addition to increasing the risk of both maternal and infant death, factors that affect the mother like poor nutrition and chronic stress reprogram how a fetus develops, setting the stage for disease development later in life. We need to prioritize taking better care of pregnant women. The benefits of improving their health extend far beyond the well-being of the individuals involved. Over time they will flow through the generations, contributing to lower rates of chronic illnesses (and reduced health care costs) in the years to come.