For Merck, understanding maternal mortality is the first step toward equity

Among so many questions Merck & Co.’s Mary-Ann Etiebet has about the U.S. healthcare system, one in particular rises to the top: “Why are we failing our mothers?”

Despite the country’s wealth relative to the rest of the world, the U.S. ranks 20th in maternal mortality, and we’re headed in the wrong direction, said Etiebet, who is the executive director of the Merck for Mothers program at the pharma giant. More than 80% of maternal deaths were preventable from 2017 to 2019, according to CDC data — and then during the pandemic, pregnancy-related mortality spiked further, especially among Black women, according to research released this year.

“We’re one of the only high-income countries that is getting worse, not better,” Etiebet said. “The disparity gap is increasing, and when you pull all of these things together, the question we have to ask ourselves is, why is this the case?”

When the Merck for Mothers program began in 2011, the company made a $500 million commitment to “create a world where no woman has to die while giving life,” not just in the U.S. but around the world. That lofty goal required a better understanding of the problem and its causes, and so Merck set out to invest in evidence generation, said Etiebet, who is also the assistant vice president of health equity at the company.

“We have come to a place where it is now the norm and an expectation that every maternal death is counted, every maternal death is investigated, and the insights and findings and recommendations are actually put into action,” Etiebet said. “That was not the case in 2011, and so we’re proud that in 10 years we’ve made those gains.”

The company committed $150 million more into the program last year for focused efforts in countries like India, Nigeria and Kenya, as well as the U.S. in direct response to Vice President Kamala Harris’s call to action.

But race and ethnicity are still leading determinants of maternal mortality, and the gap is growing.

“In New York City, where I’m from, between 2005 and 2008, the maternal death disparity gap was five to six times more likely if you’re Black — most recently, that’s risen to eight to 12 times more likely,” Etiebet said. “The first step is to understand the problem and acknowledge the problem, and we’re doing that as a society, but we need to come together for action.”

‘Systemic racism’

Social determinants drive health outcomes more so than what is happening in the health sector, Etiebet said.

“Where we live, where we work, where we play, get educated, pray — unless we address those social determinants of health and how systemic racism is reflected in the structures and processes and practices of our health system, we are not going to make a dent in reducing health inequities,” Etiebet said.

Seeing how strongly the societal current flowed against health equity was a humbling realization for Etiebet and the Merck for Mothers team. Early investments went to improving hospital systems and “safety bundles” to deal with obstetric emergencies with the hope that the benefits would lift everyone’s standards.

“But we didn’t see that,” Etiebet said. “Even when you take into account differences in education, in age, in pre-existing conditions, if a white woman and a Black woman walked into the same hospital that’s ostensibly giving the same care, the Black woman would still have worse outcomes.”

To combat these social inequities, Etiebet and Merck for Mothers needed to understand where these differences were manifesting.

“What we are learning is that more of the deaths are happening after women are being discharged from the hospital and are back in their homes and communities,” Etiebet said. “Previously a lot of the efforts were happening within the four walls of the hospital, and so realizing that dichotomy, we purposely thought through how best to partner with communities.”