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US: Heat Emergency Plans Missing Pregnancy, Racial Justice

Cities, Federal Agencies, Should Broaden Responses to Climate Change

© RuslanDashinsky/Getty Images

(Washington, DC) – Many plans by local, state, and federal authorities in the United States to respond to heat extremes and climate change miss the threat that extreme heat poses to pregnancy, particularly for low-income and Black and brown people, Human Rights Watch and partners said today. Authorities should promote racial and reproductive justice and address stark racial disparities in health outcomes.

“We reviewed more than 100 heat and climate change adaptation plans or associated documents but found only a couple of references to pregnancy,” said Skye Wheeler, senior women’s rights researcher at Human Rights Watch. “Pregnant people, and especially Black and brown people, need to be at the table as we tackle the multiple harms to health from increasing heat.”

A Better Balance, the Black Women’s Health Imperative, Human Rights Watch, the National Birth Equity Collaborative, and the National Latina Institute for Reproductive Justice-Florida released today a fact sheet, “Increasing Temperatures because of the Climate Change Crisis is a Reproductive Justice Issue in the United States.” Reproductive Justice is a global movement created by Black women’s rights activists in the US. It seeks to ensure the human right to legal and equitable access to comprehensive, high quality reproductive health services, and a healthy and safe environment for all women during pregnancy and while raising children.

Human Rights Watch reviewed 105 official heat safety web pages, climate action plans, heat plans, heat advisories, disaster plans, and sustainability initiatives for 18 large US cities, including the 15 most populous, with a total of 32 million people. As of August 2020, only two of these documents, from Chicago and Philadelphia, explicitly addressed the danger heat poses during pregnancy. Since the review was conducted, Human Rights Watch has seen that New York City has also included this group in a list of vulnerable populations. Concerns about the dangers of heat for pets were found 37 times.

Buzzfeed article from August also found that out of 25 US cities, only Chicago and Philadelphia mentioned pregnancy in public heat guidelines.

Heat-related illnesses range from heat rashes and cramps to heat exhaustion and heat stroke, which is a medical emergency and can be fatal or cause permanent disability. Every year, more people die in the US from heat than from any other weather-related cause, and the number of heat-related deaths is increasing. Heat stress threatens health during pregnancy and fetal health exposure to high temperatures results in higher rates of premature birth as well as other adverse birth outcomes.

Because of systemic racism, Black women and other women of color in the US face dramatically worse pregnancy health and birth outcomes than white women. Some studies suggest that Black pregnant women may be especially vulnerable to the emerging threat of heat. Women of color and low-income women may also face more hours of dangerous heat, because they work in hot conditions – for example about one-fifth of US farmworkers are women – or because they live in parts of cities with less green space and higher average temperatures.

The 2020 summer was hotter than usual, a trend that is expected to continue, although some parts of the US have had bigger heat increases than others in the past decades. Predictions for extreme increases in heat by the end of the century can only be mitigated by rapid action to cut carbon emitted into the atmosphere. Regardless, temperatures are set to rise significantly in much of the US because of increased carbon, already present because of past emissions.

City studies of local dangers of extreme weather events such as hurricanes, flooding, or heat waves, and local climate change action plans did often note, correctly, that the impact of climate change varies greatly between individuals and communities. Many said that older people, people with pre-existing conditions such as heart and respiratory disease, as well as athletes and children, are especially vulnerable to illness and death from extreme heat.

Some plans or warnings cited outdoor workers as an at-risk group. There is no federal heat standard protecting US workers from extreme heat, although laws protecting access to cooling or water, shade, and rest in at least some circumstances are in place in California, Minnesota, and Washington states. An incomplete but increasing number of states provide accommodations for pregnant workers such as additional water breaks. In September 2020, the US House of Representatives passed a federal bill, the Pregnant Workers Fairness Act, that would provide explicit protections nationally, though it remains pending in the Senate.

Some climate change or heat plans reviewed discussed how low-income communities, communities with less access to air conditioning, or communities of color are more likely to be hit harder by heat or other extreme weather. Most did not include recommendations to address racial inequities and racism as part of the response to the climate crisis, although some did. Scholars, climate activists, and public health officials have cited these inequities and said that local plans addressing climate change should be as inclusive as possible.

A 2020 study estimated that there may have been 12,000 heat-related deaths a year during the last decade in the contiguous US and warned that the number could increase to 110,000 a year under high-emission “business-as-usual” scenarios by the year 2100. The US Centers for Disease Control and Prevention (CDC) has not published complete data on heat-related deaths over the last decade; from 1999 to 2010 it recorded around 618 heat-related deaths every year. But because the recorded cause of death is often another health event, such as a heart attack, this is an underestimation.

Many studies show that heat exposure is linked to premature birth and others also link exposure to heat to low birth weight, birth defects, and stillbirth. Several reviews of studies warn that more needs to be done to address these findings, especially given predictions of hotter days and nights as well as acute heat wave periods. Premature birth is a leading cause of infant death and linked to higher rates of lifelong intellectual and physical health problems. Premature birth can also create a heavy financial and emotional toll on families.

The rates of premature births in the US grew for a fifth year in a row in 2019. The CDC says that Black women’s pregnancies end in premature birth 50 percent more often than those of white women. Low birth weight is also twice as common among babies born to Black women, and stillbirth is more than twice as common for Black women as for white women. The March of Dimes, which fights premature birth in the US, provides analysis that shows that Hispanic and Native American women also have worse birth outcomes than white women.

The federal Environmental Protection Agency (EPA) has explicitly called for including pregnancy when “prioritiz(ing) the most vulnerable” to climate change. The US government should increase funding for efforts addressing the impact of climate change on human health. Cities, states, and Native American tribes should also ensure that their programming to prepare for climate impacts on human health includes pregnancy health and addresses reproductive injustice because of racism and poverty.

The US Congress should pass federal heat protection for all workers, for example through passing the Asuncion Valdivia Heat Illness and Fatality Prevention Act, and the Senate should pass the Pregnant Workers Fairness Act so that pregnant workers have an explicit right to accommodations, including to prevent heat-related illnesses during pregnancy. States should ensure that workers have and know about workplace protections for pregnancy already in place, including accommodations.

“The effects of climate change and extreme heat on pregnant people are a matter of racial, gender, and economic justice and cannot be ignored,” said Sarah Brafman, senior policy counsel and director of the DC office at A Better Balance. “One key step our lawmakers need to take is to pass the Pregnant Workers Fairness Act to ensure that pregnant people – especially low-income women and women of color who are too often exposed to higher rates of extreme heat – are able to seek accommodations so they don't have to choose between their paycheck and their health by continuing to work in dangerously hot environments.”

Climate change impacts on health should be included in medical education. Doctors, midwives, and community birth workers can provide information about the importance of hydration and keeping cool during pregnancy. Doctors should ask pregnant patients about their work and exposure to heat and, where appropriate, provide letters to employers to help workers access reasonable workplace accommodations.

Cities and other US jurisdictions should revise their plans and websites before the next heating season to include pregnancy and to address the special needs in communities of color, Human Rights Watch and its partner groups said.

“Black women experience higher rates of premature birth and negative birth outcomes, which affect their and their children's chances for a healthy life,” said Kelly Davis, Chief Equity Officer at the National Birth Equity Collaborative. “Climate change impacts, including heat, remains a challenge for Black people, along with other marginalized and minority groups, for achieving healthy pregnancies and supportive parenting environments. The movement to combat climate change must include addressing structural racism and gender oppression in service of birth equity.”

For more information on the health impacts of increasing heat and reproductive justice, please see below.


No Federal Action Plan on Climate Change, Health Impact
The National Climate Assessment, written by the US Global Change Research Program, a body mandated by the US Congress to summarize current and future impacts of climate change on the US, has, together with many scientists and advocates, warned over the past 20 years of extensive negative health impacts from climate change, including increases in heat-related illness and deaths.

The US has struggled with increasing numbers of extreme weather events over the past decade including heat waves, hurricanes, wildfires and massive flooding that have devastated communities and, between 2007 and 2017 alone, cost the US government $350 billion. Weather-related disasters have cost the US over $46 billion so far in 2020 alone.

Despite this, the US government has no federal plan to address the climate crisis or its detrimental impact on human health. Under the administration of President Donald Trump the United States has reversed course on reducing carbon emissions. Trump canceled his predecessor’s climate action plan and pulled the US out of the Paris Agreement on climate change.

But President Barack Obama’s plan was also not ambitious enough in reducing emissions and contained little on the health impact of climate change. Funding for the federal flagship climate change and health program “Building Resilience Against Climate Effects” (BRACE), allows for little more than providing advice and modest grants for a total of 18 tribes and states to address some climate impacts. The program received about $10 million for 2019.

Pregnancy Information in Government Heat Plans
Many cities, counties, and states in the US have begun to independently plan for and take action on climate change. Heat awareness efforts have understandably largely focused on reducing mortality and heat-related illnesses. This approach risks authorities missing the hidden costs of heat such as adverse birth outcomes, increases in violence during periods of hotter weather, mental health impacts, and reductions in productivity and educational achievements.

BRACE and academic experts on the relationship of heat to health have urged authorities to assess how heat affects different populations and to recognize that some are much more vulnerable than others. One guiding document by BRACE provides a strong emphasis and substantial supporting research on the importance of including racial inequities in addressing heat illness and other impacts.

Although information on the added vulnerability to heat illness during pregnancy and the link between heat and adverse birth outcomes have been available for years, only two cities included in the Human Rights Watch analysis included this in their planning or analysis. The Chicago Office of Emergency Management and Communications recommends that during pregnancy people should “avoid extreme heat, stay well hydrated and follow advice of their medical providers.” Philadelphia’s page on heat safety includes pregnant women as a vulnerable population. Since the review was conducted, Human Rights Watch has seen that New York City has also included this group, noting on one webpage: “[p]regnant people are sensitive to heat. An increase in body temperature may bring on labor, preterm birth or lower birth weight. Those who are pregnant should stay in a cool place, drink fluids and take it easy when it’s hot.”

The CDC and the EPA have acknowledged pregnant people as an at-risk population in their “Extreme Heat Guidebook.” The National Climate Assessment 4 (2018) included studies on heat and preterm birth and included pregnant people as an at-risk group. The US Global Change Research Program also noted that climate-related exposures “may lead to adverse pregnancy and newborn health outcomes, including spontaneous abortion, low birth weight (less than 5.5 pounds), preterm birth (birth before 37 weeks of pregnancy), [and] increased neonatal death.”

State-level climate change planning documents from North Carolina, New York, and Oregon have noted that pregnancy presents additional vulnerability as well as the link to preterm birth and other adverse birth outcomes.

Although the impact of heat on pregnancy health may be acknowledged elsewhere, front-facing heat public education webpages for the CDC and the Federal Emergency Management Agency do not include pregnant people as an at-risk group. Communication efforts should include pregnancy vulnerabilities, including through a reproductive and racial justice lens.

Heat and Pregnancy Health
For hormonal and other reasons, such as their increased size and smaller skin-to-volume ratio, during pregnancy people are less able to regulate their body temperature and are more vulnerable to heat stress. The additional vulnerability to heat has been noted by the Occupational Safety and Health Administration. The CDC’s National Institute for Occupational Safety and Health (NIOSH, a government research and education agency) says:

If your job causes your body temperature to become higher than 39°C (102.2°F), you may suffer from heat exhaustion, heat stroke, or dehydration, which are not good for either you or your developing baby. If you are pregnant, you are more likely to get heat exhaustion or heat stroke sooner than a nonpregnant worker. This is because your body must work harder to cool down both your body and your unborn baby. If you are pregnant, you are also more likely to become dehydrated. This also means you won’t be able to cool yourself as well by sweating. ... Exposure to excess heat at work could increase your chances of having baby with a birth defect or other reproductive problems.

A 2020 review paper of academic peer-reviewed studies in the US found that “five out of five studies on heat and preterm birth found an effect, and three out of three studies on heat and low birth weight found an effect.” Increased risk of preterm birth because of high temperature exposures “range(d) … from 8.6 percent to 21.0 percent.” Two reports “found an association of racial/ethnic disparity and heat exposure with an increasing risk of preterm birth; higher risk was found among black mothers.” Another study on pregnancy health and heat found that pregnant Black women had more hospitalizations due to heat exposure during their pregnancy than other women.

One 2017 review of 28 peer-reviewed papers on heat and adverse birth outcomes found: “There is evidence that temperature extremes adversely impact birth outcomes, including, but not limited to: changes in length of gestation, birth weight, stillbirth, and neonatal stress in unusually hot temperature exposures.” Findings from another review of 15 studies, also published in 2017, “confirm the crucial importance of the adverse health effects of climate change especially in the perinatal period.”

Heat has other impacts on pregnancy health. Another important effect is that warming temperatures increase the formation of ground-level ozone, which can cause respiratory illness in pregnant women and can lead to low birth weight or preterm birth. Forest fires, like those in California in recent years, also worsen air quality and release large amounts of fine particulate matter, PM 2.5, a toxic pollutant in smoke that is linked to poor pregnancy outcomes.

Heat and Inequity
Activists and scholars examining racial and environmental justice in the US are increasingly recognizing the negative health effects of heat exposure, and have noted, in a CDC report for example, that “many pathways that modify vulnerability to extreme heat vary by race and ethnicity.”

A study published in 2020 found that areas formerly subjected to redlining – a racist housing policy banned in 1968 that made Black and other minority neighborhoods less valuable, leading to further marginalization – in 108 urban areas across the US are still mostly – 94 percent – hotter than non-redlined areas, by as much as 7 degrees Celsius. An investigation by the National Public Radio service found a strong correlation between poverty, often in communities of color, and heat in cities.

One study of 234,042 adult deaths during warm periods between 2000 and 2011 in New York City found that “deaths during heat waves were more likely to occur in black individuals than other race/ethnicity.” A study of Portland, Oregon, found “groups with limited adaptive capacity, including those in poverty and non-white populations, are at higher risk for heat exposure” noting that “climate change is catalyst for injustice.”

Air conditioning protects against heat, but is unequally distributed. In one study, for example, prevalence of central air conditioning among Black households was less than half that among white households in Chicago, Detroit, Minneapolis, and Pittsburgh, and deaths among Black people were more strongly associated with hot temperatures. Energy burdens – the proportion of family income spent on energy bills – are higher for minority groups in the US and when money is tight families may not be able to use air conditioning.

As temperatures increase, heat exposure is also increasingly an issue of concern to labor unions and others working to protect the rights and health of outdoor workers – for example construction workers, farmworkers and airport workers, and people working in hot indoor sites such as some warehouses. The nongovernmental organization Public Citizen estimated that in July 2017, over 1.1 million outdoor workers labored in dangerous heat each working day, including 265,000 agriculture workers. A study in Florida found that pregnant farmworkers found it difficult to access health services that included information about occupational health, including exposure to heat.

While government health agencies advise workers to take “plenty of breaks” in cool or air-conditioned areas, this may not be possible for pregnant farmworkers, and especially women who need to earn money before their baby is born and have no paid parental leave.

A national heat standard, which would protect outdoor workers by mandating water, rest, shade, and other protections, has long been needed. NIOSH issued criteria for a heat standard in 1972 and then updated it in 1986 and 2016.

However, the Occupational Safety and Health Agency, which is responsible for work safety and rules and regulations, has never issued a heat standard. It has only the vague and hard-to-enforce general duty clause (of the Occupational Safety and Health Act) to punish employers for forcing people to work in health-threatening heat. Pregnancy accommodations, such as to be able to take more frequent water and cooling breaks, should be better protected, as envisaged in the Pregnant Workers Fairness Act, Human Rights Watch and partners said.


This news release was updated on October 23 to include mention of relevant findings in a Buzzfeed article from August.

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