Maternal mortality in the United States

Illustration in black and white from an American obstetric textbook showing two images of a woman in labor. She is on her back lying in a bed with her head resting on a pillow in both illustrations, with a blanket covering the lower half of her body.The top image shows her wearing an abdominal binder and a breast binder. The bottom image shows her belly exposed and bigger than in the top image.

Maternal mortality refers to the rate in which mothers die from pregnancy-related causes. Although the United States of America spends more on healthcare than any other country in the world, more than two women die every day during childbirth, therefore making maternal mortality the highest in the USA compared to 49 other countries in the developed world.[1] In 2016, the number of pregnancy-and-childbirth related deaths totaled approximately between 700 to 900 with their ages ranging from 16 to 43. [2] Furthermore, the Centers for Disease Control and Prevention (CDC) declares that 60% of these deaths are preventable.

According to the United Nations, maternal mortality has worsened over the years and remains a human rights issue at the forefront of American healthcare. [3] In the US, hospital bills for maternal healthcare costs over $98 billion. Race, location, and financial status all contribute to how maternal mortality affects women across the country. According to many studies conducted by but not limited to Amnesty International, the United Nations, and federal programs such as the CDC, maternal mortality has not decreased within the past 20 years, and evidence shows that the death rate might be on the rise instead.[4]

Measurement

Image of 1,200 hospital gowns hung from a rack in the middle of Daley Plaza in Chicago to represent all the mothers who died during childbirth in the USA in 2013. Some of the gowns are folded into triangles to mimic the way the American flag is folded at the funeral of a soldier. The gowns are pink, blue, yellow, green, and purple with various patterns.

Amnesty International considers maternal mortality a healthcare crisis, based on their extensive research between 2008 and 2009. Healthy People is a federal organization that is managed by the Office of Disease Prevention and Health Promotion (ODPHP) at the U.S. Department of Health and Human Services (HHS). In 2010, the US maternal mortality ratio was 12.7 (deaths per 100,000 live births) which was 3 times as high as the Healthy People goal. Moreover, the US maternal mortality ratio, at 12.7 (deaths per 100,000 live births), was 3 times as high as the Healthy People 2010 goal, a national target set by the US government. [5]

In the United States in 1987, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) created the Pregnancy-Related Mortality Surveillance System to monitor maternal death within a year of women giving birth and dying from any and all pregnancy and childbirth related causes per 100,000 live births. Prior to this change, the maternal mortality ratio monitored women 6 weeks postpartum per 100,000 live births.[6] With maternal morbidity and maternal mortality on the rise in the United States, studies have consistently shown that African American women are four times as likely to suffer from both, compared to Caucasian or Asian or Hispanic women.[6]

Causes

Maternal death can be traced to maternal health, which includes wellness throughout the entire pregnancy and access to basic care. In this context, the causes of maternal death can be illustrated as a continuum wherein "maternal health from wellness to morbidity to severe morbidity to death" is the cycle in which mothers often die of pregnancy related causes.[6]

More than half of maternal deaths occur within the first 42 days after birth. According to Amnesty International, five medical conditions collectively account for 74% of maternal deaths in the US.

  1. Embolism 20%
    • A blood clot that blocks an essential blood vessel
  2. Hemorrhage 17%
    • Severe blood loss
  3. Pre-eclampsia and eclampsia 16%
    • Disorders associated with excessively high blood pressure
  4. Infection 13%
  5. Cardiomyopathy 8%

Social factors and healthcare access issues also contribute to the maternal mortality rate. In no particular order, these factors include:

  1. Access to healthcare
    • Prenatal care
      • Doctors may be unwilling or unable to provide care for pregnant mothers, due to high costs. Many women are turned down due to Medicaid fees, as well. Women have also reported access and mobility as reasons why they are unable to seek prenatal care, such as lack of transportation and/or lack of health insurance. Women who do not have access to prenatal care are 3-4 times more likely to die during or after pregnancy than women who do. Access to prenatal care is an essential component for a healthy pregnancy, which decreases the chances of maternal mortality; however, women in America do not have easy and equal access to it.
    • Insurance
      • Insurance companies reserve the right to categorize pregnancy as a pre-existing condition, thereby making women ineligible for private health insurance. Even access to Medicaid is curtailed to some women, due to bureaucracy and delays in coverage (if approved).
  2. Discrimination
    1. Racial disparity
      • African-American women have maternal mortality rates that are four times higher than white women, and there has been no large-scale improvement over the course of 20 years to rectify these conditions.[7] Furthermore, women of color—especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English" [1]—are deterred from seeking the care they need, due to discrimination.
    2. Economic disparity
      • It is estimated that 99% of women give birth in hospitals with fees that average between $8,900-$11,400 for vaginal delivery, and between $14,900-$20,100 for a cesarean.[1] Many women cannot afford these high costs, nor can they afford private health insurance, and even waiting on government-funded care can prove to be fatal, since delays to coverage usually result in women not getting the care they need from the start.
    3. Social disparity
      • Studies have shown that women are affected by the stress of being lower income, which then affects their pregnancies and unborn babies. In the US, women of color disproportionately experience stress related to financial burdens and racism when trying to gain access to healthcare. These women have a harder time maintaining or gaining access to healthy nutrition and even safe housing. These social factors are directly linked to the outcome of maternal care.
  3. Cesarean birth
    • The Healthy People 2010 goal was to reduce the c-section rate to 15% for low-risk first-time mothers, but that goal was not met and the rate of c-sections has been on the rise since 1996, and reached an all-time high in 2009 at 32.9% (which is double what the WHO recommends between 5%-15%). Excessive and non-medically necessary cesareans can lead to complications that contribute to maternal mortality.[1]
  4. Postpartum care
    • Women in the US usually meet with their physicians just once after delivery, six weeks after giving birth. Due to this long gap during the postpartum period, many health problems remain unchecked, which can result in maternal death. Just as women, especially women of color, have difficulty with access to prenatal care, the same is true for accessibility to postpartum care. Also, postpartum depression can also lead to untimely deaths for both mother and child.

Inconsistent obstetric practice, increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the US. A nationally implemented guideline for pregnancy and childbirth, along with easy and equal access to antenatal services and care, and active participation from all 50 states to produce better maternal health data are all necessary components to reduce maternal mortality.[8]

Prevention

Black and white image of an African-American midwife with glasses holding twins in front of a house, with another African-American woman standing behind her to the left. The photo was taken in Tallahassee, Florida.

Research shows that, in the US and in many other countries, women and infants both benefit from a midwifery model of care. These studies conclude that a midwifery model of care has been proven to reduce the amount of medical interventions that may lead to complications and death, when administered unnecessarily and excessively (i.e. episiotomies and cesareans). [1] That is not to say that cesarean births are in any way bad or useless. In fact, cesarean births can save lives when medical emergencies arise. However, in the US, excessive rise in cesarean births have been linked with maternal mortality.

Image of a woman about to give birth in the delivery room of Loretto Hospital in New Ulm, Minnesota. The mother is on her back with her legs spread across, two hospital attendants in on the right, her husband on the left, and everyone is wearing a facemark and hospital gown. Industrial equipment are in the room with a light above the mother.

The Hospital Corporation of America has found that a uniform guideline for birth can improve maternal care, thereby reducing the amount of "lower maternal and fetal injury, fewer c-sections and reduced litigation." However, no such mandated guideline currently exists. [1]

To prevent maternal mortality moving forward, Amnesty International suggests these steps:

  1. Increase government accountability and coordination
  2. Create a national registry for maternal and infant health data, while incorporating intersections of gender, race, and social/economic factors
  3. Improve maternity care workforce
  4. Improve diversity in maternity care

According to the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, out-of-hospital births (such as home births and birthing centers) "generally provided a lower risk profile than hospital births." [9] Contextually, birth trends are indicative of birth statistics, and midwifery models of care and mainstream obstetric care are not mutually exclusive nor do they have to be.[4] For example, in Canada where the maternal mortality rate is lower than the United States, midwifery and obstetric care often complement each other to offer woman a wide arrange of pregnancy and birthing options, wherein informed choice and consent are fundamental tenants of their reformed maternity care. [10] The maternal mortality rate is twice as low in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank.[11]

Gender bias and obstetric violence in the medical field also important factors when discussing maternal wellness, care, and death in the United States.[12]

See also

References 

  1. 1 2 3 4 5 6 Deadly delivery : the maternal health care crisis in the USA. Amnesty International. London, England: Amnesty International Publications. 2010. ISBN 9780862104580. OCLC 694184792.
  2. ↑ Martin, Nina (2017-07-17). "Lost Mothers". ProPublica. Retrieved 2017-07-26.
  3. ↑ Deadly Delivery: The Maternal Healthcare Crisis in the USA One Year Update, Spring 2011. New York: Amnesty International, 2011. PDF.
  4. 1 2 Morton, Christine H. "Where Are the Ethnographies of US Hospital Birth?" Anthropology News 50.3 (2009): 10-11. Web.
  5. ↑ "Frequently Asked Questions (FAQs) | Healthy People 2020". www.healthypeople.gov. Retrieved 2017-07-26.
  6. 1 2 3 Kilpatrick, Sarah J (2015-03-01). "Next Steps to Reduce Maternal Morbidity and Mortality in the USA". Women's Health. 11 (2): 193–199. doi:10.2217/whe.14.80.
  7. ↑ "Maternal Health – Amnesty International USA". Amnesty International USA. Retrieved 2017-07-26.
  8. ↑ "WHO | Maternal mortality and morbidity in the United States of America". www.who.int. Retrieved 2017-07-26.
  9. ↑ MacDorman, Marian F., T. J. Mathews, Eugene R. Declercq, and National Center for Health Statistics , Issuing Body. Trends in Out-of-hospital Births in the United States, 1990-2012. NCHS Data Brief (Series) ; No. 144. 2014.
  10. ↑ MacDonald, Margaret. Chapter 4, At Work in the Field of Birth. 2007. Vanderbilt University Press.
  11. ↑ "U.S. maternal mortality rate is twice that of Canada: U.N". Reuters. Thu Nov 12 09:40:42 UTC 2015. Retrieved 2017-08-02. Check date values in: |date= (help)
  12. ↑ Diaz-Tello, Farah. "Invisible Wounds: Obstetric Violence in the United States." Reproductive Health Matters 24, no. 47 (2016): 56-64.
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