Why is it such a problem?
When you’re expecting a baby, it’s a joyous time. One of the last things you’re thinking about is the chances of the mother dying. Unfortunately, maternal mortality in the United States is much higher than in other countries of similar stature. Why? What needs to be done to improve outcomes?
Maternal mortality is a significant public health indicator because the ability to protect the health of mothers and babies in childbirth is an essential measure of a society’s development. It’s one of the health measures included in the United Nations Sustainable Health Goals. According to the World Health Organization (WHO), maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” The number is measure per 100,000 live births.
Globally, maternal mortality has decreased 43% since 1990. In the United States, it fell by 99% from 1955 to 1985. Since then, it’s gone steadily up. The number of American women dying from pregnancy-related complications more than doubled between 1987 and 2016. According to the 2018 report from the Centers for Disease Control and Prevention (CDC), there were 17.4 maternal deaths per 100,000 live births (or 658 women died). The 2019 numbers are even higher at 20.1 deaths per 100,000 live births (or 754 women died). An analysis by the CDC Foundation found that nearly 60% of deaths are preventable. Another finding was that the maternal mortality rate gets higher with each older age group. Women 40 and older are 7.7 times more likely to die than women under age 25. Also, the maternal death rate for black women (37.1) was more than double that of white women (14.7) and more than three times the rate for Hispanic women (11.8). What’s concerning is that experts feel the numbers are a conservative estimate of what’s really happening because they don’t include new moms over 44 or deaths that occur after 42 days of giving birth. The CDC estimates that 24% of maternal deaths happen six or more weeks after a woman gives birth. Deaths that occur within one week postpartum (19% of all maternal deaths) are primarily attributed to severe bleeding, high blood pressure, and infection. Why more women are dying because of them is unclear.
The information was obtained using a new method of coding maternal deaths designed to limit past errors. It represents the first time every state has a comparable “pregnancy” checkbox on death certificates that must be filled out. In 2003, the federal government added the pregnancy checkbox to the US standard death certificate, asking whether the person who died was pregnant or had recently given birth. However, states weren’t required to use the checkbox, and some were slow to adopt the change. The result was no reliable way to compare what was happening across states. The inconsistencies lead the National Center for Health Statistics to pause the publication of maternal mortality trends. The gap lasted 11 years. This began to draw national attention in 2016 when researchers published a study suggesting that an even higher proportion of women (23.8 for every 100,000 births) died from causes related to childbirth than what was being “reported.” This led to the change of requiring states to use the checkbox.
Comparing the CDC figures to other countries in the World Health Organization’s latest maternal mortality ranking, the US ranks 55th. That would put us just behind Russia (17 per 100,000) and just ahead of Ukraine (19 per 100,000). If you limit the comparison to those similarly wealthy countries, the US ranks last. Among 11 developed countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom), the US has the highest maternal mortality rate, a relative undersupply of maternity care providers, and no guaranteed access to provider home visits or paid parental leave in the postpartum period. In addition, we spend the highest percentage of its gross domestic product on health care. The Commonwealth Fund found the US is the only high-income country that doesn’t guarantee paid leave to mothers after childbirth. All the other countries guarantee at least a 14-week paid leave from work. Several actually provide more than a year of maternity leave.
Why is this happening?
There are several reasons why maternal mortality is getting worse. One of the main factors is that the health of the population as a whole is changing. Chronic health problems, such as obesity, heart disease, high blood pressure, and diabetes, are more common than they used to be. They all can raise the risk for pregnancy-related complications. Since half of the pregnancies in the US are unplanned, many women don’t address chronic health issues beforehand. The demographics of childbirth are also changing, resulting in more high-risk pregnancies. More and more women have children later in life. Combine this with the rise in chronic conditions, posing a significant challenge in taking care of pregnant and postpartum women.
Another issue with the rise in chronic health conditions is the care of these individuals often needs to be managed by more specialists. Each specialist keeps their own health records, which adds more chances for miscommunications among a woman’s care providers or essential details falling through the cracks. This problem is more common than most people realize. There’s a significant disparity in how women of color are treated for pregnancy-related complications. Part of the reason is women of color are more likely to have chronic conditions. Also, they’re more likely to be financially challenged and lack access to healthcare. All of these increase the chances that these issues go untreated, resulting in issues that could lead to maternal death.
An additional barrier to quality care is the lack of available healthcare personnel to care for pregnant women. The US has one of the lowest overall supplies of midwives and obstetrician-gynecologists (OB-GYNs) — 12 providers per 1000 live births. In contrast, all other countries have a supply that is between 2 and 6 times greater. Midwives can manage a normal pregnancy, assist with childbirth, and provide care during the postpartum period. OB-GYNs are doctors trained to identify issues and intervene should abnormal conditions arise; they usually work in hospital-based settings. The role of midwives is not only comparable but preferable to physician-led care in terms of mother and baby outcomes. Also, it’s a more efficient use of healthcare resources. In the UK and the Netherlands, midwives provide most prenatal care and deliveries. Dutch midwives also assist with home births (13% of all births); they have the highest rate in developed countries. In the US, midwife services are not uniformly covered by private insurance plans. Under the Affordable Care Act (ACA), Medicaid programs are required to cover midwifery care. The problems are state licensure laws, restrictive scope-of-practice laws, and rules requiring physician supervision of midwives. These lead to a short supply of midwives. The staffing issue also applies to hospitals. They are often staffed differently on weekends due to the lack of personnel. An analysis from Baylor College of Medicine found that 45 million pregnancies in the US from 2004 to 2014 found mothers who deliver on Saturday or Sunday have nearly 50%t higher mortality rates, increased blood transfusions, and more perineal tearing.
Another issue is that women may be misdiagnosed or get ineffective treatments. A great example of this is preeclampsia, a type of high blood pressure that occurs only in pregnancy or the postpartum period and can lead to seizures and strokes. Globally, it kills an estimated five women an hour. In developed countries, it’s highly treatable if you act quickly. It affects 3 – 5% of expectant or new mothers in the US, up to 200,000 women a year, and accounts for about 8% of maternal deaths (50 to 70 women). According to leading medical organizations in the US and the UK, if pregnant women with no previous history of high blood pressure have an increase in blood pressure to 140/90, they probably have preeclampsia. When systolic readings hit 160, treatment with anti-hypertensive drugs and magnesium sulfate to prevent seizures should be initiated immediately. The situation is considered even more dangerous if other symptoms, like upper abdominal (epigastric) pain, swelling, rapid weight gain, vomiting, headache, and anxiety, are present. HELLP syndrome, an acronym for the most extreme variation of preeclampsia, is characterized by hemolysis, or the breakdown of red blood cells; elevated liver enzymes; and low platelet count, resulting in a clotting deficiency that can lead to excessive bleeding and hemorrhagic stroke. Unfortunately, failure to diagnose preeclampsia or differentiate it from chronic high blood pressure is very common. The traditional treatment for preeclampsia was to deliver the baby as soon as possible. However, this method is outdated, so unfamiliarity with best practices and lack of crisis preparation hinders the response. The UK’s National Health Service recently announced the rollout of a blood test for preeclampsia that can reduce maternal stroke, seizure, and death rates by 20%. They have lowered their preeclampsia deaths to one in a million as a result. We don’t have something like that in the US.
Compared to countries with nationalized healthcare, the US’s fragmented system is tougher to navigate. Even though we spend more than any other country on hospital-based care, many pregnant women or new moms with Medicaid or who don’t have health insurance are unable to access free or affordable care. This increases the chances of complications and raises the risk of death four-fold. Part of the issue is that both federal-state grant programs and Medicaid devote significantly more funding and coverage to babies than new moms. For instance, under the Title V federal-state program supporting maternal and child health, in 2016, about 6% of block grants went to programs for mothers, compared to 78% for infants and special-needs children. The Medicaid program (which pays for about 45% of births) covers moms for 60 days postpartum but covers their infants for an entire year. In 2009, the Joint Commission, which accredits 21,000 healthcare facilities, adopted a series of national perinatal standards that have been shown to reduce complications and improve patient outcomes. Of the five measures, only one focuses on maternal health (bringing down the C-section rate, a major surgery that can lead to numerous complications and isn’t always necessary). Per CDC reports, infant mortality has fallen to its lowest point in history, showing 50 years of efforts by the public health community to prevent birth defects, reduce preterm birth, and improve outcomes for very premature infants have been effective. Obviously, this is important, but further attention needs to be paid to taking care of mothers before, during, and after pregnancy. In some states, appeals courts have ruled to end Medicaid funding to Planned Parenthood clinics. They provide several health services to low-income women, including postpartum care. Postpartum care is associated with improved mental health and breastfeeding outcomes and is associated with reduced healthcare costs. Another issue is that when women are discharged, they’re routinely given information about how to breastfeed and what to do if their newborn is sick but not usually given information on how to tell if they need medical attention themselves. Symptoms, such as very heavy bleeding, trouble breathing, chest pain, or a bad headache, are signs that could indicate a serious or life-threatening complication. However, reports show that not all women and their families are aware of these warning signs, which means they are less likely to seek immediate medical care.
An area of major concern is the mental health of women during pregnancy and the postpartum period. Perinatal mood disorders affect up to 15% of women. In fact, suicide ideation occurs more in pregnant women and new moms than in the general population, especially during the late postpartum period (43 to 365 days after giving birth). One of the main factors is hormones, but plenty of others need to be considered, such as social isolation, lack of support, racism, poverty, and lack of access to insurance, transportation, or healthcare providers. One factor is that is on the rise is substance abuse. According to CDC data, the use of opioids during pregnancy quadrupled from 1999 to 2014. In some parts of the country, up to 20% of pregnant women are prescribed opioids.
How can it be fixed?
It’s important to note that some gains have been made to improve maternal mortality. The passing of the ACA helped women gain access to maternity care. It mandated coverage for free preventive services, expanded Medicaid eligibility, offered premium subsidies for low-income women, and provided coverage for young women. However, much more work needs to be done, such as strengthening postpartum care, guaranteeing paid maternity leave, and working to close the racial disparity gap.
One thing that is essential to realize is that better surveillance and data reporting could account for some of the increase in maternal mortality in the past two decades. Since we didn’t have standardized medical protocols to deal with maternal health emergencies, the numbers were probably not overly accurate. A way to enhance the progress already made would be to follow California’s model on a national scale. The state implemented its own protocol in 2008, resulting in a considerable reduction in maternal mortality below the national average. The model is based on the UK process. The California Maternal Quality Care Collaborative began by analyzing maternal deaths in the state over several years. In almost every case, they discovered that there was some possibility to alter the outcome, with the most preventable deaths coming from hemorrhage (70%) and preeclampsia (60%). To address these findings, they created a series of toolkits to help doctors and nurses improve their handling of emergencies. To address bleeding, they recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of estimating blood loss, nurses learned to collect and weigh postpartum blood to get precise measurements. Hospitals that adopted these practices saw a 21% decrease in near deaths from maternal bleeding in the first year, whereas hospitals that didn’t use the protocol had a 1.2% drop. The goal with standardized protocols, such as consistent guidelines and best practices, is that they can be replicated in many different settings, ensuring consistent care in hospitals, clinics, and private providers. According to the Institute of Medicine, it takes an average of 17 years for a new medical protocol to be widely adopted, which is why we need to start implementing these changes nationally as soon as possible.
One thing that could further help is that some other countries look into what went wrong and how it can be prevented next time. For instance, when a woman in the UK dies of a pregnancy-related complication, a national committee analyzes the details of her death. This includes reviewing her medical records, interviewing family members, and even asking hospitals and healthcare providers to explain what went wrong. All the information is compiled into a public report used to improve care policies across the country. Sometimes, coroners also hold public inquests, forcing hospitals and their staff to answer for their mistakes. The US doesn’t have a system like this. Instead, maternal mortality reviews are left up to states. Currently, only 26 states (and one city, Philadelphia) have a process in place. However, resources are tight, so the reviews take years, and the findings get little attention. If we genuinely want to improve maternal mortality rates, fixing this failure is critical.
An additional area that needs to be looked at is providing the appropriate care for women before they become pregnant. By doing that, women will begin their pregnancies in a healthier state and be well supported after they’ve had their baby. The focus needs to be on helping women get access to stable housing, chronic condition treatment, substance abuse treatment, mental health treatment, and reliable care and transportation. It also means having standardized protocols for family planning, increased outreach to at-risk minority groups, and increasing the availability and affordability of long-acting reversible contraceptives. Community outreach has long been a staple of health interventions. So, community health workers could assist women by providing in-home visits throughout pregnancy and postpartum. They may also offer doula (labor) support, help manage chronic conditions, navigate health services, connect women to community resources (ex. housing, education, and emergency supplies), and provide information about breastfeeding, immunizations, and childcare. The goal is to empower women to take responsibility for their own care and treatment.
There are hundreds of preventable pregnancy-related deaths each year. Unfortunately, the rate appears to be rising. Many areas need to be addressed to correct the inequities. The solution is two-fold. We need to create policy and take action on a federal level that screens and appropriately treats pregnant and postpartum individuals. We also need to provide women and their loved ones with more information about pregnancy, pregnancy-related complications, and factors that affect maternal mortality. Only by tackling these will we be able to mitigate this growing public health crisis.