Recent studies reveal that, in the last 15 years, the maternal mortality rate in the United States has increased significantly, even as it has gone down in other wealthy nations. Though the reasons for the rising maternal death rate in the United States are complex, at least some of this increase is due to failures in the healthcare system to adequately address the needs of expectant mothers. Although, in 2017, “dying in childbirth” may seem like something that only happens in Victorian novels, pregnancy and labor continue to represent very real risks to the health of thousands of American women — but that doesn’t have to be the case. Changes to the way that the government and healthcare system approach pregnant women and mothers could prevent thousands of deaths and near deaths every year.
Last week, NPR, in partnership with ProPublica, published an in-depth report on the rising maternal mortality rate in the United States. It’s a long, harrowing piece that nevertheless deserves to be read in its entirety. As writers Nina Martin and Renee Montagne reported, between 700 and 900 American women die from causes related to pregnancy and childbirth every year, and 65,000 more experience serious medical complications. Those numbers represent a sharp increase in maternal deaths: From 2000 to 2014, the American maternal mortality rate rose by 26.6 percent, according to a 2016 study led by University of Maryland professor Marian F. MacDorman. “[T]he maternal mortality rate for 48 states and Washington D.C. from 2000 –2014 was higher than previously reported, is increasing, and places the U.S. far behind other industrialized nations,” researchers wrote. (California and Texas are not included in that statistic; California’s maternal death rate has decreased in recent years, while Texas’s rose suddenly in 2011 - 2012.)
The U.S.’s high maternal mortality rate is especially stark when compared to that of other nations. NPR reports that the United States has the worst maternal death rate among wealthy countries, and it is the only developed nation whose rate of maternal mortality is rising, rather than falling. American women are three times more likely to die from issues related to pregnancy or childbirth than Canadian women, and six times more likely than those in Scandinavia. And perhaps the most disturbing of all the statistics is this: As many as 59 percent of maternal deaths in America are preventable, according to the CDC Foundation.
So what the hell is going on? The rise in maternal deaths isn’t tied to demographics. African American women, poor women, and women in rural areas have higher rates of maternal mortality, but NPR notes that women of every race, background, education level, profession, and income status die due to pregnancy-related complications. These issues include “cardiomyopathy and other heart problems, massive hemorrhage, blood clots, infections and pregnancy-induced hypertension (preeclampsia).”
There are wide variety of factors contributing to the increase in maternal mortality, including the fact that women are having children later in life; more women are having C-sections, which carry extra risks; conditions like obesity, hypertension, and diabetes increase risk; and many women lack consistent care. As the NPR report tracks in detail, there are also major systemic problems at multiple levels of healthcare that lead to unpreparedness in dealing with pregnancy and childbirth-related health complications.
The complexity of the issue means that there isn’t an easy fix for the rising maternal mortality rate, but addressing these key problems with American healthcare wouldn’t be a bad start:
1. Care — and funding — focuses on babies, not moms.
As mortality rates for mothers have risen, infant mortality rates have dropped, reaching a historic low in 2014, according to the CDC. Obviously, a decreasing infant mortality rate is excellent news — but the fact that more women are dying even as more babies are being saved is evidence of a medical system that places infant and fetal health ahead of maternal health.
According to NPR, 78 percent of 2016 block grants from the Maternal and Child HealthBlock Grant Program (Title V) went to infants and children with special needs. In contrast, only 6 percent of the grants went to support for mothers. In many states, Medicaid (which covers almost half of births) provides insurance coverage for infant care that far outstrips that which it provides for maternal care.
The emphasis on infant health over maternal care extends beyond funding allocations and impacts the care that women and their babies receive from medical providers. “Newborns in the slightest danger are whisked off to neonatal intensive care units…, staffed by highly trained specialists ready for the worst, while their mothers are tended by nurses and doctors who expect things to be fine and are often unprepared when they aren't,” reports NPR. New mothers are also often given training to recognize warning signs for problems with their infants’ health, but not their own.
2. Many women lack consistent access to healthcare.
“There is no question that lack of access to affordable and good quality care is playing a role in the overall increasing maternal mortality rate,” Elise Turner, associate professor of nursing at Belhaven University in Mississippi, told CNN.
A 2017 Gallup-Healthways poll found that 11.3 percent of U.S. adults are uninsured, and, according to the World Health Organization, American women without health insurance are “three to four times more likely to die of pregnancy-related complications than their insured counterparts.” This statistic is especially chilling considering the healthcare bill currently under consideration in the Senate. The AHCA is projected to result in millions of people losing insurance — and even women who do have insurance may be left out in the cold. Under current law, insurance policies must cover maternity and newborn care, but the AHCA would allow states to apply for waivers that would remove this requirement. Thus, insurance plans would be allowed exempt maternity care from coverage, leaving women without affordable, consistent healthcare during and immediately after their pregnancies.
3. There is a lack of standardized care.
One major contributor to maternal mortality is that most states don’t have standardized practices in place for diagnosing and treating complications linked to pregnancy and labor. “If you're in Sweden, everybody gets treated the same way. If you are in New York City, you get treated one way. If you're in Buffalo, you get treated another way and if you're in Missouri, you get treated another way," Dr. Michael Brodman, chairman of the department of obstetrics, gynecology and reproductive science at New York’s Mount Sinai Health System, told CNN. “This is that sort of U.S. individualistic kind of thing, ‘I know what I'm doing. This is how I'll do it.’ In health care, at the end of the day, that doesn't work.”
Programs that standardize maternal care, including ones in the UK and California, have shown that establishing set protocols for care can have a significant impact on maternal mortality. For example, NPR cites the California Maternal Quality Care Collaborative (CMQCC) as drastically changing the maternal death rate in California. One effort of the CMQCC has been to create standard “toolkits” for hospitals for dealing with common maternal health problems, like maternal bleeding and preeclampsia. Hospitals that used the toolkits for bleeding found that, in the first year, critical complications from obstetric bleeding went down by 21 percent.
4. Nearly half of states have no review boards for maternal deaths.
The inconsistency of care for mothers can at least in part be attributed to a lack of reliable oversight of maternal mortality cases. As The New York Times points out, the UK, Australia, and several European countries have review boards in place to examine cases of maternal mortality and use their findings to guide policy. The UK’s review board, especially, approaches each instance of maternal mortality as, in NPR’s words, a “system failure,” rigorously investigating maternal deaths to see how future deaths might be prevented. The effort has led to a significant reduction of deaths caused by preeclampsia in Britain.
Despite these successes elsewhere, only about half of U.S. states have review boards in place to evaluate maternal deaths, and many of those that do exist are stretched thin. This results in what the World Health Organization describes as a “general lack of good data — and related analysis — on maternal health” in the United States.
5. There are no federal provisions in place to fix the problem.
Right now, there is no federal policy to standardize or improve maternal care. In March, representatives introduced the Preventing Maternal Deaths Act of 2017 to Congress. If passed, the law would provide funds to establish or bolster state committees to review maternal deaths and support the national sharing of information on maternal mortality via the Centers for Disease Control and Prevention.
The good news is that precedent shows that something can be done about the maternal mortality rate. Efforts in the UK and California, for example, have shown that placing a greater emphasis on maternal care, standardizing that care, and having review mechanisms in place can go a long way toward reducing maternal deaths. But this much-needed reduction will only happen if there is a substantial, coordinated effort across the United States to better protect pregnant women and mothers.