Maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated, if the death was related to her pregnancy.[1] The United States Centers for Disease Control and Prevention (CDC) monitors maternal death per 100,000 live births. The CDC reported a baseline rate of 18.8 maternal deaths per 100,000 births in 2016,[2] which was higher than anticipated. In 2014 there was a 26.6% increase representing 23.8 maternal deaths per 100,000 births.[2][3] Maternal mortality as well as maternal morbidity has been increasing over the last several decades in the United States, with an estimated 50% of deaths due to preventable causes.[4]

By 2010, although the United States was spending more on healthcare than any other country in the world, more than two women died every day during childbirth, therefore making maternal mortality the highest in the United States compared to 49 other countries in the developed world,[5] three times higher than neighboring Canada.[6] In 2016, as many as 900 women between the ages of 16 and 43, died from pregnancy- and childbirth-related causes.[7] The Centers for Disease Control and Prevention (CDC) declares that 60% of these deaths are preventable.

In the U.S., hospital bills for maternal healthcare costs over $98 billion, and concerns about the degradation of the MMR resulted in a state-by-state breakdown. Race, location, and financial status all contribute to how maternal mortality affects women across the country, but Texas has the worst MMR, which caused the Department of State to create the Maternal Mortality and Morbidity Task Force in 2013.

Centers for Disease Control and Prevention (CDC)

In 1986, the Centers for Disease Control and Prevention (CDC)[8] 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.[9]

In 2016 the CDC Foundation, the Centers for Disease Control and Prevention (CDC) and the Association of Maternal and Child Health Programs (AMCHP) undertook a collaborative initiative—"Building U.S. Capacity to Review and Prevent Maternal Deaths"— funded by Merck under the Merck for Mothers program. They are reviewing maternal mortality to enhance understanding of the increase in MMR in the United States, and to identify preventative interventions.[10] Through this initiative, they have created Review to Action website which hosts their reports and resources.

In their 2017 report, four states, Colorado, Delaware, Georgia, and Ohio, supported the development of the Maternal Mortality Review Data System (MMRDS) which was intended as a precursor to the Maternal Mortality Review Information Application (MMRIA).[11]

The three agencies have partnered with Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah to collect data for the Maternal Mortality Review Information Application (MMRIA). The nine states submitted their first reports in 2018.[12]

After decades of inaction on the part of the U.S. Congress towards reducing MMR, the United States Senate Committee on Appropriations voted on June 28, 2018 to request $50 million to prevent the pregnancy-related deaths of American women.[13] The CDC would receive $12 million for research and data collection. They would also support individual states in counting and reviewing data on maternal deaths.[13] The federal Maternal and Child Health Bureau would receive the remaining $38 million directed towards Healthy Start program and "life saving, evidence-based programs" at hospitals.[13] MCHB's Healthy Start was mandated to reduce the infant mortality rate.[14]

Measurement and data collection

A widely-cited 2016 study by Centers for Disease Control and Prevention (CDC) statistician Marian F. MacDorman and others, reported a baseline rate of 18.8 maternal deaths per 100,000 births, which was higher than previously thought. In 2014 there was a 26.6% increase representing 23.8 maternal deaths per 100,000 births.[3]:427 MacDorman et al concluded that, "the 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."[2]

According to the Centers for Disease Control and Prevention (CDC) Foundation 2018 report, 60% of maternal deaths are preventable."[12]

According to a 2016 article in Obstetrics and Gynecology by MacDorman et al, one factor affecting the US maternal death rate is the variability in calculation of maternal deaths. The WHO deems maternal deaths to be those occurring within 42 days of the end of pregnancy, whereas the United States Pregnancy Mortality Surveillance System measures maternal deaths as those occurring within a year of the end of pregnancy.[2] Some states allow multiple responses, such as whether death occurred during pregnancy, within 42 days after pregnancy, or within a year of pregnancy, but some states, such as California, ask simply whether death occurred within a year postpartum.[2]

In their article, the authors described how data collection on maternal mortality rates became an "international embarrassment".[2][3]:427 In 2003 the national U.S. standard death certificate added a "tick box" question regarding the pregnancy status of the deceased. Many states delayed adopting the new death certificate standards. This "muddied" data and obstructed analysis of trends in maternal mortality rates. It also meant that for many years, the United States could not report a national maternal mortality rate to the OECD or other repositories that collect data internationally.[2][3]:427

In response to the MacDorman study, revealing the "inability, or unwillingness, of states and the federal government to track maternal deaths",[7] ProPublica and NPR found that in 2016 alone, between 700 to 900 women died from pregnancy- and childbirth-related causes. In "Lost Mothers" they published stories of some of women who died. They ranged in age from 16 to 43.[7]

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). This was 3 times as high as the Healthy People 2010 goal, a national target set by the US government.[15]

According to a 2009 article in Anthropology News, studies conducted by but not limited to Amnesty International, the United Nations, and federal programs such as the CDC, maternal mortality has not decreased since 1999 and may have been rising.[16]

By November 2017, Baltimore and Philadelphia, and New York City had established committees to "review deaths and severe complications related to pregnancy and childbirth" in their cities to prevent maternal mortality. New York's panel, the Maternal Mortality and Morbidity Review Committee (M3RC) doctors, nurses, "doulas, midwives and social workers".[17] New York City will be collaborating with the State of New York, the first such collaboration in the US.[17] In July 2018, New York City's de Blasio's administration announced that it would be allocating $12.8 million for the first three years of its five-year plan to "reduce maternal deaths and life-threatening complications of childbirth among women of color".[1]

Comparisons with other countries

In the 2017 NPR and ProPublica series "Lost Mothers: Maternal Mortality in the U.S." based on a six-month long collaborative investigation, they reported that the United States has the highest rate of maternal mortality than any other developed country and it is the only country where the rate of women who die has been rising.[18] The maternal mortality rate in the United States is three times higher than that in neighboring Canada[6] and six times as likely to die of as Scandinavians.[19]

In the 1950s the maternal mortality rate in the United Kingdom and the United States was the same—1 in 1000 pregnant and new mothers died. By 2018, the rate in the UK was three times lower than in the United States.[20]


According to a 2015 WHO report, in the United States the MMR between 1990 and 2013 "more than doubled from an estimated 12 to 28 maternal deaths per 100 000 births."[21] By 2015, the United States had a higher MMR than the "Islamic Republic of Iran, Libya and Turkey".[22][23]

Comparison of the US maternal death rate to the death rate in that of other countries is complicated by the lack of standardization. Some counties do not have a standard method for reporting maternal deaths and some count in statistics death only as a direct result of pregnancy.[24]

In 2010, Amnesty International published a 154-page report on maternal mortality in the United States.[25] In 2011 the United Nations described maternal mortality as a human rights issue at the forefront of American healthcare, as the mortality rates worsened over the years.[26]

Comparisons by state

Texas

According to a 2017 BBC report, Texas has the highest MMR in the United States and the lowest number of people covered by health insurance.[27]

The Department of State created the Maternal Mortality and Morbidity Task Force in 2013.

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.[9]

More than half of maternal deaths occur within the first 42 days after birth. According to Amnesty International's 2010 report, five medical conditions collectively account for 74% of maternal deaths in the US. These are Embolism (20%), Hemorrhage (17%), Pre-eclampsia and eclampsia (16%), Infection (13%), and Cardiomyopathy (8%).[25]:4

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 are four times as likely to suffer from maternal morbidity and maternal mortality, compared to Caucasian or Asian or Hispanic women.[9] and there has been no large-scale improvement over the course of 20 years to rectify these conditions.[28] Furthermore, women of color—especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English" [5]—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.[5] 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.[5]
  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 (which can allow complications to progress to fatal conditions),[6] increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the US. According to a 2015 WHO editorial, 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.[22]

Recent improvements in pregnancy-related health care have focused on fetuses and newborns, which has left mothers neglected in comparison. Mothers get 6% of federal block grants in this area, and even hospitals with intensive care units for newborns can be unprepared for maternal complications (like having platelets on hand for bleeding).[6] A significant proportion of physicians in maternal-fetal medicine programs are able to complete a program in without ever attending a labor.[6]

Prevention

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.[5]

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 with midwifery assistance) "generally provided a lower risk profile than hospital births." [29]

Procedures such as Episiotomies and cesareans, while helpful in some cases, when administered unnecessarily increase the risk of maternal death.[5] Midwifery and mainstream obstetric care can be complementary,[16] which is commonly the case in Canada, where women have a wide arrange of pregnancy and birthing options, wherein informed choice and consent are fundamental tenants of their reformed maternity care.[30] 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.[31]

The UK has had success drastically reducing preeclampsia deaths by implementing a nationwide standard protocol.[6]

Gender bias and obstetric violence in the medical field are also important factors when discussing maternal wellness, care, and death in the United States.[32]

Historical images

See also

References

  1. 1 2 "De Blasio Administration Launches Comprehensive Plan to Reduce Maternal Deaths and Life-Threatening Complications from Childbirth Among Women of Color". NYC. July 20, 2018. Retrieved August 4, 2018. Severe maternal morbidity is defined as life-threatening complications of childbirth; maternal mortality is defined as a death of a woman while pregnant or within one year of the termination of pregnancy due to any cause related to or aggravated by the pregnancy or its management.
  2. 1 2 3 4 5 6 7 MacDorman, Marian F.; Declercq, Eugene; Cabral, Howard; Morton, Christine (2016). "Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues Short title: U.S. Maternal Mortality Trends". Obstetrics and gynecology. 128 (3): 447–455. doi:10.1097/AOG.0000000000001556. ISSN 0029-7844. PMC 5001799.
  3. 1 2 3 4 Chescheir, Nancy C. (September 2016). "Drilling Down on Maternal Mortality". Obstetrics & Gynecology. 128 (3): 427–8. doi:10.1097/AOG.0000000000001600. PMID 27500323.
  4. ↑ Troiano, Nan H.; Witcher, Patricia M. (2018). "Maternal Mortality and Morbidity in the United States". The Journal of Perinatal & Neonatal Nursing. 32 (3): 222–231. doi:10.1097/jpn.0000000000000349. ISSN 0893-2190.
  5. 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.
  6. 1 2 3 4 5 6 Martin, Nina; Montagne, Renee (May 12, 2017). "Focus On Infants During Childbirth Leaves U.S. Moms In Danger". Lost Mothers: Maternal Mortality in the U.S. ProPublica NPR. Retrieved August 4, 2018.
  7. 1 2 3 Martin, Nina; Cillekens, Emma; Freitas, Alessandra (July 17, 2017). "Lost Mothers". ProPublica. Retrieved August 4, 2018.
  8. ↑ "Pregnancy Mortality Surveillance System". Atlanta, Georgia. July 25, 2018. Retrieved August 4, 2018.
  9. 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.
  10. ↑ "Building U.S. Capacity to Review and Prevent Maternal Deaths". CDC Foundation. n.d. Retrieved August 4, 2018.
  11. ↑ "Report from Maternal Mortality Review Committees: A View Into Their Critical Role" (PDF). CDC Foundation. Building U.S. Capacity to Review and Prevent Maternal Deaths. January 1, 2017. p. 51. Retrieved August 4, 2018.
  12. 1 2 Reports from Maternal Mortality Review Committees (Report). Building U.S. Capacity to Review and Prevent Maternal Deaths. CDC. 2018. p. 76.
  13. 1 2 3 Martin, Nina (June 28, 2018). "U.S. Senate Committee Proposes $50 Million to Prevent Mothers Dying in Childbirth". Lost Mothers: Maternal Mortality in the U.S. ProPublica. Retrieved August 4, 2018.
  14. ↑ "Healthy Start". Mchb.hrsa.gov. Retrieved 2013-12-31.
  15. ↑ "Frequently Asked Questions (FAQs) | Healthy People 2020". www.healthypeople.gov. Retrieved 2017-07-26.
  16. 1 2 Morton, Christine H. "Where Are the Ethnographies of US Hospital Birth?" Anthropology News 50.3 (2009): 10-11. Web.
  17. 1 2 Fields, Robin (November 15, 2017). "New York City Launches Committee to Review Maternal Deaths". ProPublica. Lost Mothers. Retrieved August 4, 2018. Nationally, such data is so unreliable and incomplete that the United States has not published official annual counts of fatalities or an official maternal mortality rate in a decade.
  18. ↑ Martin, Nina; Montagne, Renee (May 12, 2017). "U.S. Has The Worst Rate Of Maternal Deaths In The Developed World". Lost Mothers: Maternal Mortality in the U.S. ProPublica NPR. Retrieved August 4, 2018.
  19. ↑ Martin, Nina; Montagne, Renee (May 12, 2017). "The Last Person You'd Expect to Die in Childbirth". Lost Mothers: Maternal Mortality in the U.S. ProPublica. Retrieved August 4, 2018.
  20. ↑ Womersley, Kate (August 31, 2017). "Why Giving Birth Is Safer in Britain Than in the U.S." ProPublica. Retrieved August 4, 2018.
  21. ↑ Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division (PDF). World Health Organization (Report). Geneva. 2014. Retrieved August 4, 2018.
  22. 1 2 Agrawal, Priya (March 2015). "Maternal mortality and morbidity in the United States of America". Bulletin of the World Health Organization. pp. 133–208. doi:10.2471/BLT.14.148627. Retrieved July 26, 2017.
  23. ↑ Maternal mortality in 1990-2015 (PDF). World Health Organization (Report). Trends in maternal mortality: 1990 to 2015. Geneva: WHO. 2005. Retrieved August 4, 2018. WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division
  24. ↑ "Medscape". www.medscape.com.
  25. 1 2 "Deadly Delivery: The Maternal Healthcare Crisis in the USA". Amnesty International. London, UK. March 10, 2010. p. 154. Missing or empty |url= (help); |access-date= requires |url= (help)
  26. ↑ "Deadly Delivery: The Maternal Healthcare Crisis in the USA One Year Update 2011" (PDF). Amnesty International. New York. May 7, 2011. (pdf file: link). Retrieved August 4, 2018.
  27. ↑ "Why do so many US women die giving birth?". America First?. BBC. November 20, 2017. Missing or empty |url= (help) Video by Franz Strasser; produced by Ashley Semler and filmed by Pete Murtaugh.
  28. ↑ "Maternal Health – Amnesty International USA". Amnesty International USA. Retrieved 2017-07-26.
  29. ↑ 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.
  30. ↑ MacDonald, Margaret. Chapter 4, At Work in the Field of Birth. 2007. Vanderbilt University Press.
  31. ↑ "U.S. maternal mortality rate is twice that of Canada: U.N". Reuters. 2015-11-12. Retrieved 2017-08-02.
  32. ↑ Diaz-Tello, Farah. "Invisible Wounds: Obstetric Violence in the United States." Reproductive Health Matters 24, no. 47 (2016): 56-64.
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