Maternal mortality in the United States

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Number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 births

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this only includes causes related to her pregnancy and does not include accidental causes.[1] Some sources will define maternal mortality as the death of a woman up to 42 days after her pregnancy has ended, instead of one year.[2] In 1986, the CDC began tracking pregnancy related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System.[1] Although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.[3] The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase;[4] It is estimated that 20-50% of these deaths are due to preventable causes, such as: hemorrhage, severe high blood pressure, and infection.[5]

Monitoring maternal mortality[edit]

In 1986, 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 deaths during pregnancy and up to one year after giving birth. Prior to this, women were monitored up to 6 weeks postpartum.[1]

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 the maternal mortality ratio in the United States, and to identify preventative interventions.[6] 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).[7] 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.[8]

After decades of inaction on the part of the U.S. Congress towards reducing the maternal mortality ratio, 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.[9] 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.[9] 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.[9] MCHB's Healthy Start was mandated to reduce the infant mortality rate.[10]

Graph showing the trend in pregnancy related deaths in the United States from 1987 to 2014.

Measurement and data collection[edit]

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.[4] 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.[4]

In their article, the authors described how data collection on maternal mortality rates became an "international embarrassment".[4][11]: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.[4][11]:427

In response to the MacDorman study, revealing the "inability, or unwillingness, of states and the federal government to track maternal deaths",[12] ProPublica and NPR found that in 2016 alone, between 700 and 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.[12]

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.[13]

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.[14]

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".[15] New York City will be collaborating with the State of New York, the first such collaboration in the US.[15] 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".[16]

Causes[edit]

Medical causes[edit]

This figure shows the top causes of pregnancy related deaths in the United States from 2011-2014.

Maternal death can be traced to maternal health, which includes wellness throughout the entire pregnancy and access to basic care.[17] More than half of maternal deaths occur within the first 42 days after birth. Race, location, and financial status all contribute to how maternal mortality affects women across the country.

In response to the high maternal mortality ratio in Texas, in 2013 the Department of State created the Maternal Mortality and Morbidity Task Force. According to Amnesty International's 2010 report, five medical conditions collectively account for 74% of maternal deaths in the US.

  1. Embolism: blood vessels blocked likely due to deep vein thrombosis, a blood clot that forms in a deep vein, commonly in the legs but could be from other deep veins.* Pulmonary embolisms and strokes are blockages in the lungs and brain respectively and are severe, could lead to long term effects, or be fatal.
  2. Hemorrhage: severe bleeding. Hemorrhages can be caused by placenta accreta, increta, and percreta, uterine rupture, ectopic pregnancy, uterine atony, retained products of conception, and tearing. During labor, it is common to lose between half a quart to a quart depending on whether a mother delivers naturally or by cesarean section. With the additional and severe amount of bleeding due to hemorrhage, the mother’s internal organs could go into shock due to poor blood flow which is fatal.
  3. Pre-eclampsia: at about 20 weeks until after delivery, pregnant women could have an increase in blood pressure which could indicate pre-eclampsia. Pre-eclampsia involves the liver and kidneys not working properly which is indicated by protein in the urine as well as having hypertension. Pre-eclampsia can also become eclampsia, the mother seizes or is in a coma, which is rare but fatal.
  4. Infection: each person has a different immune system, when a woman is pregnant, their immune systems behaves different than originally causing increased susceptibility to infection which can be threatening to both mother and baby. Different types of infection include, infection of amniotic fluid and surrounding tissues, influenza, genital tract infections, and sepsis/blood infection. Fever, chills, abnormal heart rate, and breathing rate can indicate some form of infection.
  5. Cardiomyopathy[18]: the enlargement of heart, increased thickness, and possible rigidness which causes the heart to weaken and die. This may lead to low blood pressure, reduced heart function, and heart failure. Other cardiovascular disorders are contributory to maternal mortality as well.

Postpartum depression is widely untreated and unrecognized, leading to suicide. Suicide is one of the most significant causes of maternal mortality,[18][19] and reported to be the number one cause by many studies.[20] Postpartum depression is caused by a chemical imbalance due to the hormonal changes during and after birth and is more long term and severe than “baby blues.”


Social factors[edit]

Social determinants of health also contribute to the maternal mortality rate. Some of these factors include access to healthcare, education, age, race, and income.[21]

Access to healthcare[edit]

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.[22] Just as women, especially women of color, have difficulty with access to prenatal care, the same is true for accessibility to postpartum care. Postpartum depression can also lead to untimely deaths for both mother and child.[22]

Maternal-fetal medicine does not require labor-delivery training in order to practice independently.[23] The lack of experience can make certain doctors more likely to make mistakes or not pay close attention to certain symptoms that could indicate one of the several causes of death in mothers. For women who have limited access, these kinds of physicians may be easier to see than more experienced physicians. In addition, many doctors are unwilling to see patients who are pregnant if they are uninsured or unable to afford their co-pay, which restricts prenatal care and could prevent women from being aware of potential complications.

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). Many women are turned down due to Medicaid fees, as well. Although the supportive care practice of a doula has potential to improve the health of both the mother and child and reduce health disparities,[24] these services are underutilized among low-income women and women of color, who are at greater risk of poor maternal health outcomes.[25] Women may be unable to find or afford services or unaware that they are offered.[25] A 2012 national survey by Childbirth Connection found that women using Medicaid to pay for birth expenses were twice as likely as those using private insurance to have never heard of a doula (36% vs. 19%).[26] Medicaid does not cover doula care during a woman's prenatal or post-partum period.[24] 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.[27]

Education[edit]

It has been shown that mothers between ages 18 and 44 who did not complete high school had a 5% increase in maternal mortality versus women who completed high school.[28] By completing primary school, 10% of girls younger than 17 years old would not get pregnant and 2/3 of maternal deaths could be prevented.[29] Secondary education, university schooling, would only further decrease rates of pregnancy and maternal death.

Age[edit]

Young adolescents are at the highest risk of fatal complications of any age group. [30] This high risk can be accounted for by various causes such as the likelihood of adolescents giving birth for the first time compared to women in older age groups.[31] Other factors that also may lead to higher risk among this age group includes lower economic status and education.[32] While adolescents face a higher risk of maternal mortality, a study conducted between 2005-2014 found that the rate of maternal mortality was higher among older women.[33] Additionally, another study found that the rate is higher specifically among women aged 30 years or older.[31]

Race[edit]

African American women are four times as likely to suffer from maternal morbidity and mortality than Caucasian women,[3] and there has been no large-scale improvement over the course of 20 years to rectify these conditions.[34] Furthermore, women of color, especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English", are less likely to obtain the care they need. In addition, foreign-born women have an increased likelihood of maternal mortality, particularly Hispanic Women.[35] Cause of mortality, especially in older women, is different among different races. Caucasian women are more likely to experience hemorrhage, cardiomyopathy, and embolism whereas African American women are more likely to experience hypertensive disorders, stroke, and infection.

The US has shown to have the highest rate of pregnancy related deaths o/c maternal mortality amongst all the industrialized countries. The CDC first implemented the Pregnancy Mortality Surveillance System in 1986 and since then maternal mortality rates have increased from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births in 2015. The issue of maternal mortality disproportionately affects women of colour when compared with the rate in white non-Hispanic women. The following statistics were retrieved from the CDC and show the rate of maternal mortality between 2011 and 2015 per 100000 live births: Black non-Hispanic -42.8, American Indian/Alaskan Native non-Hispanic-32.5, Asian/Pacific Islander on-Hispanic -14.2, White non-Hispanic-13.0, and Hispanic -11.4. Black non-Hispanic women tend to have limited access to pre- and post-natal healthcare services.

Income[edit]

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.[36] 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.

Other risk factors[edit]

Some other risk factors include obesity, chronic high blood pressure, increased age, diabetes, cesarean delivery, and smoking. Attending less than 10 prenatal visits is also associated with a higher risk of maternal mortality.[28]

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%.[clarification needed] Excessive and non-medically necessary cesareans can lead to complications that contribute to maternal mortality.[3]

Geographic location has been found to be a contributing factor as well. Data has shown that rates of maternal mortality are higher in rural areas of the United States. In 2015, the rate of maternal mortality in rural areas as 29.4 per 100,000 live births as compared to 18.2 in metropolitan areas.[37]

Prevention[edit]

Inconsistent obstetric practice,[38] increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the United States. According to a 2015 WHO editorial, a nationally implemented guideline for pregnancy and childbirth, along with easy and equal access to prenatal services and care, and active participation from all 50 states to produce better maternal health data are all necessary components to reduce maternal mortality.[39] The Hospital Corporation of America has also found that a uniform guideline for birth can improve maternal care overall. This would ultimately reduce the amount of maternal injury, c-sections, and mortality. The UK has had success drastically reducing preeclampsia deaths by implementing a nationwide standard protocol.[38] However, no such mandated guideline currently exists in the United States.[3]

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."[40]

Procedures such as Episiotomies and cesareans, while helpful in some cases, when administered unnecessarily increase the risk of maternal death.[3] Midwifery and mainstream obstetric care can be complementary,[14] 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.[41] The maternal mortality rate is two times lower in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank.[42]

Gender bias, implicit bias, and obstetric violence in the medical field are also important factors when discussing maternal wellness, care, and death in the United States.[43]

Comparisons by state[edit]

In the U.S., hospital bills for maternal healthcare costs over $98 billion, and concerns about the degradation of the maternal resulted in a state-by-state breakdown.

Maternal Mortality by State in 2018[2]
State Status MMR*
California 1 4.5
Massachusetts 2 6.1
Nevada 3 6.2
Colorado 4 11.3
Hawaii 5 11.7
West Virginia 5 11.7
Alabama 7 11.9
Minnesota 8 13.0
Connecticut 9 13.2
Oregon 10 13.7
Delaware 11 14.0
Wisconsin 12 14.3
Washington 13 14.8
Virginia 14 15.6
Maine 15 15.7
North Carolina 16 15.8
Pennsylvania 17 16.3
Illinois 18 16.6
Nebraska 19 16.8
New Hampshire 19 16.8
Utah 19 16.8
Kansas 22 17.7
Iowa 23 17.9
Rhode Island 24 18.3
Arizona 25 18.8
North Dakota 26 18.9
Kentucky 27 19.4
Michigan 27 19.4
Ohio 29 20.3
New York 30 20.6
Idaho 31 21.2
Mississippi 32 22.6
Tennessee 33 23.3
Oklahoma 34 23.4
Maryland 35 23.5
Florida 36 23.8
Montana 37 24.4
Wyoming 38 24.6
New Mexico 39 25.6
South Carolina 40 26.5
South Dakota 41 28.0
Missouri 42 32.6
Texas 43 34.2
Arkansas 44 34.8
New Jersey 45 38.1
Indiana 46 41.4
Louisiana 47 44.8
Georgia 48 46.2

No data on Alaska and Vermont.

*MMR: maternal mortality ratio- number of deaths per 100,000 births.[2]

Comparisons with other countries[edit]

Comparison of the US maternal death rate to the death rate in that of other countries is complicated by the lack of standardization. Some countries do not have a standard method for reporting maternal deaths and some count in statistics death only as a direct result of pregnancy.[44]

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,[45] due to implementing a standardized protocol.[38] In 2010, Amnesty International published a 154-page report on maternal mortality in the United States.[46] 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.[47] 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."[48] By 2015, the United States had a higher MMR than the "Islamic Republic of Iran, Libya and Turkey".[39][49] 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 mortality rate has been rising.[50] The maternal mortality rate in the United States is three times higher than that in neighboring Canada[38] and six times higher than in Scandinavia.[51]

Maternal Mortality Is Rising in the U.S. As It Declines Elsewhere[52][edit]

Deaths per 100,000 live births

Country MMR (deaths per 100,000 live births)
United States 26.4
U.K 9.2
Portugal 9
Germany 9
France 7.8
Canada 7.3
Netherlands 6.7
Spain 5.6
Australia 5.5
Ireland 4.7
Sweden 4.4
Italy 4.2
Denmark 4.2
Finland 3.8

There are many possible reasons to why the United States has a much larger MMR than other developed countries: many hospitals are unprepared for maternal emergencies, 44% maternal-fetal grants do not go towards the health of the mother, and pregnancy complication rates are continually increasing.

See also[edit]

References[edit]

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