Commentary: Birthing in America

Did you know, the US has the worst rate of maternal deaths In the developed world — that’s women simply giving birth? Between 1990 and 2015 maternal death rates went up 26.4 percent while our European counterparts dramatically went down.

I don’t know about you, but recent articles in the NYT and USA Today reporting on this issue astonished me. These news agencies document studies indicating what states need to do to save the lives of women in labor and postpartum. The rate of maternal death is shocking and preventable.

Complicated, high-risk deliveries in the US, affect approximately 1 in 10 women. An American woman is three times as likely to die from childbirth as a Canadian and six times as likely as a woman in Scandinavia. This rate is higher for women of color.

A number of variables account for higher maternal mortality in the US: new and/or older women are at higher risk; half of the pregnancies in the US are unplanned with women not addressing health issues, increased C-sections can lead to more life-threatening complications, the “weekend effect” — Baylor College of Medicine analysis of 45 million pregnancies in the US from 2004-2014 found mothers who deliver on Saturday or Sunday have nearly 50 percent higher mortality rates as well as more blood transfusions and more perineal tearing — and better educate women to manage birth and postpartum. The fragmented health system also makes it harder for those without good insurance, to get appropriate care.

In 2011, there were 45 unintended pregnancies for every 1,000 women aged 15-44 in the United States. Specifically, 27% of all pregnancies were “wanted later” and 18% of pregnancies were “unwanted.”

Publicly funded family planning services, such as Planned Parenthood, help women avoid pregnancies they do not want and plan pregnancies they want. In 2014, services helped women avoid 2 million unintended pregnancies, which would likely have resulted in 900,000 births and nearly 700,000 abortions.

The increasing US maternal mortality numbers contrast with impressive progress in saving babies’ lives. Infant mortality in the US has fallen to its lowest point in history. The divergent trends for mothers and babies highlight a theme that emerges in ProPublica’s and NPR’s recent research. Since 2000, under the assumption maternal mortality had been conquered, the American medical system focused on fetal and infant survival versus mother’s health and well-being.

Under Title V, the federal-state program supporting maternal and child health, states devoted about 6% of block grants in 2016 to programs for mothers, compared to 78% for infants and special-needs children.

In 2017, NPR and ProPublica teamed up for a six-month investigation on maternal mortality in the U.S. Among key findings: more American women die of pregnancy-related complications than any other developed country; hospitals —  including those with intensive care units for newborns — can be woefully unprepared for a maternal emergency.

However, California is leading the way to reverse the nationwide trend. Since 2006, California has cut its rate of women dying in childbirth by more than half.

The committee found two well-known complications could be survived if treated properly: hemorrhage and the pregnancy-induced high blood pressure called preeclampsia. All woman are at risk for hemorrhage during delivery. Acknowledging every woman is at risk prepares the birthing team for the worst-case scenario and is key to saving mothers. From 2006 to 2013, the maternal death rate in California fell 55 percent following these protocols.

By standardizing its approach, Britain has also reduced preeclampsia deaths to one in a million — a total of two deaths from 2012 to 2014. In the U.S., on the other hand, preeclampsia still accounts for about 8 percent of maternal deaths —  50 to 70 women a year.

Without standardized care, triggers clearly indicating serious deterioration in the patient’s condition may not be recognized in a timely manner, leading to delays in diagnosis and treatment.

CMQCC Maternal Quality Improvement Toolkits aim to improve the health care response to the leading causes of preventable death among pregnant and postpartum women. Most California hospitals have adopted this standardized care “toolkit’ with a 21 percent decrease in near deaths from maternal bleeding in the first year. By 2013 maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.

OK, so California is again a leader, this time, in decreasing the loss of a woman in childbirth. But my research indicates the increase in maternal deaths continues to rise nationally depending on where you live. This is not just a women’s issue. 

The death of a mother is a tragedy for her family in so many ways. This standard of care needs to be federally addressed by our hospitals and birthing centers nation-wide to benefit women committed to bringing a child into the world.

This issue needs to be at the forefront of local and national candidates. Why is this old problem still an issue today when the trajectory began to go up dramatically before 2000?


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