Medical Journal Editorial on U.S. Maternal Mortality as a Human Rights Failure
By Rachel Walden — March 21, 2011
The March editorial for the journal Contraception frames rates of maternal mortality in the United States “not just a matter of public health, but a human rights failure.” The authors, from WomanCare Global, AWHONN, and Amnesty International, explain the problem:
The rise of maternal deaths in the United States is historic and worrisome. In 1987, maternal death ratios hit the all-time low of 6.6 deaths per 100,000 live birth. These ratios were essentially maintained for more than a decade. Around 2000, the ratio began to increase and has since nearly doubled, hovering between 12 and 15 deaths per 100,000 live births between 2003 and 2007…’near misses’ (maternal complications so severe the woman nearly died) have also increased by 27% between 1998 and 2005, now affecting approximately 34,000 women a year; and appalling disparities in maternal health outcomes exist between racial and ethnic groups, and among women living in different parts of the United States.
The authors draw attention to troublesome disparities, noting that “for the last 50 years, black women who give birth in the United States have been approximately four times as likely to die as white women,” although they do not seem to have higher rates of medical complications that are common causes of maternal death and hemorrhage. They also note that 25% of white women, 32% of black women and 41% of American Indian and Alaska Native women do not receive adequate prenatal care.
Authors Francine Coeytaux, Debra Bingham, and Nan Strauss explore possible reasons for the increase in maternal mortality, including lack of access to prenatal care, primary care, and insurance, inadequate or poor quality intrapartum care, limited postpartum care, overuse of medical interventions, and a lack of data collection and accountability.
They conclude with a call to action focused on systemic change, rather than smaller interventions in the health of individual women, arguing that “system-level improvements ensuring a uniformly high quality of care are also needed, and these improvements are beyond the control of the individual woman or an individual provider.” Action steps outlined in the piece include initiating, supporting and advancing legislation to reduce maternal mortality through improving care and reducing disparities, expanding data collection and analysis, and investigating more thoroughly why maternal deaths and injuries happen in the U.S. and taking steps to reduce those causes.
This and other editorials from Contraception are freely available online.
The fact that maternal mortality has doubled does not surprise me. I work on a postpartum unit with high risk patients. Most of these patients are over 40 and have co-morbidities already. This places the infant at risk and mother. More women are also having IVF or other assistance in getting pregnant. Being that the body did not want to get pregnant in the first place may have been a protective factor to save the mother from serious injury or death. Going to the clinic is for the sick, pregnant women are not sick and therefore don’t go to their visits. Most women are also dealing with the stress of working, being a mother and wife. All these responsibilities make women put themselves last and therefore their health suffers.
I commend Women’s Care Global, AWHONN, and Amnesty International for shedding light to this issue and I am hoping that the politicians that hear this plea with act appropriately.
I am not surprised by the increase in maternal mortality. I am a PhD prepared researcher in high-risk pregnancy. As I have conducted my research across the past 20+ years and made numerous observations of obstetric care, several things strike me. First, there has been almost no attempt to improve prenatal care by exploring new models that could improve both maternal and fetal outcome. The same model of prenatal care has been used to decades despite evidence that indicates the current model does not work well for minority women and for women with complications. We know such women are at increased risk. They need to be seen earlier in the pregnancy and more frequently to prevent or reduce complications rather than waiting until they occur. “Woman Care” to prevent adverse outcomes of pregnancy also needs to be extended to focus on preventive care that should begin far before a pregnancy. Healthy children lead to healthy childbearing women.
Second there is a continued and increased use of medical interventions to “treat” women with high risk pregnancy that are often un necessary and also not based upon in solid evidence for their effectiveness. For example, we know that maternal risk is increased by at least 50% when a cesarean section is done. Yet, our elective cesarean section continues to rise. Similarly elective inductions are not without risk yet women are offered the option to be induced when there is not indication. There is also a continued use of several physically invasive treatments and treatments with major side effects to prevent preterm birth whose effectiveness has not been demonstrated or is marginal. In addition, these problems are complicated by a general resistance to change among obstetricians which leads to doing to same things year after year without seriously examining the quality of obstetric care. Lastly there appears to be a lack of medical profession leadership in addressing discrepancies in the delivery of quality of obstetric care and in implementing evidence based care.