Several articles on U.S. maternal mortality rates have popped up over the last month or so, most of them using an NPR report as their primary source. Working conjointly with ProPublica, NPR spent six months conducting an in-depth investigation to uncover why the United States has a maternal mortality rate so much higher than any other developed country and why the U.S. rate has risen steeply since the 1990s while other countries’ rates have declined. Let’s see what they found. I’ll add my opinions as parenthetical remarks as we go.
According to their report, the U.S. statistics are dire. The U.S. maternal mortality rate was 26 per 100,000 as of 2014 vs. 4 to 9 per 100,000 in Canada, Australia, and Western European countries. Every year, 700 to 900 U.S. women die and 65,000 experience a near miss. Nearly half of those deaths are preventable, and while low-income, black, and rural women are at greater risk, no one is immune. The NPR article illustrates this point with the story of a healthy, white neonatal intensive care nurse who died of postpartum HELLP syndrome after giving birth at the hospital where she worked.
What’s at the Root of the Problem?
The article starts with some of the common explanations for why U.S. maternal mortality rates have gone up. Mothers are older, which means they are more likely to have health problems. The overuse of cesarean surgery contributes (largely by increasing the numbers of women with placental attachment complications in subsequent pregnancies). A poorly integrated medical-care system makes it difficult for women to access the care they need, especially if they lack insurance.
The investigative team, though, then argues that something else is at work: “Under the assumption that it had conquered maternal mortality, the American medical system has focused more on fetal and infant safety and survival than on the mother’s health and well-being.” (I don’t think it’s that simple because that shift didn’t happen in other countries despite maternal mortality being much rarer. Subtle and pervasive, I think deep rooted sexism in the American culture is in play, valuing babies over women. Case in point: the U.S. maternity care system views the fetus as a separate patient with needs potentially at odds with the mother’s rather than seeing pregnant women as an indivisible mother-baby dyad, and when perceived conflicts arise, the woman’s rights may be overridden even to the extent of depriving her of autonomy. In evidence of this, see “Do Laboring Women Retain Their Right to Make Medical Decisions about Their Care?” or any number of cases on the National Advocates for Pregnant Women’s website.)
In support of their assertion, the NPR team points first to lopsided funding allocation:
- The federally funded Maternal-Fetal Medicine Units Network, which they describe as the “pre-eminent obstetric research collaborative,” lists only 4 of 34 initiatives targeting mothers while 24 target infants and 4 target both.
- Only 6% of Title V block grants for maternal-child health go to programs for mothers while 78% go to infants and special-needs children.
- At least 20 hospitals have established multidisciplinary centers for high-risk fetuses and children; only one has one for high-risk pregnant women.
- Maternal-fetal medicine specialists can complete their training without once setting foot in a labor & delivery unit.
- Some states cut off Medicaid coverage, which covers the costs of nearly half of all U.S. pregnancies and births, for mothers at 60 days after the birth but cover babies for 1 year. (Texas is one of them, which may partially explain why Texas has a maternal mortality rate of 36 women per 100,000, far exceeding the already unconscionably high national rate of 26 per 100,000. More than half of all Texas births are covered by Medicaid, and 60% of maternal deaths occurred 6 weeks or more after delivery. What happens at the end of the 60 days if a woman can’t afford her anti-depressant or blood pressure medication? Does she even know she’s sick if she can’t afford to see a doctor? It also didn’t help that the state rejected a federally funded expansion of Medicaid that would have covered 1.1 million more women and defunded Planned Parenthood clinics, which provided family planning and women’s health care to large numbers of low-income women.)
The team also points to the contrast in preparedness to handle serious complications in babies compared with their mothers. Hospitals are usually vigilant in monitoring for and well-prepared to manage newborn complications but may be woefully ill-prepared to do the same in women. Staff may fail to recognize the significance of or respond to worrisome symptoms in a timely manner. Even major medical centers may lack standardized policies to address obstetric emergencies, clinician skills may be inadequate, specialists may not be consulted when they should, and care may be poorly coordinated.
Making matters worse, the report continues, maternal deaths in the U.S. are regarded as private tragedies, not systems failures. The U.K., by contrast, has a national program that thoroughly investigates every maternal death, analyzes the data, and publishes reports that can be used to inform maternity care policies. The U.S. has no comparable effort. Maternal mortality reviews are left up to the states. Only 26 states have a well-established process in place with an additional 5 having instituted a process less than a year ago. (Texas has gone backward and chosen not to continue funding maternal mortality reviews.) Even where reviews exist, they aren’t well funded, take years to complete, may not assess how deaths might have been prevented, and little attention is paid to them.
Some efforts are underway to remedy these deficiencies. The report highlights the California Maternal Quality Care Collaborative (CMQCC), which initiated an in-depth analysis of the causes of maternal deaths in California some years ago and used its findings to develop and disseminate “tool kits” hospitals could use to reduce maternal mortality and severe morbidity. The CMQCC has recently evaluated the effects of its toolkit for obstetric hemorrhage. Hospitals adopting its recommended policies and practices saw a 21% reduction in near deaths in women with heavy bleeding versus virtually no change in hospitals that didn’t. Said Dr. Elliott Main, CMQCC’s founder, “Prevention isn’t a magic pill. It’s actually teamwork [and having] a structured, organized, standardized approach.”
The concerted effort to address maternal mortality in California has paid off. As of 2013, the California rate was 7 per 100,000 (vs. 22 per 100,000 nationally that same year and half the rate it was in 2008).
(Standardizing care works well for addressing acute situations but not so well for averting them either because protocol developers are medical-model thinkers, developers must make them palatable to the medical-model practitioners responsible for implementing them, or both. For these reasons, they may not address the extent to which medical-model management precipitates complications or consider the adverse effects of the recommendations to prevent them. Case in point: The only “preventive” action in the CMQCC toolkit for hemorrhage is to administer oxytocin at birth to all women [Main 2017]. Far more effective would be to reduce cesarean surgeries and labor inductions and refrain from high-dose oxytocin protocols when inducing or augmenting labor, all of which are known to predispose to postpartum hemorrhage. Furthermore, routine oxytocin administration at delivery doesn’t reduce severe postpartum bleeding by much in low-risk women—1 fewer transfusion per 100— and it is counterbalanced by 1 more woman per 100 requiring hospital treatment for bleeding complications after discharge [Begley 2010]. What is more, physiologic approaches do better than routine precautionary oxytocin at preventing hemorrhage [Davis 2012; Fahy 2010; Saxton 2015].)
Nonetheless, despite their proven results, disseminating standard protocols remains an uphill battle. According to the NPR report, only half of California hospitals have adopted the toolkits. Dr. Main blames inertia. Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians & Gynecologists (ACOG), says money can be an issue. Because maternal death is so rare, hospitals are reluctant to allocate funding to resources and training for something they don’t see as a problem. The hierarchical organizational structure typical in hospitals may also be a barrier. The maternity nurses’ professional organization developed an initiative to reduce hemorrhage, but efforts to roll it out have had trouble gaining the co-operation of obstetricians in some places. New toolkits being issued by ACOG may meet with greater success. Even if they do, though, according to Institute of Medicine findings, it takes an average of 17 years for a new protocol to be widely adopted. That means women will continue to die who could have been saved for years to come. Grimmer still, the federal government is poised to gut maternal health-care coverage. The report stops short of saying so, but if Texas is any example, results will be calamitous for women in this country with low-income women taking the brunt of the blow.
If you want a hospital birth because you think hospitals have better resources and ability to handle emergencies, make sure that’s actually the case.
- Find out if your hospital has 24/7 obstetric, pediatric, and anesthesia staff on duty and that it has at least a Level II nursery, that is, a nursery capable of caring for newborns with moderate problems and stabilizing sicker babies for transport to a hospital with a neonatal intensive care unit.
- Find out whether your hospital uses standardized protocols to recognize and treat severe maternal as well as newborn complications.
Implement your own preventive measures.
- Ask your care providers what their cesarean rate is in healthy, 1st-time mothers. You’ll have to check with all of them because individual members of group practices can have widely varying statistics. If they hedge, ask for a ballpark figure. If you hear a number much higher than 15%, be concerned. It means that if your care provider recommends a cesarean, you won’t know whether you can trust their judgment.
- Ask your care providers what symptoms in your early days and weeks at home merit follow-up.
- If you go to your hospital’s emergency room because of concerns about bleeding, pain, or symptoms of pre-eclampsia, insist on seeing an obstetrician. Typically, emergency room staff are not trained to distinguish potentially severe pregnancy or postpartum complications from run-of-the-mill complaints.