From the late 1970s through the 1990s, when I worked internationally on women’s health issues, alarm bells sounded regularly about the dramatic and unacceptable rate of maternal mortality in the so-called developing world. Today, those alarm bells are ringing again, but this time because of the rising maternal mortality rate (MMR) here in the U.S.
The MMR is defined as the number of registered maternal deaths due to birth or pregnancy related complications per 100,000 registered live births. Maternal death refers to “the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
In an article published in The New York Times in September, Sabrina Tavernise pointed out that the reduction of maternal mortality worldwide in recent years can rightly be called a public health triumph. In my day, the MMR was extraordinary. An estimated half a million women died annually of preventable pregnancy-related problems. Today that number is thought to be approaching half of that.
But in the U.S. the maternal mortality rate has been rising at an alarming rate. A 2014 report in the Washington Post revealed that maternal deaths related to childbirth had reached its highest rate in a quarter of a century. A woman giving birth then was more likely to die than a woman giving birth in China, one study showed.
At that time, we were one of only eight countries seeing a rise in mortality along with Afghanistan, Greece, and some countries in Africa and Central America. Our MMR was more than double that of Saudi Arabia and more than triple that of the United Kingdom.
Today, “the United States has become an outlier among rich nations in maternal death,” says Sabrina Tavenise. In 2013 there were 28 maternal deaths per 100,000 births, up from 23 in 2005. Recent research shows that the MMR has increased by 27 percent for 48 states and the District of Columbia. In Texas, it has nearly doubled.
“How is it that the United States, a country with some of the most cutting edge medical treatments, has some of the worst maternal mortality rates in the developed world?” Tavenise asked.
The answer is complex. Part of it is that maternal mortality no longer resides in such events as hemorrhage, eclampsia (pregnancy-related high blood pressure) or infection – the three most common causes of maternal death in the developing world. Today, heart problems, diabetes and other chronic medical conditions as well as obesity may be contributing factors. Even record-keeping may have impacted the collection of accurate data until recently when a pregnancy question was added to the U.S. standard death certificate.
One thing is clear, however, and that is that racial disparities play a role, as Dr. Amy Tuteur, a retired OB-GYN who blogs as Skeptical OB, points out. “Maternal mortality is closely tied to race and socio-economic status,” she says. “Often the women most in need of highly technological medical care are failing to get it.”
A sophisticated study carried out in 2016 showed “a significant correlation between state mortality rankings and the percentage of non-Hispanic black women in the delivery population.” While such factors as marital status, number of prenatal visits and C-section rates emerged as factors, the data “strongly suggests that racial disparities in health care availability, access, or utilization by underserved populations” were important indicators. Washington, DC, for example, has the highest maternal mortality ratio in the country but non-Hispanic white patients there have the lowest mortality ratio in the U.S. Clearly “excellent care is available but is not reaching all the people.”
Whatever the reasons, “the rise [in maternal mortality] is real,” as one researcher put it. And as his colleagues concluded, “Clearly at a time when the World Health Organization reports that 157 of 183 countries had decreases in maternal mortality between 2000 and 2013, the U.S. maternal mortality rate is moving in the wrong direction [when] among 31 countries reporting maternal mortality data, the U.S. ranked 30th.”
These findings are not only alarming (and embarrassing) on their face. They also speak loudly to debates about health care, and particularly women’s reproductive health care, swirling around us in this election year. Anyone who cares about health care policy, and/or women, should clearly take note.
Elayne Clift writes about women, health, politics and social issues from Saxtons River, Vt.