The CDC recently released data on the maternal mortality rate in the United States. The numbers show the rate at which women die during pregnancy, childbirth, or up to 42 days after — and they are incredibly alarming.
The study revealed that in 2018, there were 17.4 maternal deaths for every 100,000 births, which equals 658 women. This puts the United States at worst when compared with 10 countries with similar levels of wealth and on par with some third world countries.
While this data is alarming in and of itself, perhaps the most alarming data shows itself in the disparity of who dies and who lives when giving birth. Black women die at double the rate of white women: 37.1 black women die per 100,000 births and 14.7 white women die per 100,000 births. The numbers for Native women, American Indian, and Alaskan Native women are also alarming. .
“Native women, American Indian, and Alaskan Native women are dying at a much higher rate as well,” says Jennifer Jacoby, Federal Policy Council at the Center for Reproductive Rights, an international legal organization that aims to advance the rights of women and moms across the world. “They’re about two times more likely than white women to die from preventable, pregnancy-related complications.”
The maternal mortality rate also worsens as women age, meaning that women who give birth after 40 are 7.7 times more likely to die compared to those under 25. Women aged 25-39 died at a rate of 16.6 deaths per 100,000 births and women under 25 died the least often, at a rate of 10.6 deaths per 100,000 births.
At first glance, much of this follows reporting that has been done over the past few decades — especially reporting on the the high maternal mortality rate for black women, which has been well known. But this data, at points, raises more questions than answers, largely about the healthcare system that appears to be failing modern women giving birth. For instance, one report estimated that 90 percent of hemorrhage-related deaths are preventable. That same report estimated that so are the 60 percent of deaths due to high blood pressure. If three in five of all total deaths due to pregnancy or childbirth are preventable, it stands to reason that many of the women who die, die of these causes.
Looking at the big picture, it’s clear that it’s a failure of the medical system at large — not a failure on the women who give birth or the single doctors who make medical decisions about them. Women are being failed on several levels, with disastrous effects.
A Lack of Standardized Care
The high mortality rate of women giving birth in the U.S. is a complex, multi-layered issue, not one that can be boiled down to a single policy consideration or a problem at the point of care. One major problem, however, is that pregnancy care varies depending on which state government and state Medicaid plan moms live under.
This matters because more and more women who give birth are on Medicaid. Some states might have excellent birth and pregnancy protocols, while others might not. As every state has its own care plan, this more or less means that there is no national standard for maternal care in the United States. There are many, many different standards, which leads to many different levels and standards of care in hospitals, in between hospitals, and across state lines.
One leading cause of maternal mortality is postpartum hemorrhage. Postpartum hemorrhage is essentially when a woman has heavy bleeding after giving birth — and it can happen the day that a woman gives birth, but also up to 12 weeks after having a baby, well beyond when most Medicaid coverage plans for pregnant women lapse (most end at 60 days postpartum.) Women do not have to be ‘at risk’ to hemorrhage, which can lead to it not being caught until it’s too late. About 1 to 5 percent of women who have babies have postpartum hemorrhage, and although it is extremely preventable, saving women who are going through it is largely a matter of time — meaning that the quicker that a mom gets treatment, the more likely she is to survive.
There are plenty of steps that doctors can take if they suspect a mom giving birth is losing too much blood, including counting the amount of blood that a mom is losing to begin with, which is not a given. But 40 percent of maternity hospitals that answered one USA Today investigation said they were not quantifying blood loss during and after every birth, despite the fact that counting blood is a standard practice in major medical events and for birth in other countries and can allow doctors to step in to take next steps if they suspect a mom might be losing too much blood, like calling in blood from the blood bank to thaw.
This alone might help save many women from dying from hemorrhage before it’s too late to save them. (One study published in 2018 listed hemorrhage, alongside cardiovascular conditions and infection, as half of all maternal-mortality rate of deaths in the United States; the vast majority of these are preventable.) Want proof? Just look at the United Kingdom. It has a regularly updated toolkit and standardized checklist set by the Royal College of Obstetricians and Gynecologists for OBs and nurses to follow. This includes quantifying blood loss. Since these tool kits were enacted in the U.K., the rate of deaths due to hemorrhage has plummeted to 6.5 percent of maternal deaths and the maternal mortality rate is a third of that of the United States. Nearly every death in childbirth in the U.K. is investigated — while only 26 states in the United States have standards for reviewing maternal mortality.
Another major issue is that many OBs haven’t actually dealt with a high-risk birth, as they are still a statistically rare event. Many births happen in hospitals that see between 500 to 1,000 births per year. This means that many OB’s working in medium-sized or small hospitals have never dealt with a crisis situation. Compound small hospitals that haven’t dealt with something like preeclampsia or hemorrhage with a lack of a national federal guideline and, of course, many women fall through the cracks.
When it comes to blood, there tends to be a hierarchy of priorities in hospitals. The OB ward is often not at the top of the priority list when it comes to receiving blood, because, again, complicated births are statistically rare. If blood is needed, it needs to be thawed, which takes time. If the blood loss of a woman giving birth is not tracked, and the OB ward is not on the priority list for blood, and then a woman has to wait to get the blood she needs, hemorrhage-related death is a distinct possibility.
It’s a problem of culture, then, of hospitals and providers largely experience births that are, well, normal. Without a mandated reporting system of the births that go wrong, be it through death or major injury to the mom, many hospitals can’t effectively learn from their mistakes or put systems in place that would stem the hemorrhage, infection, and cardiovascular disease and blood-pressure related deaths that account for about half of all maternal deaths and are, by all accounts, preventable.
But only 26 states in the U.S. have an established committee to review maternal deaths. Since hospitals often don’t have a standard for responding to emergencies, women die. Even if they do, the level of care a mom could receive varies depending on doctors and hospitals and states.
The Issue of Mom Bias
Beyond the lack of standardized care — and a lack of OB experience dealing with abnormal births — there is the fact that implicit and explicit bias affects the level of care that moms receive.
“Why is this happening?” asks Jacoby. “The answer, I 100-percent believe, is structural racism. The history of oppression, gender oppression, and racism in these communities lives in our healthcare system. We can’t avoid that.”
Many doctors have implicit biases. Studies have shown that women’s pain, and in particular, black women’s pain, is taken less seriously by doctors and nurses and not investigated as often as male patients. This can lead to preventable death or near-death experiences. Another major reason that the disparate rates of maternal mortality are so extreme across race is because but in the United States, black women are more likely to be poorer and have a lack of consistent access to health insurance before and after pregnancy.
Bias, stereotyping, a lack of consistent prenatal health care, and entering pregnancy less healthy than richer women can have a major effect on how women are treated — and for a long time, the blame was shunted onto patients, not the doctors themselves.
As a whole, people in the United States have been getting progressively unhealthier. It stands to reason that the population of pregnant women would be no different. For much of human history, the majority of women giving birth were younger and healthier than they are today. Women enter pregnancy today more often overweight and with pre-existing conditions, and at later ages. Half of all women who give birth every year are on Medicaid and are women of color.
Has the quality of care and resources been allocated correctly to deal with the fact that more women entering pregnancy are poor, might not have access to a full suite of prenatal health care services, only have health insurance for up to 60 days after birth, and are more likely overweight and therefore more likely to experience comorbidities in birth? Not exactly. Research shows that hospitals are more likely to blame patients when birth goes wrong, not their approach to birthing and follow-up in general.
The C-Section Problem
There’s also the fact that Cesarean-sections are increasing in regularity in the United States. One third of babies born every day are born via C-section. If the baby has turned over during labor, or if a woman has placenta previa, a condition that could cause hemorrhaging, the procedure is mandatory. But c-sections are also riskier than vaginal births, with a higher chance of blood loss, infection, and blood clots in recovery. These are all preventable concerns that are known to kill women in childbirth. In fact, a 2007 study found 40 percent of first-time moms aged 40-44 — otherwise known as the cohort that is 7.7 times more likely to die in childbirth — had C-sections.
So, older moms have c-sections more often than younger moms and older moms who have c-sections are also four times more likely to have complications after birth than women their age who deliver vaginally. Why, then, do physicians give older moms more c-sections? At least one explanation is that doctors make more money by doing c-sections. C-sections also tend to peak at certain times of the day, like near lunchtime. But much of the picture is still unclear, given that many studies on c-sections don’t record the weight of the mother or whether they had conceived through IVF or another similar procedure, which can increase the risk of pregnancy complications.
Even after a normal birth, new moms don’t need to see a doctor for up to six weeks after a normal birth or two weeks after a c-section or a complicated birth.
“You have to go take your baby to the pediatrician two days after you leave the hospital,’ says Jacoby. “There’s a one-week [check-up], two week, one month. You’re constantly checking on the baby. But the mom is thrown out after delivery, which is actually compounding the issue. Things like high blood pressure or blood clots are just not being caught, because you’re not getting screened for it.”
The Maternal Age Issue
The age disparity in maternal mortality is, on paper, quite astounding. That a woman over 40 is 7.7 times more likely to die than a woman under 25 is shocking on its own. But the fact actually obscures a far greater crisis — women in their 30s are having more babies than they had since the 1960s. In a handful of states, they account for the majority of births. The age range in which most women who are dying the most are those who are most commonly giving birth.
That does not blow away the severity of the fact that moms 40 and up are dying from preventable issues in the delivery room or in postpartum care. In fact, it can make this fact more alarming: if more women choose to have babies later, it stands to reason that the maternal mortality crisis — and the rate of pregnancies that occur at “advanced maternal age” — could worsen, unless hospitals or the federal government enacts a handful of best practices and standards. After all, more women over 40 are getting pregnant. Women aged 40 to 44 in 2017 had almost 115,000 of the 3.8 million babies born that year.
What The Data Doesn’t Show About Maternal Mortality
There are a lot of question marks when it comes to the maternal mortality rate in the United States. So much so that many experts suggest that cutting data collection off at 42 days is far too soon.
“What would be more helpful is to [collect data] up to one year,” says Jacoby. “Most women and birthing people are dying in the fourth trimester, from delivery up to one year. That’s when things tend to happen.” Plus, what’s considered incidental data, like death by suicide, domestic violence, or intimate partner violence after pregnancy, is not necessarily captured in the CDC findings. Suicide, for example, is important because maternal mortality is not just about physical health, but about the mental health of women who have given birth. And when women who are in abusive relationships get pregnant, statistics show that abuse can get worse during or after pregnancy.
There’s also the fact that reporting data on maternal mortality takes a very long time. The CDC’s data, which accounts for all known maternal deaths in 2018, took nearly two years to clean up and report. Some reports on the state level take years to be released after data is captured, due to reasonable concerns about patient privacy and more. And not all states have the same reporting requirements. What might be required to report in California — or who might be considered to have died from a maternal health complication — might not be the same in Texas, for example, creating a fuzzy picture on how and why women die.
With a problem that has so many causes, it’s hard to imagine that there could be a single solution. There isn’t. Too many women are dying preventable deaths. Too many of those women are women of color, and too many of them are older. What it looks like is that the women who are dying the most often are those who are most often giving birth — and that OB’s have so far been unprepared to deal with an aging population that might not be as healthy as they once were, if not because they’re older, then because more moms lack consistent access to health care, too. But pregnant women are just like any other part of the population. And if the populace is slightly less healthy (or underinsured) that means that the birthing population will also be slightly less healthy (and underinsured). What that doesn’t mean is that moms should die. It means that doctors, hospitals, federal guidelines, and reporting systems must align for transparency and accurate data. According to Jacoby, there are steps that can be taken to save these lives.
“What’s top of mind for us is holding health care systems accountable for discriminatory care,” she says. For the CFRR, that means that hospitals should be required to take implicit and explicit bias training for employees who work at the intake desk to surgeons in the back rooms. Increasing postpartum visits to ensure that all people who give birth have to go in to their doctor within a week of giving birth would catch troubling conditions earlier and help stem preventable death.
Extending Medicaid coverage for pregnant women would also help save the lives of new moms. Currently, Medicaid covers pregnant women for up to 60 days after their pregnancy — but many policy experts and health experts suggest that extending coverage to up to a year after childbirth, what Jacoby referred to as the “fourth-trimester.” States like Tennessee have recognized the need to do this and are attempting to extend coverage on the state-level.
As maternal mortality is not something that happens in equal rates, at the same rate at hospitals across the country, and doesn’t impact the same populations to the same degree, another policy lever that could help end the crisis would be to pour funding and training and support systems into communities that are most impacted by the maternal mortality crisis. This could be done by working with community based health care workers such as doulas and midwives, who are shown to help, in particular, black women navigate the healthcare system and have positive impacts on birth outcomes.
Jacoby also suggests that addressing maternal mental health — whether it be Postpartum depression (PPD) related or about substance abuse in new moms — would help prevent deaths. Otherwise, things are going to worsen.
“This is, like I said, not about health insurance, or access to health insurance,” says Jacoby. “It’s a factor but it’s not everything. It’s not about education. It’s not about even being able to speak up for yourself. There’s something going on.”