Opinion: The U.S. maternal mortality crisis and how we can fix it

As we go into the 2020 election season, many issues are on every voter’s mind, but there is one which — although much less controversial — deserves a little more spotlight. 

In the United States, women face an elevated risk of dying during pregnancy. The United States ranks 46th in maternal mortality, behind countries like Saudi Arabia and Kazakhstan, according to CBS News. This means a mother giving birth in the U.S. is about three times as likely to die as one in Britain and Canada, according to NPR.

According to CBS, “the U.S. is the only industrialized country where the rates of maternal deaths have increased, not decreased.”

Indeed, the rate of women nearly dying almost tripled between 1993 and 2014, according to the CDC, meaning mothers today are more likely to die during pregnancy than their own mothers were.

For each woman who dies in childbirth, 70 nearly die, with a total of 50,000 women who suffer “severe maternal morbidity” from childbirth each year. 

“An experience that we would hope and expect would be natural, beautiful, uplifting, becomes one that’s terrifying,” obstetrician Peter Bernstein, the director of the Maternal-Fetal Medicine division at Montefiore Medical Center in New York told NPR. 

These complications can unsurprisingly cause physical, emotional, and financial stress upon a mother during an already exhausting process.

So what has caused this maternal mortality crisis? For one, American women are giving birth at older ages and are more likely to have problematic conditions like obesity, high blood pressure and diabetes, according to NPR.

But some medical professionals say the real problem is how babies are delivered. More women are opting for C-sections over vaginal deliveries, possibly due to concerns about their future sex life and the idea that a cesarean is safer. 

But according to The Lancet, “In cases where cesarean sections aren’t truly medically necessary, there are no health benefits for moms and only potential harms. The risk of maternal death and disability is higher after the procedure, recovery tends to be longer, and there’s a greater chance of complications in future births.” 

Nonetheless, the C-section rate in the U.S. increased by 60% between 1996 to 2011 and is now more than double the World Health Organization’s recommended range of 5% to 15% at 33%, according to Amnesty International.

Meanwhile, obstetricians might have underlying motivations to allow or encourage their patients to receive C-sections even if they are not necessary. For example, obstetricians in many medical settings might be paid more for C-sections.

In a new working paper published by the National Bureau of Economic Research, health care economists Erin Johnson and M. Marit Rehavi calculated that doctors might make a few hundred dollars more for a C-section compared to a vaginal delivery, and a hospital might make a few thousand dollars more. Furthermore, doctors’ fears of being sued, which is more likely for vaginal deliveries, might also be a factor.

In addition, a decline of obstetric services in rural America could also play a factor. 

“When the natural birth movement took hold in the 1980s, hospitals got on the bandwagon because there was competition for deliveries, and women are loyal to the hospitals they give birth in and control many of the healthcare decisions of the family,” nurse-midwife Linda Robinson said in her TED Talk. “But when insurance reimbursement changed, maternity care became more costly for hospitals with low volume, and many in rural areas eliminated those services.”

As a result, more than half of the nation’s rural counties no longer have hospital obstetric services, and 9 percent of them lost those services between 2004 and 2014. 

Furthermore, it would appear that we fail to provide mothers with support after they give birth. This is because, according to Harvard Public Health, “Once a baby is born, he or she becomes the focus of medical attention. Mothers are monitored less, their concerns are often dismissed, and they tend to be sent home without adequate information about potentially concerning symptoms.” 

“Women are sent out of the hospital two days after they’ve delivered and basically told to wait for a six-week postpartum check, which is useless to them, given that most of the postpartum concerns, the morbidity and the mortality, occurs within the first couple of weeks after the baby’s born,” midwife Jenny Joseph said.

It is for this reason that “the overwhelming majority of deaths happen in the period surrounding the birth, including pregnancy and until the infant is one,” not during the delivery itself.

This also might explain why African American women are three to four times more likely to die during or after delivery than are white women. 

“[W]hen black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less,” said Neel Shah, an obstetrician-gynecologist, according to Harvard. “It’s forced me to think more deeply about my own approach. There is a very fine line between clinical intuition and unconscious bias.”

It’s become apparent that there is an urgent problem at hand, but fortunately, there is hope that the rest of the country could take after a recent outlier in maternal mortality: California. While the rest of the US’ rate increased between 2006 and 2013, California’s actually decreased by 55% according to the state Department of Public Health. 

The state did so by ensuring the availability of emergency hemorrhage toolkits, training doctors and nurses how to address specific conditions which commonly cause pregnancy-related deaths, and disclosing to mothers the full risks of C-sections. Most importantly, they constantly reviewed and adapted their strategies using data collected and analyzed statewide in the Maternal Data Center. Adopting similar strategies might prove helpful for the rest of the country in reversing their own upward trends maternal mortality. 

According to the CDC, 60% of the deaths in the United States are preventable according to the CDC. That means that there are many mothers who could have been here today to care for their children who aren’t, but it also means that future deaths are not inevitable. We are not helpless in this crisis, but much work still needs to be done. For more information about how the 2020 candidates seek to combat this issue, read more here.