While pregnant with my first child, I remember an alarming phone call from a friend whose wife had just given birth. He was reporting that the baby, though many weeks premature, was doing well, but that his wife was “touch and go” due to a severe childbirth complication that could have claimed her life. She survived, fortunately, but many other new mothers are not as lucky. I also remember my first thought after that phone call: “Wait, women don’t actually still die in childbirth, do they?” This was in 1999, and I naively believed that death in childbirth was mostly a relic of our frontier past, when women gave birth at home, at great distances from doctors, hospitals, and civilization, and without the wonders of modern medicine. I couldn’t have been more wrong.
Maternal mortality rates are rising in the United States, even as they fall in other countries. The US is now the most dangerous place in the developed world to have a baby. Let that sink in: the most dangerous place in the developed world to have a baby. In this column, I’ll discuss the findings of the new USA Today investigation, which places the blame for this problem at the feet of hospitals. But I’ll also discuss the misguided and dangerous policy choices that many states have made, which have contributed mightily to the danger of giving birth in this country.
Maternal Mortality Rates
Maternal mortality is the term used to describe the death of a woman during childbirth or within one year of giving birth in the absence of another known cause. Governments, NGOs, and international entities like the United Nations have expended great efforts to reduce the risk of maternal death across the globe. And on a global scale, these efforts have met with success. According to the World Health Organization, the global rate of maternal death decreased 44 percent between 1990 and 2015. In some regions with particularly high rates, the decreases have been even more substantial. In the United States, however, the rate has actually increased steadily over the last twenty years.
The CDC tracks maternal death using the Pregnancy Mortality Surveillance System, established in 1986, which shows that the rate has increased from 7.2 per 100,000 live births in 1987 to 18 per 100,000 live births in 2014. (A helpful graph and explanation can be found here.) The rates are not even across the nation—with some states showing vastly higher numbers than others. During that same period, rates in other developed nations have fallen. In Germany, for example, the rate per 100,000 live births fell from 20 to just under 10.
What’s behind the numbers is more complicated. Some of the increase might be due to increased reporting or changes in the way deaths are recorded, both of which might inflate the rate without reflecting an increase in actual risk or deaths. But other information suggests that pregnancy and childbirth are, indeed, getting riskier rather than safer in the United States. We have seen, for example, an increase in chronic health conditions like diabetes and high blood pressure, both of which aggravate pregnancy risk.
Pregnancy-related risk is not even across geographical regions, racial groups, or socioeconomic status. For 2011–2014, for example, 40 black women died for every 100,000 who gave birth, compared with only 12.4 white women. The maternal mortality rate also varies considerably state-to-state, with the highest rates in states like Louisiana (58.1), Georgia (48.4), and Indiana (43.6).
Results from the USA Today Investigation
Among women who give birth each year, 50,000 are severely injured, and 700 die. Reporters sought to understand those alarming statistics by reviewing hospital records from dozens of hospitals in three states. In a published report, the reporters documented widespread failures in the medical management of childbirth. The focus of the study is on preventable deaths.
A leading cause of maternal mortality and injury is high blood pressure. Yet, experts estimate 60 percent of deaths related to hypertension could be prevented. The USA Today study notes that the American College of Obstetricians and Gynecologists since 2011 has been warning that high blood pressure can cause maternal death—and gave hospitals and doctors detailed instructions in how and when to treat the condition. Three years later, a coalition of leading medical societies developed another program, called AIM, that categorizes risk into “safety bundles,” each of which provides the tools and instructions necessary to counteract or treat a particular maternal risk. Despite these forms of assistance—and the evidence-based recommendations they reflect—hospitals are failing to implement the protocols in a huge percentage of cases. That appears to be true even at hospitals that function as the primary birthing center for a metropolitan area.
Hemorrhaging is a second leading cause of maternal death and injury. Experts estimate that a whopping 90 percent of deaths from blood loss could be prevented. But, again, most hospitals are failing to consistently take the steps necessary to measure blood loss, which is key to assessing its severity, and to stop it. Care for this condition tends to be spotty and uneven, with unnecessary delays that often result in catastrophe.
Reducing Maternal Mortality: Trial and Error
Several states have convened commissions to study maternal mortality in recent years. When lawmakers follow the recommendations of such commissions, they can be a useful vehicle for reducing preventable maternal deaths. California, for example, put substantial resources into a study of pregnancy-related deaths. The state uses a painstaking process to accurately count pregnancy-related deaths, to understand their likely causes, and to identify potential remedies for future cases. Since undertaking this process, the state has been able to reduce its maternal mortality rate from 14.6 per 100,000 live births in 2003 to 7.3 in 2016. It did this by focusing on specific, evidence-based reforms. Even simple reforms, like making sure hospitals had a hemorrhage cart with all the appropriate medication and devices to stop sudden, uncontrolled bleeding, can save lives. The California reforms also focused on increasing the frequency and quality of prenatal care.
Other state committees and commissions have done similar work and, typically to a lesser degree, instituted relevant reforms. Alabama has managed to reduce its maternal mortality rate by instituting reforms to reduce infant mortality—chief among them by expanding access to prenatal care—and those reforms had the indirect effect of also helping mothers. Texas, in contrast, has studied the problem, but instituted no reforms the evidence might justify.
Maternal Mortality in Context
Maternal death is not an isolated problem. It is a moment in time—potentially a catastrophic one—that is preceded and followed by other aspects of the reproductive cycle. And while hospitals play a significant role in the safety of childbirth, so do lawmakers. There are so many different points at which we can do right, or not do right, by women and their babies. Unfortunately, at many of those points, we have adopted policy preferences that minimize the chance of healthy pregnancy, birth, and childhood. Instead, we should be making choices that do just the opposite. Lawmakers are driven by ideology rather than evidence, and they often prefer short-term cost-savings over expenditures that will reap savings in the long term.
A system that prioritized maternal and infant health would include comprehensive sex education from an early age to give women the information necessary to make informed choices about sex, reproduction, and healthcare. It would ensure access to contraception so women could avoid unwanted or unsafe pregnancy. It would make abortion accessible so women could choose whether to continue an unwanted or unsafe pregnancy to term. It would ensure that pregnant women had access to prenatal care from the first trimester, a proven contributor to safe and healthy pregnancy and birth. It would ensure that pregnant women had access to hospitals within a reasonable distance for childbirth. It would provide access to the health care and social services necessary to recover from childbirth and provide assistance with postpartum depression and any other health condition associated with pregnancy. It would ensure access to infant medical care. And the government should facilitate these goals because they are proven to increase the well-being of its mothers and children. Increasingly, however, we make policy preferences that undermine women’s health—and sometimes actively sabotage it.
By way of example, consider the State of Texas. Texas has one of the highest rates of maternal mortality. Its comparative status is hard to accurately assess because of differences in the definition of mortality used in different studies, but every study places Texas near the top of the list. Texas also has the highest proportion of uninsured individuals in the country and the highest proportion of uninsured adult women (2.4 million total). It has the second lowest income ceiling for Medicaid eligibility and does not permit childless adults to enroll. More women in Texas need subsidized reproductive health care than in any state other than California, yet Texas meets less of the need than most other states.
Moreover, Texas has taken steps to actively dismantle the system that serves the reproductive health needs of low-income women. In 2011, Texas took several steps to cut family planning services and funding, motivated largely by the desire to put Planned Parenthood out of business in Texas. It instituted the Women’s Health Program, which banned Planned Parenthood from participating, even though Planned Parenthood had been serving 4/10 women in the program statewide. The new program violated federal law, causing Texas to lose $9 in federal money for every $1 of state money spent. Texas then reallocated 2/3 of its state family planning budget to other efforts.
Let’s not even talk about its highly restrictive rules on abortion access, which include mandatory counseling, a waiting period, mandatory ultrasounds, a prohibition on telemedicine, and a new law that bans private insurance companies from including abortion care in a policy without a separate rider that charges the full cost of the anticipated care for the insured group. But the ideologues who have erected these barriers to abortion have also supported measures that increase unwanted pregnancy and increase the abortion rate, such as reducing access to comprehensive sex education and family planning services.
Some aspects of sexual and reproductive health are controversial. But keeping women alive during pregnancy and childbirth should not be one of those things. We have a collective responsibility to support programs and interventions that maximize the chances of a healthy start for moms and babies. In this divided era, couldn’t we at least agree on that?