Why Childbirth Is Still So Risky in the U.S. (And What to Do About It)

The United States has something in common with Afghanistan, Belize, El Salvador, Guinea-Bissau, Greece, Seychelles, and South Sudan: rising maternal mortality ratios—a measure of how many women die from pregnancy-related causes. In the period leading up to the Millennium Development Goals, 157 other countries were able to demonstrate decreases in maternal mortality, but the U.S. did not. Among all the high income countries in the world, the United States falls dead last.

“Even as the Affordable Care Act expands the number of people with insurance protection in the U.S.,” says Lynn Freedman, professor of Population and Family Health and director of Averting Maternal Death and Disability (AMDD), “maternal health and survival data indicate more fundamental issues of health systems access and quality of care.”

Maternal mortality ratio (MMR) is defined as the number of maternal deaths per 100,000 live births. With an MMR of 25, maternal mortality in the United States still a relatively rare occurrence. But it has increased as much as 27 percent between 2000 and 2014—a number that bucks the downward trend seen across most of the world during that same time period.

No Easy Answers

There is no single reason for the increase, says Freedman. A host of complex factors need to be considered, including better data collection, increasing prevalence of pre-existing conditions like diabetes, heart disease, and obesity, as well as the complications that accompany C-sections, whose numbers are on the rise.

Unsurprisingly, maternal mortality is closely tied to issues of race, poverty, and socioeconomic status. Black women are 3 to 4 times more likely to die during childbirth than white women nationally. In New York City, non-Hispanic black women are 12 times more likely to die than white women. Disparities exist within NYC’s boroughs as well: the Bronx has a significantly higher MMR than Manhattan.

These gaps also play out across state lines. Washington D.C., Georgia, New Mexico and Maryland fare much worse than states such as Vermont, Maine, and Massachusetts. Texas, a state at the center of many recent debates around women’s health, has seen its MMR double over the last two years.

Again, no single factor that can explain these disparities in ranking. In some states a single large city accounts for the majority of deaths, whereas in others it is largely the rural poor. Varying Medicaid coverage rates seem to play a role, as do deeper issues of institutional racism and inequitable quality and access to care.

Universal Rights

Globally, there is a growing shift to look beyond the issues of clinical interventions and to address issues of quality of care. The Respectful Maternity Care Movement promotes a charter of the “Universal Rights of Childbearing Women,” developed in response to studies showing women around the world endure disrespectful and abusive treatment at the hands of health care providers. Maltreatment ranges from shouting at or scolding patients and requesting bribes to conducting procedures without consent, physical abuse, or even detaining mothers and babies for failure to pay.

Rather than naming and shaming providers, the movement works to better understand and address the root causes of the problem, finding that providers themselves often feel abused by the larger health care system. AMDD has played a leading role in this movement, including early work with communities and healthcare practitioners in Tanzania to document prevalence and to support their efforts to tackle the problem. Early results show the efforts are paying off, as women’s reports of disrespect and abuse have declined in facilities testing the intervention.

As urgency around MMR in the U.S. grows, Shanon McNab, associate director of AMDD, says the group will bring its global experience to join the fight against mistreatment of women during childbirth in the U.S. too. “Continuous emotional and social support during childbirth has been shown to have several positive effects on the health of both the mother and the child,” she says, “These include shorter labor, decreased incidence of C-sections, and higher levels of reported satisfaction.”

That’s just the beginning.

Experts say better and more complete data on maternal mortality are needed in the U.S. because there is no national standard for reporting maternal deaths. Other strategies include engaging community-based organizations to link women at greatest risk to companions to accompany and support them through the birthing process, and to better understand the numerous social determinants that contribute to poor outcomes for pregnant women and their babies.

“We in public health recognize the connection between individual women’s experience in our healthcare system and the broader social dimensions of sexual and reproductive health,” says Freedman. “And we can make a difference.”