The State of Birth: The Critical Condition of Maternal Health in America

In much of the world, the quality of care for mothers and their babies has improved in recent years. At the start of the century, the United Nations rallied global leaders to make a series of commitments to advance the state of the world. Maternal health was one of the priorities for the Millennium Development Goals. As a result of commitments made on the global stage and initiatives deployed at the local level, maternal mortality fell 44% between 1990 and 2015, more births had skilled health personnel present, and infant mortality was more than halved [1].

But while much of the world has progressed, the United States has fallen backwards. While America spends more per birth than any other country in the world, it is the only developed nation where maternal mortality is on the rise. In fact, expecting mothers in America are 75% more likely to die from complications today than they were at the end of the last century. And the quality of care differs greatly across the country, with families in low-income and high-minority communities suffering the most.

The US ranks 56th out of 224 countries in the world in infant mortality. Share on Twitter.

Simply put, the state of birth in America is dire, and our nation’s mothers deserve better. We need more collaboration across sectors. We need smarter investments in technology to advance access to care. We need better information dissemination to inform the choices of mothers. We need better assessments to adequately measure the quality of care providers. We need commitments from leaders across health care, government, philanthropy, and academia. And we need a national focus on improving the state of birth for all families, in all communities across America.

Simply put, the state of birth in America is dire, and our nation’s mothers deserve better.

This brief outlines where we currently stand, and offers recommendations for how we can move the country forward on maternal health. Just as the Millennium Development Goals delivered for mothers around the world by acknowledging the problem and marshaling stakeholders and resources, it is time for a similar commitment here in the United States. This is our future, and we must act today to deliver better outcomes for our nation’s mothers and babies.

We need a framework for implementing solutions that create a measurable impact on maternal health. Share on Twitter.

We Are Falling Behind And Failing Our Mothers

The United States maternal health ranking is the worst of all developed countries and progress is inconsistent at best. In fact, the United States is the only developed nation where maternal mortality is on the rise, with pregnancy-related deaths nearly doubling from 7.2 deaths per 100,000 live births in 1987 to 14 deaths per 100,000 in 2015. Also not captured in the mortality rate is the more than 60,000 women per year that have near-death experiences during pregnancy or childbirth — one mother every ten minutes [2].

The United States is the only developed nation where maternal mortality is on the rise. Share on Twitter.

Compared to all other countries, the United States ranks 46th worldwide in maternal mortality, and 56th in infant mortality [3]. With a maternal mortality rate of 14 per 100,000 live births, women in the United States are over three times more likely to die during childbirth than women in Italy and twice as likely as women in Belgium or Canada.

Additional facts on maternal health in the United States include:

  • Nearly half of all births nationwide — 1.8 million — are financed by Medicaid [4]
  • Thirty-three percent of women in the United States deliver via cesarean section, more than double the World Health Organization’s recommendations, resulting in unnecessarily traumatic birth experiences [5]
  • There are slightly fewer than 4 million births per year in the USA [6]
  • 98.5% of all births occur in hospitals [7]
  • 38,094 births occurred at home, which may not seem like many, but is the highest since 1989, when this statistic was first collected [8]
  • In 2013, certified nurse midwives and certified midwives were present at 12% of all vaginal births and 8.2% of all births [9]. In the UK, midwives handled 88.6% of spontaneous deliveries and 55.6% of all births [10]
With a maternal mortality rate of 14 per 100,000 live births, women in the United States are over three times more likely to die during childbirth than women in Italy and twice as likely as women in Belgium or Canada.

How Maternal Health Impacts a Baby’s Future Health

An unhealthy or complicated birth has repercussions beyond the birth experience. It is the foundation upon which this child will begin her life. The health of the mother has a direct correlation with her pregnancy experience and future health of her child. This is true for a variety of infections that can be passed from the mother to the baby. For now, however, we will focus on the intergenerational transfer of more chronic conditions (i.e. obesity, hypertension, and diabetes), a relationship which is less intuitive and not carried through the bloodstream.

For example, children born to obese mothers have a greater chance of being born early and of developing obesity and hypertension themselves [11]. In fact, a mother’s obesity more than doubles the risk of her child being obese by the time the child is two years old [12]. Other studies have shown that the main risk factors for becoming obese by seven years old are parental obesity, birth weight, and weight gain in the first year of life [13]. Additionally, children of mothers who had gestational diabetes are more likely to grow up to be obese and to have greater insulin resistance [14]. While yet to be conclusively studied, this data suggests a generational cycle in which daughters of obese mothers are more likely to grow up to become obese themselves, further repeating this cycle when they have children of their own [15].

Obesity is not the only maternal condition to affect the fetus. When a mother has hypertension, or in its more extreme form, preeclampsia, there is a risk that the placenta may fail to develop properly, leading to something called utero-placental vascular insufficiency. When this happens, the fetus receives less nutrition than otherwise and is forced to adapt, forever altering its metabolism and structure. This may lead to future complications, such as coronary heart disease, stroke, diabetes, or hypertension [16]. Like obesity, the child of a mother with hypertension is more likely to grow up to become hypertensive themselves.

Approximately one in every ten babies is born prematurely.

A mother with obesity, hypertension, or diabetes is also more likely to deliver a baby before term. Delivering a baby before term interrupts the developmental processes that occur within the womb and has varying levels of complication, depending on the how early the delivery is. Approximately one in every ten babies is born prematurely (before 37 weeks), which can result in both physical and intellectual disabilities, as well as long term respiratory and intestinal complications [17]. Research has shown that even children born as late as the 38th week are more likely to experience cognitive deficits compared to those born in the 40th week [18].

Disparity across Health Outcomes

A child’s future health is not only a product of the mother’s health and genetic predisposition. The well-being of an infant is also a result of the care that the mother in afforded, the family’s socioeconomic status, and the infant’s environment after birth. Too often, a mother’s zip code determines her access to nutrition, education, and quality medical services.

33% of women in the US deliver via cesarean section, more than double the World Health Organization’s recommendations. Share on Twitter.

As in so many social services, across the country, maternal health strongly correlates with income. For example, states with poverty rates greater than 18 percent have a 77 percent greater risk of maternal mortality than wealthier states[19]. With an infant mortality rate of 9.6 per 1,000 live births [20], Mississippi is faring worse than both Botswana (8.93) and Bahrain (9.35) [21]. The quality of care also differs greatly between communities of different race and ethnicities. Between 2011 and 2012, there were 11.8 deaths per 100,000 live births for white women, 41.1 deaths per 100,000 live births for black women, and 15.7 deaths per 100,000 live births for women of other races [22].

With an infant mortality rate of 9.6 per 1,000 live births, Mississippi is faring worse than both Botswana (8.93) and Bahrain (9.35 ).

A study of hospitals by the population they serve, found that most black mothers deliver their children in a concentrated set of hospitals — hospitals with higher maternal mortality rates [23]. These differences in care affect not only the outcome of the mother, but also the baby. In 2013, the fetal death rate was 6.0 deaths per 1,000 live births. For black babies it was 11.11 per 1000, more than twice that of white babies, which was 5.06 per 1000 [24]. This disparity in maternal health demands not just broader collaboration, but also, more targeted investment to deliver better care to high-need communities.

How Did We Get Here: A Social and Biomedical Reality

The state of maternal health is a multidimensional problem lacking a single cause, but with many developed theories to explain the poor performance of the United States. While there are certainly medical reasons to explain the high rate of maternal mortality, such as rising obesity rates and the increased reliance on C-sections, many of the causes are social in nature. It is difficult to medically explain why black women have poorer outcomes than other races. However, when looking at the social determinants of health, it becomes a bit more clear. For example, we know stress is bad for both the mother and baby and that black women experience very different stresses than other racial groups.

Unfortunately, when advancements are made, they are not being disseminated in an impactful way. Research and innovation is often created within silos and fail to reach a broader audience. Crouse Hospital in Syracuse, New York has a c-section rate of 15 percent [25], half the national average. It is important for other hospitals to understand how Crouse reached these low rates. But the lack of coordination occurs even within city lines. At the University of Chicago Medical Center, 30 percent of low-risk pregnancies result in a c-section, while just 10 miles away at Northwestern Memorial Hospital, that figure is only 17 percent [26]. Best practices need to be identified, concretized, and shared widely.

Some of the most innovative interventions targeting maternal health may not even be medical in nature. For example, recent research has found a correlation between rates of stillbirth and ambient air pollution, which could be addressed through changes in environmental policy and innovation [27]. More widespread illnesses amongst women are having an impact on labor and delivery patterns.

The passage of the Affordable Care Act has provided pregnant women with greater access to coverage, providing access to prenatal appointments and screening to best help them prepare for birth. Furthermore, the increased access of care for non-pregnant women may even provide additional benefits in the future. Earlier access to insurance and care can help women identify any medical conditions earlier, equipping them with tools and knowledge to mitigate complications proactively.

However, lack of insurance is just one aspect of a multidimensional problem. It will not help a mother to avoid a c-section, nor will it standardize care across hospitals.

Birth Reborn: Connecting the Dots

Maternal mortality transcends geography and demography. Tackling this issue will require innovative coordinating efforts from parties both within and outside of the medical sector. There needs to be a focus on both population health and individual health. This includes interventions on both the systems and individual level that focus not only on crisis management but also prevention. Any efforts to improve maternal health must address both the overall health of the population and also the disparities within it.

Recommendations include:

  1. Establish national standards for maternal health care. We need a national benchmark and metrics that detail when and why a c-section is necessary, as well as other interventions that might occur. There is no reason that c-section rates should vary so much across the hospitals.
  2. Document and distribute ratings for both care providers and facilities. These ratings will be based on both patient outcomes and overall experiences and will help patients to manage their expectations and prepare for a birth.
  3. Encourage every woman to create a birth plan. Given the current state of birth, where women often feel disempowered and pressured, every expecting mother should be given the opportunity to create a birth plan in coordination and with the support of her care provider. These birth plans must provide insight on the impact of various choices, and be accepted and used by care providers.
  4. Foster local city programming with perinatal community health care workers to address c-section and preterm birth rates as well as access to health resources. Significant research shows how auxiliary care, such as doula support, helps decrease poor maternal and infant health outcomes, improves satisfaction with the care process, and helps to reduce the existent health disparities.
  5. Ensure mothers have easy access to evidence-based information. There is an over saturation of information right now available to pregnant women. Sifting through it all for the best evidence-based recommendations can be a full time job, but a mother shouldn’t need a PhD to have a healthy birth. Self-efficacy is developed through confidence, and confidence is a derivative of education.

These recommendations, coupled with a national awareness of the gravity of our maternal health challenges and a commitment at all levels and across all communities, will help ensure that we can finally improve the state of birth for all families in America.

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Sources

[1] WHO (2015) The Millennium Development Goals Report 2015

[2] Callaghan, W. M., Creanga, A. A., & Kuklina, E. V. (2012). Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstetrics and Gynecology.

[3] The World Factbook 2016–17. Washington, DC: Central Intelligence Agency, 2016.

[4] Fowler, T. T., Schiff, J., Applegate, M. S., Griffith, K., & Fairbrother, G. L. (2014). Early elective deliveries accounted for nearly 9 percent of births paid for by Medicaid. Health Affairs, 33(12), 2170–2178.

[5] WHO, UNICEF, UNFPA, World Bank (2015). Trends in Maternal Mortality 1990–2015.

[6] Hamilton B.E., Martin J.A., Osterman M.J.K., et al. (2010) Births: Final data for 2008. National vital statistics reports; vol 59 no 1. Hyattsville, MD: National Center for Health Statistics.

[7] Ibid.

[8] Ibid.

[9] American College of Nurse-Midwives. (2015) Fact Sheet: CNM/CM-attended Birth Statistics in the United States. http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000005464/CNM-CMAttendedBirthStatisticsJune2015.pdf

[10] Hospital Episode Statistics Analysis, Health and Social Care Information Centre (2015) Hospital Episode Statistics NHS Maternity Statistics — England, 2013–14 http://www.hscic.gov.uk/catalogue/PUB16725/nhs-mate-eng-2013-14-summ-repo-rep.pdf

[11] Leddy, M. A., Power, M. L., & Schulkin, J. (2008). The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol, 1(4), 170–178.

[12] Oken, E., Taveras, E. M., Kleinman, K. P., Rich-Edwards, J. W., & Gillman, M. W. (2007). Gestational weight gain and child adiposity at age 3 years. American journal of obstetrics and gynecology, 196(4), 322-e1.

[13] Reilly, J. J., Armstrong, J., Dorosty, A. R., Emmett, P. M., Ness, A., Rogers, I., … & Sherriff, A. (2005). Early life risk factors for obesity in childhood: cohort study. Bmj, 330(7504), 1357

[14] Catalano, P. M. (2010). The impact of gestational diabetes and maternal obesity on the mother and her offspring. Journal of developmental origins of health and disease, 1(04), 208–215

[15] Dabelea, D., & Crume, T. (2011). Maternal environment and the transgenerational cycle of obesity and diabetes. Diabetes, 60(7), 1849–1855.

[16] Lapidus, Alicia M. (1999) Effects of preeclampsia on the mother, fetus and child. Gynaecology Focum 4(1)

[17] Long-term health effects of premature birth. (2013, October ). Retrieved June 13, 2016, from March of Dimes, http://www.marchofdimes.org/complications/long-term-health-effects-of-premature-birth.aspx

[18] Chan, E., Leong, P., Malouf, R., & Quigley, M. A. (2016). Long‐term cognitive and school outcomes of late‐preterm and early‐term births: a systematic review. Child: care, health and development.

[19] Delivery, D. (2010). The Maternal Health Care Crisis in the USA. London: Amnesty International.

[20] Mathews, TJ, MacDorman, MF, Thoma, ME (Aug 2015) Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set National vital statistics reports; vol 64 no 9. Hyattsville, MD: National Center for Health Statistics.

[21] The World Factbook 2016–17. Washington, DC: Central Intelligence Agency, 2016

[22] CDC. “Pregnancy Mortality Surveillance System.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 21 Jan. 2016. Web. 23 Jan. 2016.

[23] Howell, E. A., Egorova, N., Balbierz, A., Zeitlin, J., & Hebert, P. L. (2016). Black-white differences in severe maternal morbidity and site of care.American journal of obstetrics and gynecology, 214(1), 122-e1.

[24] Lorenz, J. M., Ananth, C. V., Polin, R. A., & D’Alton, M. E. (2016). Infant mortality in the United States. Journal of Perinatology.

[25] Haelle, T. (2016, April 14). Your biggest c-section risk may be your hospital. Retrieved June 13, 2016, from Consumer Reports, http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

[26] Ibid.

[27] Siddika, N., Balogun, H. A., Amegah, A. K., & Jaakkola, J. J. (2016). Prenatal ambient air pollution exposure and the risk of stillbirth: systematic review and meta-analysis of the empirical evidence. Occupational and environmental medicine, oemed-2015.