Maternal Mortality in the United States — A Skewed Scenario
Many of us have heard the phrase “Money can buy health, but not happiness.” Maternal health in the United States proves to be an exception to this idea. Despite high spending on healthcare, the U.S. still has one of the highest rates of maternal mortality in the developed world, with too many mothers — and especially black mothers — dying from preventable pregnancy complications. Tennis star Serena Williams’s painful experience of her daughter’s birth early this year is a testament to the ordeal that many mothers go through every year in the U.S., and the fact that money does not always translate into dignified healthcare.
According to a 2016 estimate, the U.S. spends about 17.8 percent of its Gross Domestic Product on healthcare, a figure significantly higher compared to other high-income countries. The U.S. also spends the highest amount on hospital-based maternity care but the returns do not meet expectations. The maternal mortality ratio (MMR) in the U.S. worsened from 1990 to 2015 from 17 to 26 deaths per 100,000 live births-an undesirable increase of 35%. MMR is a measure of the number of women who die while pregnant or within 42 days of the termination of their pregnancy due to pregnancy-related issues.
Why are mothers dying from preventable causes in the U.S. despite living in a country with seemingly adequate resources to protect them? The World Health Organization highlights three reasons for high and increasing maternal mortality in the U.S. First and surprisingly, there are no uniform standards across the U.S. for managing obstetric care and emergencies, resulting in a late diagnosis of health complications both for the mother and the infant. Secondly, many mothers have pre-existing chronic conditions such as obesity, diabetes, and hypertension, which complicate pregnancy and, in the absence of proper care management, put a mother’s life at risk. On top of these issues, the lack of insurance coverage can be a serious barrier for an expecting mother to seek healthcare. And lastly, the absence of proper data surveillance prevents us from obtaining a complete picture of the maternal health sphere and identifying areas in dire need of intervention.
In addition to the aforementioned factors, in the U.S. context, racial disparities define discussions around maternal mortality. Black mothers are disproportionately impacted by high MMR figures, with rates for black mothers recorded at four times higher than for white women: 42 deaths per 100,000 births compared to 12 deaths per 100,000 births. Across the nation, states with high rates of maternal mortality are directly correlated with the percentage of the population that identifies as black.
Maternal health metrics in the state of New Jersey, where I currently work as a Global Health Corps fellow at a local nonprofit, align with these national trends. According to a report on the New Jersey Department of Health’s website, between 2009 and 2013, while 44 percent of the state’s deliveries were attributed to white mothers and 13 percent to black mothers, 46 percent of pregnancy-related maternal deaths were attributed to black mothers and 27 percent to white mothers. This persistent gap is an indication of the disproportionate suffering of black mothers. In fact, the MMR for black women in New Jersey is a striking 80 deaths per 100,000 live births, a rate higher than many developing regions in the world.
The reasons for poor health outcomes amongst black mothers are usually separated into two major categories: socio-economic factors and individual behaviors. In New Jersey, data shows that women of reproductive age between 18 to 44 years are the largest segment of the population that lives in poverty. About 67 percent of black non-Hispanic mothers have an annual household income level in the range of $0-$37,000. This means that many do not have the monetary means to seek prenatal care, which can lead to stressful situations and consequently adverse birth outcomes. Despite the existence of the Affordable Care Act, healthcare remains unaffordable for many. Reports published in the New York Times and NPR humanize the statistics on maternal deaths and narrate experiences of mothers who either died or suffered at great length during their pregnancy and childbirth experiences.
From a behavioral perspective, American women overall are getting pregnant at an older age and almost half of all pregnancies are unplanned without accounting for the associated complications. Black women in particular exhibit higher rates of pre-existing chronic conditions such as obesity, diabetes, and hypertension that complicate birth. In New Jersey specifically, black women are more likely to be obese and smoke during pregnancy. Interestingly, in New Jersey, foreign-born Hispanic mothers who have similar income status as poor black mothers tend to have better birth outcomes, a phenomenon termed as the ‘Hispanic Paradox’. The relatively better birth outcomes amongst foreign-born Hispanic mothers are attributed to stronger social ties and support as well as a lower prevalence of pre-existing conditions.
The lack of reliable and relevant data is another reason why the MMR in the U.S. remains alarmingly high. Timely data is a resource to make adjustments and improvements in the system and healthcare quality. Maternal review boards exist in 31 states, including five new ones, such as one recently established in Washington, D.C. after the closure of two maternity facilities in the area. The impact of these boards is often limited and even nonexistent if their data and findings are not translated into best practices for mothers. Despite having the second oldest maternal review board, with the mission to capture maternal mortality data to take steps for its prevention, New Jersey ranks 45th in the nation for MMR. This reflects a disconnect between data and its application in improving maternal health.
It is also important to acknowledge the impact of social determinants of health on maternal health. The U.S. can learn from the UK, where one maternal death is considered a health system failure, and hence, increases the gravity of the situation and asks for immediate remediation. The Preventable Maternal Act of 2017 in the U.S. is a step in the right direction to galvanize synchronized national efforts in collecting, assessing, and sharing information to achieve the uniform goal of reducing the MMR figure to a single digit and eventually zero. If the U.S. wants to achieve the Healthy People 2020 goal of reducing MMR by 10 percent, it must strive for a nation-wide cohesive effort that is informed by data and a patient-centered approach to maternal care. Furthermore, it is important to reassess the healthcare spending and channel it into preventative measures for mothers. We must realize that pregnancy is not a disease, but rather a human condition that brings new life into this world and is deserving of dignified care.
Naina Qayyum is a 2018–2019 Global Health Corps fellow in the U.S.
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