US Maternal Health Crisis, Part 1
Updated: Apr 2
Every day 2-3 women die in pregnancy or childbirth in the US
Women in the US are 3 times more likely to die during pregnancy or within the first year of giving birth than women in Canada and 7 times more likely to die than women in Finland where the rate of death is lowest.
"Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015," The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal.
Source: The Lancet
Credit: Rob Weychert/ProPublica
A tragic but insightful investigative report by NPR and ProPublica tells the story of Lauren Bloomstein - a neonatal nurse who died shortly after childbirth in the hospital where she worked. As an Ob/Gyn, a woman and a mother, I audibly gasped multiple times listening to this story during my commute home.
This story - and multiple others like it that have been reported in the media over the past several months - provide human faces to back up the statistics. Each story is tragic in its own way with nuances that make the situations different but some key lessons underly the fact that American has fallen behind all other developed countries in preventing maternal mortality.
In the US, nearly 50% of all pregnancies are unintended. This, combined with an overall lack of preventative healthcare (which has only recently started to improve due to coverage provided by the Affordable Care Act (ACA)), leads to women becoming pregnant with pre-existing chronic medical conditions (such as diabetes, obesity or high blood pressure) that can complicate pregnancies, particularly if they are not in good control before or during pregnancy. The ACA has expanded access to health insurance for 9.5 million women of reproductive age and ensures that all insurance plans cover pre-natal care which is a critical element of reducing maternal mortality. However, our maternity care system in the US is uncoordinated and inconsistent and women may have to change healthcare providers multiple times during pregnancy if they change insurance plans. I know firsthand the difficulties in sharing medical records across different healthcare systems in the US which can lead to a lack of critical medical history or lab results when medical urgent decisions need to be made. And these already unacceptably high maternal mortality rates are significantly worse for African American women - likely due to disparities in health care insurance coverage and access. Under the current House and Senate bills that aim to "repeal and replace" the ACA, this spotty coverage and inconsistent care would be far worse.
Beyond the statistics and policy problems, there is a general complacency around the health risks women face in pregnancy. Seen as "natural" and "what women do" it is difficult to communicate that women literally risk their lives when they become pregnant and this risk increases significantly with giving birth. As an Ob/Gyn, I've struggled to communicate that risk to women who are refusing medical intervention because I know as well that the medical profession in the US has a bad history of intervening in the natural process of labor when it isn't necessary. However, as pointed out in the NPR/ProPublica report, the entire system of "maternity" care in this country is focused on protecting the developing fetus and newborn with very little attention to the real risks that women face in pregnancy, delivery and the post-partum period.
I've written earlier about the inadequate system of post-partum care in the US as it relates to screening and treatment for post-partum mental health problems. But the immediate post-partum period is the most dangerous for women and this is not something that is emphasized in medical training, even for Ob/Gyn specialists. As an example, though I trained in Obstetrics at a very well known high risk tertiary care hospital, I didn't understand the dramatic increase in blood clot risk during the post-partum period (even greater than during pregnancy) until I worked for the World Health Organization and was involved in developing global guidelines for post-partum contraception which included reviewing all of the evidence on this issue.
Ultimately, most women in the US will have an uncomplicated labor and delivery. But even these women are provided little or no information on what to expect in the post-partum period. For more on post-partum care (or lack thereof) in the US, check out part 2 of this SFOTD.