A pregnant couple looks at a sonogram image. (Getty Images)
Our society faces a number of health care challenges, but the one I find most troubling is maternal mortality — women dying as a result of child birth.
The actual numbers are quite small but the tragedy associated with them is immense. Furthermore, these deaths provide a window into the overall functioning, or rather the dysfunction, of our health care system. They are essentially the “canary in the coal mine.”
The deeply alarming fact is that at a time when we could reasonably expect that the situation would be improving it is actually getting worse. A century ago, the death rate associated with childbirth was roughly 900 maternal deaths per 100,000 live births. With the advent of better infection control, safer anesthesia and a variety of other improvements in medical care, that rate had dropped to 9.8 deaths per 100,000 live births by 2000. Alarmingly, since then, the rate has steadily increased. It reached 21.5 in 2014 and went to 23.8 in 2020.
When compared with outcomes in other wealthy developed countries these data are even more alarming. Maternal death rates in the U.S. are twice as high as our next closest competitor (South Korea at 11.8) and three- to eightfold higher than countries like Canada (8.4), Sweden (7.0) and Australia (2.9).
A further sobering fact is that detailed analysis of these cases reveals the disturbing conclusion is that 80-90% of them are completely preventable.
How can this be? Major identified risk factors are maternal age, access to reliable care, and issues of race and poverty.
Maternal age is the most clear-cut. More women in the U.S. are having babies at later stages of life. As a person ages, other medical conditions such as high blood pressure, cardiovascular disease, diabetes, etc., become more common. Each of these can have a major impact on the risk of the pregnancy. The risk of maternal death for women ages 25-39 is 50% higher than for those under 25, and for those over 40 it is as much as sixfold higher. Certainly older women can have successful pregnancies. The risks, however, must be recognized and dealt with.
Barriers that limit access to care are both geographic and financial. In rural areas, travel distances are greater, making it more difficult for patients to get the regular prenatal care and especially emergency and delivery care. They also present challenges for providers. Because of small volumes, financial stresses and the difficulty in maintaining acceptable staff skill levels, many rural hospitals have stopped providing obstetric services. This means that if obstetric emergencies occur, the local facilities are less equipped to handle them, and access to the full range of obstetric care is delayed.
Financial barriers to care are obvious and well known. Even for patients with insurance, co-pays and deductibles are sometimes enough to cause patients to delay prenatal appointments or to be hesitant to report new symptoms. All of these factors contribute to poorer outcomes.
Racial and ethnic factors impacting maternal mortality are complex and in many ways the most difficult to analyze. Maternal death rates among Black women are threefold higher than among white women. Some of this is due to increased levels of preexisting disease such as high blood pressure and diabetes, but studies clearly show that inherent racism is a significant factor. A recent study showed that complaints from Black women were taken less seriously by providers, potentially leading to delayed identification of serious conditions. Poverty and other “social determinants of health,” including lack of literacy, clearly contribute to poor outcomes.
What can be done? This is definitely a multifaceted problem. However, the underlying message is that early identification of risk factors with careful follow-up management is the key to improving outcomes.
The countries that have much better outcomes than we do all have universal health care coverage, thereby eliminating financial barriers. In rural areas, the establishment of telehealth consultations and risk identification protocols hold promise for patients and providers. Mental health issues, especially postpartum depression, must be identified and taken seriously. Obviously we must continue to analyze and work to eliminate the destructive impacts of racism.
Again, the actual numbers are not large. but their importance is enormous. Having a baby should be a joyous and not a risky event.
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