Americas Maternal Mortality Crisis

Today I would like to bring up an issue that has been occurring inside of the United States, which is the apparent maternal mortality crisis in America. Now, you’ve probably seen bits and pieces of this being talked about by people like 2020 Democratic presidential candidate Kamala Harris and Kirsten Gillibrand talk about it in the news. You’ve also had Bill and Melinda Gates talking about it in a recent interview stating that the maternal mortality crisis was “incredibly disturbing”. Now If you’re wondering what maternal mortality is and why I’m talking about it today, simply put, women who give birth in the United States have a greater risk of dying relative to other rich/developed nations. The concern here is backed up by a 6-month long investigation by ProPublica and NPR in 2017, that ranks America’s maternal mortality rate is the worst in the developed world by a significant margin. Now March of Dimes president Stacey D. Steward testified on the issue stating that “There are 700 mothers who die every single year and almost fifty thousand who experience dangerous complications that could have killed them. Making the U.S. the most dangerous place in the developed world to give birth, and we think and we think you agree that this is completely unacceptable.”.

Number of deaths from any cause related to or aggravated by pregnancy or its management during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 births

Now let’s go more into what maternal mortality is. The CDC defines maternal mortality as deaths which occur as a result of pregnancy-related complications before, during, or up to the forty-two days after childbirth. The thing is post-pregnancy complications happen well after the forty-two-day mark. So in 1986, the CDC started collecting data on women who died after the 42-day mark and up to one year after. The data is limited though due to the fact that not all of the states have been tracking these deaths. According to a 2018 study by a CDC funded report over sixty percent of the 700 pregnancy-related deaths that took place last year, were preventable. Now when we see that we immediately want to know why and how this happened. This is what I hope to unpack in this article including more details into the crisis and some things that have been overlooked by the professionals.

Graph showing the trend in pregnancy related deaths in the United States from 1987 to 2014.
This figure shows the top causes of pregnancy related deaths in the United States from 2011-2014.

To get a feel for maternal mortality in America, we first have to look at the statistics. American women are three times more likely to die from childbirth than those in Canada and six times as likely as to those in Scandinavia. The number of reported maternal deaths in the U.S. has gradually increased from 17 per 100,000 pregnant women in 1990 to 26 deaths per 100,000 in 2015. Now as of 2018 the national average is 26.4. This means that women in America are fifty percent more likely from pregnancy than their mothers were during childbirth. According to the CDC, the two major causes of death are pre-eclampsia, a condition in pregnancy characterized by high blood pressure that sometimes leads to seizures and strokes; something that Beyonce experienced after the birth of her twins; and hemorrhaging which is the equivalent of bleeding. There are other post-pregnancy complications that occur like infection and blood clots which untreated could lead to death. These death are largely preventable. What’s worse is that doctors say the treatment that could save the lives of those mothers are neither difficult nor expensive. For example, preventing a stroke requires something as simple as monitoring blood pressure during and after childbirth and medicating within an hour of childbirth.

Dr. Neel Shah, a psychic and an assistant professor at Harvard medical school spoke to Rouge Rocket on the fact that the danger doesn’t end when the pregnancy ends; “Definitely when people hear about maternal mortality their often imagining like an emergency situation that is happening to a woman in labor in the hospital. In actuality in 2019 childbirth, the event itself is relatively safe. The problem is that once you leave the hospital there are very few touch points with the systems that are meant to care for you and support you until a visit fifteen minutes long six weeks later. So we see that most of the deaths occur in this time period between visits.”

These deaths also seem to be more common with cesarean deliveries. C-sections are the most common surgeries performed in the U.S. Between 1996 and 2009 the c-section rate in the U.S. shot up by sixty percent. Overall the c-section has increased more than five hundred percent since the 1970s. “What we haven’t seen from these increases is seeing nobody better off” Dr. Shaw on the increased rate of c-sections; “Babies are not better off and moms on average are not better off in many cases they’re worse off because taking care of a newborn infant and healing from a large incision is hard”. Though it’s declined slightly in recent years, a third of all births in America are still by c-section and now c-sections now outnumber vaginal deliveries in other parts of the world like southeast Europe, Latin America, Australia, and China. For example, 80-90 percent of births in private clinics are now c-sections, compared with 30-40 percent of births in public hospitals. Even in poor countries, the rates can be extremely high at clinics. For example in Bangladesh, less than 60 percent of births happen at clinics, but when they do, about 65 percent are c-sections.

That being said there is the time where a c-section is necessary during emergencies. Emergency c-sections save lives and it makes sense to schedule a c-section when the fetus isn’t positioned right. The concern is though that low-risk pregnancies that get these c-sections will directly affect the mother. An elected c-section, where a mother chooses to do a c-section when she has a normal pregnancy, increases the chance of death of the mother by 60 percent and could risk life long complications for the mother by 5 times. C-sections are hard to recover from and lead to scarring of the womb which is attributed to bleeding, abnormal placenta development, ectopic pregnancy, stillbirth, and premature birth. Now normally women have more than one baby and this could cause problems if the first pregnancy ended in a c-section birth. As an obstetrician, someone who deals with childbirth, Dr. Shah explained this further, “As an obstetrician, I’m one of the only doctors who routinely cut in the same scar over and over again. We do the first c-section that’s a pretty straight forward surgery, but by the time you do the second and third c-section you have to cut through all that scar tissue and that could get really dicey. The surgery gets more complicated which really is what that means with all the scar tissue can sort of fuse together and it could be like operating on a melted box of crayons.”.

Another underlying but very important factor that people don’t really seem to be talking about is the preferences of the hospital. Some studies have found that face with the right thing to do and the easiest thing to do some doctors may choose the ladder. “There’s a saying that I love, where every system is perfectly designed to get the results that it gets.” Dr. Shah goes on; “Which is a way of understanding that doctors are bad actors. In fact, everyone who works in this field is well intended and relatively well informed, the challenge is that in the short term, doing a c-section always seems like it’s the right decision. Another problem is what kind of health provider you have, some health providers will let you go to hospitals where you could either have a regular or c-section birth, but some providers, like if you have HMO insurance, you may be forced to deliver in a hospital with higher than normal c-section rate.

Lastly, communication is a big issue when trying to prevent maternal mortality which can best be shown by the case of Serena Williams during her delivery. Last year Williams told Vogue that she almost died a few days after giving birth to her daughter. In her interview, she explained that the day after delivering her baby via c-section she had trouble breathing and immediately recognized the warning signs of a serious condition. She walked out of her hospital room and approached a nurse, she said that she was afraid of another blood clot and requested a CT(or a CAT Scan) scan and an IV of a blood thinner. The nurse responded by saying that the pain medication was making her confused, but Williams did what most women don’t do she insisted something was wrong until she was sent for the CT scan. The scan showed several blood clots and also that intense coughing has reopened her c-section incision and there was hemorrhaging at that site. After she was cleared, she was forced to stay on six-week bed rest. Is Serena Williams had trouble being heard and taken seriously, then what can everyone else expect?

Luckily large efforts are being done to combat the large maternal mortality in America. In recent years, the CDC and nonprofit organizations like The Preeclampsia Foundation have been working to provide hospitals with evidence-based strategies and practices to lower birth related risks and the maternal mortality rate. Just a few months ago Congress unanimously passed a bill called the Preventing Maternal Deaths Act, authorizing 12 million dollars a year for 5 years to address this crisis and president Trump signed the bill into law December 21, 2018. The money will fund health review committees in all 50 states enabling them to collect data on what’s killing women during and after childbirth. Prior to the passing of this bill 7 states did not have a maternal mortality review panel and 2 of the 7 didn’t plan to implement one. With all of these plans being implement, however, now doctors can really find out what are the main problems causing maternal mortality and how they can lower those number and prevent maternal mortality from becoming a serious issue again in the United States   

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