Maternal mortality, as defined by the World Health Organization (WHO), refers to “the death of a woman while pregnant or within forty-two days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
While pregnancy-related deaths are on a steady decline in the majority of the world, the maternal mortality ratio (MMR) in the United States continues to increase. Despite spending nearly double the average among developed countries on healthcare, more women are dying of pregnancy-related complications in the United States than in any other high-income country.
In just 23 years, the US maternal mortality ratio, measured as the number of maternal deaths for every 100,000 live births, skyrocketed from 10.3 in 1991 to 23.8 in 2014. This translates to the death of over 700 women per year due to pregnancy-related complications, 60% of which the CDC claims are preventable. These numbers stand in contrast to the the overall trend seen around the world––between 2000-2017, the global MMR declined by 38%.
Experts in maternal health blame this increasingly high rate on poverty, untreated chronic conditions, and lack of access to quality medical treatment––indicating a multidimensional issue within the healthcare system. Factors such as socioeconomic status, location, education level, and race are some of the factors that influence an individual’s ability to receive adequate medical treatment. In rural communities, for example, few local doctors and remote hospital locations create significant barriers to medical care.
As Gary Hart, the Director at the Center for Rural Health at the University of North Dakota School of Medicine, points out, “Access to providers, even family physicians, is a problem. If you want to go to an OB/GYN, depending on where you live in the country, you may have to go 200 miles.” These types of challenges worsen the growing urban-rural health care divide and the systemic problem of healthcare inequity.
Overlap between race and ethnicity in the context of maternal health only heightens these disparities in access to medical care. According to the CDC, black mothers in the US die from pregnancy-related causes at three to four times the rate of white mothers––representing one of the widest racial disparities in women’s health. This problem is part of a greater historical trend of racial disparities in maternal mortality rates.
Since 1940, the MMR for black women has consistently been two to four times higher than that of white women. This racial difference is evident among all age groups of women and persists across each of the major causes of pregnancy-related deaths, further strengthening the correlation between race and likelihood of maternal survival.
These alarming statistics can be traced back to racial inequalities in healthcare access. Black women, according to findings from the National Partnership for Women & Families, “experience pervasive disparities in access to health insurance.” This makes them more likely to start prenatal care later, or receive it less frequently, putting them at a greater risk for postpartum complications.
They are also more likely to experience chronic conditions such as obesity, diabetes and hypertension––all of which increase the dangers associated with childbirth. Additionally, the hospitals where many black women give birth are often lower in quality and have reduced access to adequate medical supplies, contributing to higher rates of life-threatening complications.
These problems are amplified by the unconscious biases that are embedded within the medical system, which dramatically affect the quality of care received. According to a six-month long investigation on maternal mortality in the US by NPR and ProPublica, more than 200 stories of African-American mothers echoed common themes of feeling disrespected and devalued by medical professionals. This has contributed to a lack of trust in the healthcare system, leading many women of color to resort to home births so that they can avoid the risks and disparities of hospital births––a choice that ultimately poses a greater risk to both their babies and themselves.
To address this complex issue, the CDC recently outlined a series of measures for hospitals to track and prevent maternal deaths more effectively. The measures call for the necessity of healthcare providers to educate women on the management of chronic conditions which could be exacerbated by pregnancy, as well as early indicators of potentially deadly complications. A swollen leg, for example, could signal a blood clot, while a fever may indicate infection. Understanding these warning signs would allow pregnant and postpartum women to identify problems early on, and therefore seek timely treatment before it becomes too late.
The CDC also urges hospitals and health systems to standardize medical responses to obstetric emergencies, such as ensuring doctors only perform C-sections if medically necessary, and calls on states and communities to provide better access to housing and transportation.
Reducing maternal mortality in the United States will require more than administrative improvements to better monitor and ultimately avoid pregnancy-related deaths. Healthcare providers and policymakers must recognize and address the broader influence of social determinants and health inequities in order to see a change in MMR for the diverse US population.