Maternal Mortality in the United States: A Human Rights Failure
Francine Coeytaux, Debra Bingham, Nan Strauss
With 99% of maternal deaths occurring in developing countries, it is too often assumed that maternal mortality is not a problem in wealthier countries. Yet, statistics released in September of 2010 by the United Nations place the United States 50th in the world for maternal mortality — with maternal mortality ratios higher than almost all European countries, as well as several countries in Asia and the Middle East.
Even more troubling, the United Nations data show that between 1990 and 2008, while the vast majority of countries reduced their maternal mortality ratios for a global decrease of 34%, maternal mortality nearly doubled in the United States...
In addition, the health care system must be free from discrimination, must be accountable and must ensure the active participation of women in decision-making. Yet, instead, too many women in the United States face shortages of providers and facilities and inadequate staffing; financial, bureaucratic, transport and language barriers; care that is not culturally appropriate or respectful; a lack of opportunity for informed decision-making and the lack of a system to ensure that all women receive high-quality, evidence-based care. The comparatively high rates of maternal deaths in the United States is an indicator of the failure to ensure that women have guaranteed lifelong access to equitable, quality health care, including reproductive health services. Indeed, in countries such as Canada and the United Kingdom where maternal deaths are reviewed and universal access to health care is guaranteed, fewer women die of preventable causes during childbirth than in the United States...
The rise of maternal deaths in the United States is historic and worrisome. In 1987, maternal death ratios hit the all-time low of 6.6 deaths per 100,000 live birth.9 These ratios were essentially maintained for more than a decade. Around 2000, the ratio began to increase and has since nearly doubled, hovering between 12 and 15 deaths per 100,000 live births between 2003 and 2007.10 The overarching statistics only scratch the surface: “near misses” (maternal complications so severe the woman nearly died) have also increased by 27% between 1998 and 2005, now affecting approximately 34,000 women a year;11 and appalling disparities in maternal health outcomes exist between racial and ethnic groups, and among women living in different parts of the United States.
The leading complications causing maternal deaths in the United States overlap with the main global causes; hemorrhage, pregnancy-related hypertensive disorders and infection are among the top causes of death in both the United States and the developing world. Other leading causes of maternal death in the United States are thrombotic pulmonary embolism, cardiomyopathy, cardiovascular conditions, and other medical conditions, whereas in developing countries, other leading causes of death are obstructed labor and unsafe abortions.
For the last 50 years, black women who give birth in the United States have been approximately four times as likely to die as white women. The greater risk of death for black women does not simply reflect a greater risk of an underlying complication occurring; in a national study of five medical conditions that are common causes of maternal death and injury (preeclampsia, eclampsia, obstetric hemorrhage, abruption and placenta previa), black women did not have a significantly higher prevalence than white women of any of these conditions. However, the black women in the study were two to three times more likely to die than the white women who had the same complication. Likewise, a study comparing maternal outcomes for Mexican-born women and White non-Latina women in California found that while Mexican-born women were less likely to suffer complications overall, they did face a greater risk of particular obstetric complications such as postpartum hemorrhage, major puerperal infections and third- and fourth-degree lacerations, suggesting that the intrapartum care they received may have been of poorer quality...
We have sufficient data to know that women in the United States face a range of barriers preventing them from obtaining the services they need for a safe and healthy pregnancy and childbirth....
Complications of pregnancy often begin even before a woman becomes pregnant, when many women are uninsured and lack affordable access to primary care including contraceptive services and information. In the United States, nearly half of all pregnancies are unintended,18 and women with unintended pregnancies are more likely to develop complications and face worse outcomes for themselves and their babies.19 Of the 17.5 million women in the United States estimated to be in need of publicly funded family planning services and supplies, Medicaid and government-funded clinics (Title X clinics) cover just over half of this need, leaving more than 8 million women without affordable family planning information and services.20 Policy and legislative measures also limit access to contraception for some.
For many women, the cost of health care puts comprehensive health care beyond reach. Low-income women are more likely to be uninsured prior to becoming pregnant, and consequently are more likely to enter pregnancy with unmanaged chronic health conditions that increase their pregnancy risks. For women who become eligible for publicly financed care upon becoming pregnant, complicated bureaucratic hurdles and a lack of providers willing to accept patients paying with Medicaid increase the likelihood that these women will face significant delays in obtaining early prenatal care.
Women who receive no prenatal care are three to four times more likely to die of pregnancy-related complications than women who do. Those with high-risk pregnancies are 5.3 times more likely to die if they do not receive prenatal care. Healthy People 2010 — national health objectives developed in 1998 by US federal health agencies — set a goal of 90% of women receiving “adequate prenatal care” (defined as 13 prenatal visits beginning in the first trimester).However, data suggest that, for 25% of women, their care falls short of this goal. This figure rises to 32% for African American women and 41% for American Indian and Alaska Native women.
Many women receive inadequate or poor-quality intrapartum care. Hospitals and clinics, particularly those serving low-income communities, are often overcrowded and understaffed. Understaffing can create pressure to care for a high volume of patients, making it difficult or impossible to provide good-quality care. The current economic downturn and the increased use of medical interventions during childbirth are is likely to exacerbate the problem of understaffing while increasing the pressure on facilities in medically underserved areas, as more people become uninsured...
For more than 20 years, the authorities have failed to improve the outcomes and disparities in maternal health care. Recent health care reform focused on improving access to care and reducing the growth in health care spending. However, improving health care coverage alone would leave largely unaddressed the issues of discrimination, systemic failures, optimizing quality of care and accountability. It is essential that the debate goes beyond providing health care coverage and ensures access to quality health care for all in a way that is equitable and free from discrimination...
There are no acceptable excuses when we consider the fact that we lag behind most developed countries and when numerous developing countries, such as Vietnam and Albania, with much fewer resources than the United States, are making strides towards meeting their goals of reducing preventable maternal deaths, while the United States is backsliding...
It is a human tragedy when a woman dies giving birth; her death forever changes her community and family for all future generations. It is both a tragedy and a human rights failure when a woman dies needlessly of preventable causes in a country that lacks the political will to have prevented her death.
http://www.arhp.org/publications-and-resources/contraception-journal/march-2011
