Amid the fierce debate over abortion and the challenges of accessing health care, American women face another problem: an increased risk of pregnancy-related death.
The U.S. maternal mortality rate, 22 deaths per 100,000 live births, is the highest among high-income countries, according to an analysis released in June by the Commonwealth Fund, based on data from the Centers for Disease Control and Prevention and the Organization for Economic Cooperation and Development, of which the U.S. is a member.
Several studies have suggested that the high maternal mortality rate in the United States may be due to certain flaws in the country's health care system, including those that particularly affect women from minority groups.
So what is the maternal mortality crisis in the United States, is there a way forward, and would abortion bans make the situation worse?
What is maternal mortality?
Maternal mortality refers to the death of a woman during pregnancy, during childbirth, or during the “postpartum” period after childbirth or the end of pregnancy due to complications or abortion. These deaths are related to or aggravated by the pregnancy, although they may also be caused by conditions such as excessive bleeding or seizures.
The US figures include deaths that occur within one year of birth or abortion. A total of 817 US women died from childbirth-related causes in the US in 2022. The US maternal mortality rate that year was 22 per 100,000 live births.
But the rates vary by ethnicity. Black women are more than twice as likely to experience a pregnancy-related death compared to the national average. In 2022, for every 100,000 births to black women, approximately 50 women died within one year of giving birth or having an abortion.
What causes high maternal mortality rates in the United States?
The main complications associated with maternal deaths are usually “obstetric” or directly related to pregnancy, such as excessive bleeding, placenta obstruction in the birth canal, or seizures.
But the types of risks facing pregnant women in the United States appear to be changing.
“Over the last 20 years, there's been a shift in mortality risk away from traditional obstetric risks,” said Alison Gemmill, assistant professor in the Department of Population, Family and Reproductive Health at Johns Hopkins University.
“What we're seeing now is that most maternal deaths are accompanied by some underlying cardiovascular disease,” she said.
Additionally, the CDC report found that some of the leading causes of maternal deaths from 2017 to 2019 were mental health and heart disease, in addition to excessive bleeding.
Pregnancies that are deemed high-risk from the start are also becoming more common, in part because of assisted reproductive technologies such as in vitro fertilization (IVF), which help women with fertility problems linked to age, pre-existing conditions and other factors conceive, said KS Joseph, a professor of obstetrics and gynecology at the University of British Columbia in Canada who has studied maternal mortality around the world.
(Al Jazeera)
Are some ethnic groups more affected than others?
Without universal health care, American women, especially those who are less likely to have health insurance, may lack access to comprehensive medical support.
Black women are particularly at risk: In 2022, 49.5 Black women will die per 100,000 live births, a rate significantly higher than the rates for white (19.0), Hispanic (16.9), and Asian (13.2) women.
Melba Kraft Blackshear, who was an assistant professor at the University of Michigan-Flint until her retirement this year, said the disparities begin with a history of inadequate or inaccessible health care and extend to implicit biases that affect the quality of care women receive during pregnancy.
“A lot of those prejudices were part of the beginning of gynecology, like the idea that black people couldn't feel pain, because gynecology started with Dr. Marion Sims, the father of obstetrics and gynecology, performing surgery on black slave women without anesthesia,” she said.
American physician James Marion Sims perfected the technique of performing surgical procedures on black women without anesthesia, and then performed the same operations on sedated white women.
Although anesthesia had not yet been fully incorporated into medical practice in the 19th century, several sources support the idea that Sims' decision not to use any anesthetic techniques on black people was based on the mistaken belief that black people did not feel pain in the same way as white people.
Kraft-Blackshear added that these misconceptions are somehow passed down through medical education and training, and as a result, Black women often have their concerns dismissed by medical professionals.
Activists and family members believe that was the case when 39-year-old Kira Johnson died in a Los Angeles hospital in 2016. Johnson, who was scheduled to give birth via Caesarean section, suffered severe abdominal pain for 10 hours before being attended to by a medical team. After emergency surgery, Johnson died, but doctors found she had been bleeding internally and had three liters of blood in her abdomen.
Research suggests that the chronic stress of experiencing racism can lead to premature aging and poorer health in Black women, increasing their risk of conditions like high blood pressure and preeclampsia, which can be life-threatening if not identified during pregnancy.
Kraft-Blackshear said social challenges such as poverty and domestic violence, which Black women in the United States face at higher rates than other groups, can affect a woman's health and her ability to attend appointments, so health care providers need to take these factors into account when treating pregnant women.
(Al Jazeera)
Is there something wrong with the way the U.S. monitors maternal mortality?
The way pregnancy-related deaths are recorded in the United States has been the subject of intense debate, raising concerns that in some cases the underlying causes of death may be obscured.
In 2003, states across the U.S. began including a “pregnancy checkbox” on death certificates, asking if the deceased had been pregnant at the time of death or within the past year. By 2017, when all states had the checkbox in place, maternal mortality rates had more than doubled.
The CDC claims the box addresses previous undercounts, but critics say it's frequently checked by mistake, resulting in an overcount of deaths.
For example, one of the CDC's own assessments found that the box was checked for 147 deceased women over the age of 85 in 2013. Findings like this led to new rules regarding the box, including limiting its application to the 10-44 age group.
But experts argue that ticking the box means a significant number of deaths are linked to pregnancy, even if pregnancy doesn't adversely affect the cause of death.
“This overestimation and lack of specificity around causes of death is hurting the system and preventing us from identifying what we need to do to prevent these deaths,” Joseph explained, pointing to data showing that 60 to 80 percent of maternal deaths in the U.S. are preventable.
She added that if death certificates specified what role pregnancy played, this could help pinpoint and address preventable or common risk factors related to pregnancy.
Kraft Blackshear, a member of the Michigan Maternal Mortality Review Committee, said she believes the U.S. maternal mortality rate is accurate and not overestimated.
She explained that the committee will not only establish whether pregnancy was an aggravating factor in the death, but will also assess additional factors such as whether the death was preventable and whether discrimination played a role in the care.
Gemmill said state-level commissions are important, but the U.S. needs to invest more in federal infrastructure to examine the reliability and validity of maternal death reports, as other high-income countries do.
“We've fallen behind because we don't have that national system, that gold standard,” she said.
What else can be done to improve outcomes for mothers in the United States?
Providing better prenatal care
According to experts, reducing maternal mortality rates requires special attention to several key stages of pregnancy, including medical evaluation before conception, antenatal care during pregnancy, home visits and regular check-ups after birth.
According to a study by the March of Dimes, a nonprofit organization that works to prevent premature birth and birth defects, roughly one in seven babies born in the United States in 2022 will be born to mothers who received inadequate prenatal care.
Ms Gemmill said many women do not receive treatment for underlying pre-diabetes until it is discovered during a pregnancy-related scan, missing the opportunity for early intervention.
Improved postnatal care and extended maternity leave
Data shows that women’s health is particularly neglected in the postpartum period: 65% of maternal deaths occur in the postpartum period, and 30% occur between 43 and 365 days after delivery.
Additionally, according to the American College of Obstetricians and Gynecologists, up to 40 percent of women don't receive postnatal care, potentially missing an opportunity for timely intervention against health risks.
The Commonwealth Fund report also found that the lack of federally mandated paid maternity leave gives women less time to “better manage the physiological and psychological demands of motherhood.”
Overall, experts say pregnant women need more intensive care in clinical settings. “The focus is on saving the baby's life and ensuring the baby's health, but in many ways that means the mother is put on the back burner,” Gemmill said.
More focus on mothers' needs and midwifery
Kraft-Blackshear also sees prenatal care as an infrastructure issue: “It's driven by doctors and hospitals, not by the needs of mothers,” she said.
Some have suggested that increasing access to midwives could lead to more comprehensive maternal and child health care, which could even help alleviate the shortage of obstetricians and gynecologists in the U.S., according to a Commonwealth Fund report.
Midwives are health professionals trained to provide medical and emotional support to women during pregnancy, birth and the postnatal period.
“Midwifery care is highly specialized care that puts women and their families at the center of care,” Kraft-Blackshear said, adding that midwives should collaborate with doctors, especially in high-risk situations.
Would US abortion bans worsen maternal mortality?
A study published in the journal Women's Health Issues by Boston researchers suggests that the several anti-abortion laws passed in the United States over the past year will worsen maternal mortality, particularly when it comes to racial inequalities in deaths.
When local abortion facilities are unavailable, pregnant women are often forced to travel to other cities, counties, or states to receive the procedure. Black and low-income patients are disproportionately affected, as they are more likely to already have children and often lack the economic stability, social support, and child care resources necessary to take time off work to travel for an abortion.
When women are already at risk of death from complications during pregnancy, abortion restrictions force them to continue pregnancies against their will, an impact that studies show is expected to be felt most severely by black and Hispanic women who lack access to comprehensive health care.
The ban could cause the United States to fall further behind other high-income countries that widely allow abortion in terms of maternal mortality.
Gemmill, who has also studied the effects of abortion restrictions, said there was not enough data at present to draw any conclusions, but it was possible there could be an increase in maternal complications.
“We're already hearing stories in some states of people not getting the medical care they need and their lives being put at risk,” she said, “so I think we're definitely going to see an increase.”
