August 14, 2021

The United States Maternal Mortality Rate is the Worst Rate among Developed Countries. This is a Scandal. By Phyllis C. Leppert

The National Center for Health Statistics (NCHS) reports that the US Maternal Mortality Rate in 2019 (the latest statistics available) was 20.1 deaths/100,000 live births. In that year 754 women died of pregnancy related conditions. This compares to 5/100,000 in the Netherlands and 7/100,000 in the UK in 2019. Because the Campion Fund is dedicated to fundamental reproductive research and to the education of the public about this research we are reporting on this statistic. Nothing is more fundamental to reproductive health and research than the compilation of vital statistics on birth and death. Nothing is more important than increasing awareness of the tragic numbers of women in the US who die from pregnancy related causes. The data is even more alarming when it is reported by race. In 2019 Black maternal mortality we 44.0/100,000 while the rate for White women was 17.9/100,000 and for Hispanics 12.6/100,000. Thus, the rate for Black women is 2.5 times higher than that of Whites and 3.5 times higher than that of Hispanics. These disparities do not change when socioeconomic status, education level and geographic location are controlled. The tragic fact is the maternal mortality for all women in the US is unacceptably high and it is a scandal that the rate of maternal death for Blacks is much, much higher.

By definition, maternal deaths related to pregnancy includes all deaths from the inception of gestation, during birth, and for one year postpartum. About fifty percent of all maternal deaths occur after birth.  Data on pregnancy associated deaths are also collected by NCHS. These deaths are caused by such things as fatal car accidents. The statistics on the number of maternal deaths do not reflect many undocumented women who may not seek prenatal or delivery care as they are fearful of detection. The statistics are most likely underreported as well due to the fact that pregnancy may not be captured on the death certificate. There maybe be misidentification and other reporting errors. The NCHS and the states have worked to assure a more accurate picture of the vital statistical record by having a standardized pregnancy checkbox on all death certificates. This check box has helped but misclassification and other challenges in the collection of vital statistics still exist. The reason that the NCHS data is reported several years after the events in question is that it takes time for hospitals and birth centers to record the necessary information in the death certificate and to check for its accuracy and to have it signed by the appropriate physician. It takes time for this information to arrive at the state agencies that compile the records and then time to send it to the NCHS. Finally, it takes time for the NCHS professional staff to analyze the data and report it.

Maternal deaths started to increase in 2000 despite efforts to reduce the rates. Most states and DC, a few large cities such as New York and Puerto Rico have formed Maternal Mortality Review Committees that review all pregnancy related deaths in their jurisdiction. In many places this is legally required. The Committees are made up of representatives of the health care professions, including physicians and midwives, pathologists and social workers. Some include informed members of the public and community organizations. These committees have access to many sources of information and have adopted a standard review process developed by the Centers for Disease Control (CDC). These committees also determine if the death was preventable. What is striking is that up to two thirds of the deaths are found to be preventable. Greater than fifty percent of the deaths occur after the birth of the child.

What are some of the reasons for our high maternal mortality rates? Access to appropriate care is a factor. The United States has a very low overall number of midwives and obstetricians. It is somewhere in the range of 12 to 15 providers for every 1000 live births. Other countries have 2 to 6 times as many. There are few physicians and nurse-midwives of color.  In addition, we do not use midwives to the fullest extent possible. There are many private health insurance companies that do not cover maternity care at all and many to not reimburse midwives. Medicaid pays for approximately 45 percent of deliveries and does cover midwifery care. However, it only pays for 60 days of postpartum care. In states that have not elected to have expanded Medicaid for pregnancy, many women have no financial ability to pay for prenatal care and thus adverse conditions are not treated. The onset of delivery is often too late to diagnosis and adequately treat complications of pregnancy. Access is limited for many women as many areas of the country such as resource poor intercity neighborhoods and rural areas lack providers of any sort.  Planned Parenthood Clinics provided prenatal care for many women, but they have often been forced to closed due to reduction in funding. Furthermore, over the past decades, medical schools in the United States have decreased the amount of time that students spend on obstetrics and gynecology rotations which means that physicians who do elect other medical specialties may not have the education they need to understand the unique physiology of pregnancy women and their needs. Thus, they might not notice early warning signs of complications in patients who are pregnant when they are seen in their specialty practices. Access is also difficult as well because of lack of transportation and limited care for other children, inability to find care that has flexible appointment times such as evening hours.  This means that appointments and services may not be available at favorable times for working women.  Wait times may be unacceptably long. Then there are barriers to care that include lack of family support, housing problems, psychosocial stresses. These factors all lead to fragmented care that leads to undiagnosed and untreated preventable condition.

The causes of death for Black women are mostly from cardiomyopathy, cardiovascular and coronary conditions, pre-eclampsia and eclampsia, hemorrhage and embolism and new- onset hypertension. In Black women this new-onset hypertension is more severe than in White women. Other causes of the increased maternal mortality are an increase in obesity and diabetes and heart disease in women. Hemorrhage and infection affect all women.

There have been many sophisticated and elegant basic research studies conducted in the United States on the physiology of pregnancy and birth. We have learned much about the molecular biology of parturition. It is a great loss that we as a nation have not been able to prevent maternal mortality. We need urgently to act. The United States needs to educate and utilize more midwives who are trained in normal pregnancy and birth and who are excellent in finding subtle early warning signs of abnormality.  We need more obstetricians who are able to treat pregnancy complications of all races and especially more obstetricians of color. We desperately need to overhaul how we provide payment for maternity care. Basic scientists have a role in alerting the pubic and are elected leaders to the tragedy of the off the chart maternal mortality. Thus, the Campion Fund urges our followers to help inform that public and our elected representatives regarding the tragedy of our high maternal mortality and to insist on action to combat it.  We are a highly developed nation and we can to much better.

Selected Reading:

Crandall K. Pregnancy-related death disparities in non-Hispanic Black women. Womens Health (Lond) 2021: 17:17455065211019888. Published online 2021, May 27. doi:10.1177/17455065211019888

ACOG Advocacy and Health Policy, January 30, 2020. ACOG: Standardized National Mortality Data by NCHS is Critical Step in Eliminating Preventable Maternal Deaths and Disparities in Outcomes.

Melillo G. US Ranks Worst in Maternal Care, Mortality Compared with 10 Other Developed Nations. AJMC, 2020, December 3