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KC Harmer

Professor Gilliland

Eng 1201

16 November 2018

Mothers Deserve Better

Becoming a parent in America is a moment that most look forward to. Before

reaching joyous milestones like baby’s first word or steps, new parents must navigate the late

nights of infancy, figuring out feedings and what different cries mean. Unfortunately, before a

mother can address any of those concerns, she must survive childbirth. This isn’t a comment

made in jest, although it is easy to assume that. Culturally, surviving birth is represented as

women yelling obscenities at doctors and partners, begging for drugs, and overall screaming,

moaning, and groaning through the physical agony. Realistically, when referring to women

surviving childbirth in America it is to discussing the fact that the number of women dying from

complications and conditions related to having children is increasing annually. Considering that

it is common knowledge that the United States is believed by many to be the wealthiest country

in the world, and one of the most technologically advanced, it is rather confusing that so many

women are during birth, or from conditions related to their pregnancies. The United States’

maternal mortality rate is unacceptable which requires improvement of the current understanding

of why maternal deaths are occurring, and implementation of national scale programs that will

ensure improved outcomes for mothers.

Maternal mortality has been defined by the World Health Organization (WHO) as “the

death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of

the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy
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or its management” (MacDorman et al. 3). There are several important factors to understand

when reading the WHO’s definition of maternal mortality. First, “termination of pregnancy”

typically elicits only the notion of abortion; however, in this case it means from the moment that

the woman was no longer pregnant. This refers to delivery of the child, regardless of whether

the child is aborted (electively or through medical necessity), born alive, dies during labor and

delivery (commonly referred to as a stillbirth) or is a result of in-utero fetal death prior to labor.

Another important consideration if the definition is WHO’s use of “site of pregnancy”.

Pregnancy, more specifically implantation, typically takes place in the uterus. When the

fertilized egg implant someplace else, however, an ectopic pregnancy can occur. Such

pregnancies present as great danger to the mother, as the fetus grows and, if not diagnosed and

treated early, has dire consequences. WHO specifically references the ‘duration’, which is

important in the understanding that deaths from pregnancy do not only occur during labor and

delivery. Deaths that occur early on in in gestation, for example when there is a rupture from an

ectopic pregnancy (which can be fatal), it typically occurs within the first trimester. Deaths of

pregnant women that have nothing to do with pregnancy are not included, so a woman that dies

in car accident whether pregnant or in the 42-day postpartum window, would not be included in

maternal mortality data. A death from a preexisting condition that was exacerbated by

pregnancy, ultimately leading to death, would be included.

Maternal mortality, is often regarded as a general indicator of health for a given

population. The Maternal Mortality Ratio (MMR) is defined as the number of women whose

death is attributable to pregnancy during a specific period of time per 100,000 live births during

that same period of time. On a global level, the MMR decreased 44% between 1990 and 2015,

which did not meet the United Nations goal of a 75% decrease in global maternal mortality
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(Kuriya 661). Considering the immense growth in population over the last thirty years, seeing a

decrease in maternal mortality is promising as it indicates that global health initiatives are having

positive effects. In stark contrast, however, maternal mortality in the United States increased

dramatically from 9.8 deaths per 100,000 live births in 2000, to 21.5 deaths in 2014

(MacDorman et al. 5).

There are over 800 deaths every day that are the resulting from childbirth or a pregnancy

related complication (Maternal Mortality, WHO). Even more troubling is that given the overall

decrease in the MMR globally, the United States’ rate worsened. Only a few other countries also

showed a worsening rate and, of those countries, the U.S. was the only industrialized nation. In

addition to deaths, over 60,000 women are surviving near fatal experiences as a result of

pregnancy or delivery annually (Barone). In the year 2000, between 18 and 19 American women

died for every 100,000 live births, with the deaths increasing to 23 to 24 deaths in 2014

(MacDorman et al. 1). Maternal mortality in the United States is not even comparable to our

western European counterparts; the United Kingdom, France, and Sweden, whose 2014 rates

stood at 3.9, 3.5, and 2.2 deaths per 100,000 live births, respectively (MacDorman and Declercq

106)

In 2003 when the U.S.’ standard death certificate was revised due to a national effort

implemented by the Centers for Disease Control and Prevention’s National Center for Heath and

Statistics to ascertain a more comprehensive collection of data by including specific questions

about female deaths (MacDorman et al. 2). Questions on the revised certificate provided

information about known, or potentially unknown, pregnancies that the decedent had within the

year and more specifically, the 42 days prior to death. However, not all states began using the

newly formatted death certificates immediately. In fact, after eleven years, California, Colorado,
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Massachusetts, Virginia, and West Virginal were still not using death certificates containing the

national standard questions regarding pregnancy (MacDorman et al. 4). Without reinforcing a

singular system of national data collection, there will continue to be barriers in reducing maternal

mortality in the United States.

Having a more complete picture of statistics is vital in identifying the many variables that

contribute to maternal mortality. Lacking a data standard indicates a problem with statistics

prior to the 2003 death certificate revision. Potentially, women could have died at rates higher

than data suggests, but because deaths were not being reported as directly related to pregnancy, a

complication of pregnancy or childbirth, or a preexisting condition that was aggravated by

pregnancy, the death would not have been included in maternal mortality statistics. An example

of this would be an incident where a woman died due to a hypertensive episode related to her

pregnancy. Her cause of death may have been documented as a complication of hypertension.

Without the questions about pregnancy on death certificates, it may not be included in maternal

death data collection despite the death being a result of pregnancy induced hypertension,

preeclampsia, or eclampsia. Not previously being able to include information about whether a

woman’s death could be linked to pregnancy is probably a contributing factor to why American

maternal mortality has increase over the last two decades. More deaths are being linked to

pregnancy, even if they are occurring at similar rates as before maternal data was included as

part of the death certificates. Officials that oversee the reporting of maternal deaths do not

believe that increase in deaths is not solely related to previously incorrect records, but that

women are in fact dying at increasing rates (Tavernise).

In the United States 59% of maternal deaths are ones which with appropriate medical

care before, during or after pregnancy, could have been avoided (MacDorman and Declercq
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106). In a general sense, the largest factor contributing to maternal death in the United States is a

lack of access to healthcare. Access to healthcare has two primary components; the first being

the financial ability to see a healthcare provider, and the second is having access to a healthcare

provider that is knowledgeable in maternal health.

A primary goal of the 2015 Affordable Care Act was to make sure that women were

receiving necessary healthcare during, and after pregnancy (Barone). This push was attributed to

the fact that uninsured women are four times more likely to die from a condition related to

pregnancy or delivery than a woman that is insured. With health insurance, women are able to

have reasonable access to birth control, reducing the number of unplanned pregnancies.

Unplanned pregnancies sometimes lead to abortions. Even when safe, legal abortions are

performed by skilled physicians, there is a possibility of infection, which would contribute to the

20.6% of maternal deaths due to sepsis (Kuriya 664). With health insurance women do not have

to pay out-of-pocket expenses for appointments where physicians can monitor maternal and fetal

health, and identify potential problems such as gestational diabetes or preeclampsia, and prepare

treatment plans; therefore, increasing the likelihood of a positive outcome for mother and baby.

As previously mentioned, a majority of maternal deaths are avoidable, and having access to

preventative and diagnostic healthcare is a crucial way to minimize these maternal death rates.

In addition to the monetary burden that may relieved by having more affordable health

insurance options, geography also plays a part in women’s access to healthcare. It is commonly

accepted that women have several prenatal appointments, delivery should be attended by a

trained professional, then have post-natal follow up with their care provider after delivery.

Newborns also have several appointments with a pediatrician in his or her first few weeks.

Making it to several appointments may prove difficult to many mothers. For women in rural
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settings there may or may not be a provider close enough. This can hinder a woman’s ability to

adhere to the recommended appointment schedule. Significant roadblocks like potential

logistical conflicts of transportation, childcare for older children, and taking time off of work,

can prevent many of the women in the United States from meeting the recommended care

standards. In addition to difficulties with the ability to physically make it to appointments, the

quality of healthcare that women have access to is also problematic. In rural and urban situations

alike, resource strain can severely impact maternal health. Facilities suffer with understaffing

which diminishes the quality of care patients are receiving, and increases the likelihood that

symptoms may be overlooked. Underfunded facilities may be unable to keep the recommended

supplies on hand, or have up to date protocols to handle emergency situations such as uterine

hemorrhage. Another problem that is being seen within the field of maternal health is the shift of

providers that specialize in fetal health. Many doctors are focusing on the baby, and maternal

health is being neglected; hence, in emergent situations, fewer individuals are prepared to treat

mothers (Barone).

Ensuring that women have access to healthcare is paramount to mothers’ safety. This is

just as important during pregnancy as before conception occurs. Physiologically, obesity,

hypertension, and diabetes, can lead to many complications during pregnancy. With the

disparity of regular and preventative healthcare across classes and races, these conditions are not

being properly managed prior to, during, and after pregnancy. The leading causes of maternal

mortality in the United States from 2011-2014, in order, are: cardiovascular diseases, non-

cardiovascular disease and preexisting conditions, sepsis, hemorrhage, cardiomyopathy,

pulmonary thromboembolism, cerebrovascular accidents, hypertensive disorders of pregnancy,

amniotic fluid embolism, anesthesia complications, and other unknown causes (Pregnancy
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Mortality Surveillance Program). Probably the most recognized, or assumed cause of maternal

mortality is hemorrhage, which is responsible for 11.5% of maternal deaths (Barone). Over 42%

of maternal deaths are directly linked to complications stemming from the previously mentioned

preexisting conditions of diabetes, hypertension, and obesity, with another 15% of deaths due to

other pre-existing conditions, such as cancer or other chronic medical conditions (Barone). These

deaths are the most preventable, but again, access to healthcare is crucial.

Dr. Felicia Lester, the medical director of gynecological services at the University of

California, San Francisco, provided an analysis regarding preventable maternal deaths. There is a

lack of nationally recognized standard protocols to assess and treat maternal health throughout

the duration of the pregnancy and after delivery (Barone). A very common example of this

relates to hypertension. When a woman in labor begins having repeated elevated blood

pressures, the care provider, being the obstetrician or midwife, should come to the hospital and

remain on site to monitor and treat the patient. Evidence based practices have shown that

adhering to this guideline reduces the chance of a serious complication due to hypertension, and

in the event that one arises, the care is immediately available, and not stuck offsite where the

provider has been calling in orders from. Implementing standards of protocol have been shown

to improve patient outcomes in the United Kingdom, and through a program in California.

The United Kingdom is a country that has been able to decrease maternal mortality. One

of the largest changes implemented was a protocol for hemorrhage. Every medical professional

across the country that oversees births is trained to follow a specific plan in a hemorrhage event,

regardless of professional experience (Womersley). The UK is so transparent in its approach to

maternal care that standard protocols are available for to anyone to review online. In addition to

maternal emergency training, there is a national committee that investigates every single
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maternal death. Singular deaths are

studied, and sometimes provide the

opportunity to create and implement

better treatment plans. A final takeaway

from the improvements that were made in

the UK is that maternal deaths in the UK

Figure 1 Graph comparing U.S. Maternal Mortality to that of are non-discriminatory, unlike the U.S.
California, emphasizing Californian maternal deaths decrease with
assistance of CMQCC (CA-PAMR (Maternal Mortality Review) where maternal deaths vary greatly

between races, ages, income levels, and location (Kuriya 663).

In 2006 Stanford University School of Medicine joined forces with the state of California

to create The California Maternal Quality Care Collaborative (CMQCC). The CMQCC began

the Supporting Vaginal Births Collaborative which promotes vaginal births after previous

cesarean births and reduce cesareans for first time mothers (What We Do). The rate of cesareans

in the United States is accounts for approximately 32% of living births (McCarthy). Cesareans

are a major factor in cases of hemorrhage during delivery, which is why CMQCC is working to

reduce Cesareans create scar tissue on the uterus, and as assumed general practice, once a

woman has a cesarean she will continue to have cesareans with subsequent pregnancies, creating

more scar tissue. In the presence of uterine scar tissue placentas implant poorly and after the

delivery of the baby and placenta the uterus continues to bleed. The MMR in California dropped

55% in the timeframe of 2006 to 2013, with the implementation of the CMQCC (Barone).

In July, 2018, two bipartisan bills were submitted to Congress to address maternal health

in the United States. The first, the Preventing Maternal Deaths Act, will make individual states

form committees that will review maternal deaths (Beutler & Krishnamoorthi). With the ability
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to recognize trends on a state level it may be easier to implement necessary changes for better

outcomes. The second, the Ending Maternal Mortality Act, will be a federal level legislation

with the aim to reduce our national maternal mortality rate by 50% within ten years, and

eliminate preventable maternal deaths entirely within twenty years. Representatives Jaime

Beutler (R-WA) and Raja Krishnamoorthi (D-IL) have said “We cannot be satisfied until we

have the lowest maternal mortality rate in the world and we can prevent any woman from dying

in childbirth due to preventable conditions for lack of proper care.” (Beutler & Krishnamoorthi).

Legislative action is a positive step for America’s fight against maternal mortality; however,

dividing the responsibility between state and federal committees is not always as successful, as it

creates gaps in communication and enforcement. As discussed previously, the 2003 death

certificate revision took over ten years to be used nationally and, in that time, comprehensive

data identifying trends and risk factors contributing to maternal deaths was not collected.

Regardless of how the data is collected and correlated, the greatest concern is about what

is being done to prevent, or even eradicate maternal mortality. Improvements in collecting data

about maternal deaths will make it easier to see pinpoint how mothers are being failed. The data

needs to be used to make sure that women are equally getting necessary healthcare. Healthcare

facilities must recognize gaps in maternal care. They should strive to utilize programs such as

those used by the United Kingdom and in California, to improve maternal outcomes. All of

these improvements must be supervised and enforced on a federal level if we are to see America

decrease maternal mortality and become the standard for others to follow.
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Works Cited

Barone, Jeanine. “Why Is Maternal Mortality So High in the U.S.?” @Berkeleywellness, Remedy

Health Media, LLC, 1 Feb. 2018, www.berkeleywellness.com/healthy-

community/health-care-policy/article/why-maternal-mortality-so-high-us. Accessed 5

October 2018.

Beutler, Jaime Herrera, and Raja Krishnamoorthi. “Alone among Developed Nations, the US

Maternal Mortality Rate Is Rising. Here's How We Can Fix That.” TheHill, The Hill, 26

July 2018, thehill.com/blogs/congress-blog/healthcare/398860-alone-among-developed-

nations-the-us-maternal-mortality-rate. Accessed 5 November 2018.

“CA-PAMR (Maternal Mortality Review).” California Maternal Quality Care Colaborative,

www.cmqcc.org/research/ca-pamr-maternal-mortality-review. Accessed 18 November

2018.

Kuriya, Anita, et al. "Incidence and causes of maternal mortality in the USA." Journal of

Obstetrics and Gynaecology Research, vol. 42, no. 6, 2016, pp. 661-668. OhioLINK

Electronic Journal Center, doi:10.1111/JOG.12954. Accessed 1 November 2018.

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doi:10.1097/aog.0000000000001556. Accessed 5 November 2018.

MacDorman, Marian F., Declercq Eugene. “The failure of United States maternal mortality

reporting and its impact on women’s lives.” Birth, vol. 45, no. 2, June 2018, pp. 105‐

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“Maternal Mortality.” World Health Organization, World Health Organization, 16 Feb. 2018,

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2018. Accessed 5 November 2018.

McCarthy, Niall. “Which Countries Have The Highest Caesarean Section Rates?

[Infographic].” Forbes, Forbes Magazine, 12 Jan. 2016,

www.forbes.com/sites/niallmccarthy/2016/01/12/which-countries-have-the-highest-

caesarean-section-rates-infographic/#582901975b19. Accessed 18 November 2018.

“Pregnancy Mortality Surveillance System.” Centers for Disease Control and Prevention,

Centers for Disease Control and Prevention, 7 Aug. 2018,

www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-

system.htm. Accessed 16 November 2018.

Tavernise, Sabrina. “Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study

Finds.” The New York Times, The New York Times, 21 Sept. 2016,

www.nytimes.com/2016/09/22/health/maternal-mortality.html.

“What We Do.” California Maternal Quality Care Collaborative, www.cmqcc.org/about-

cmqcc/what-we-do. Accessed 16 November 2018.

Womersley, Kate. “Why Giving Birth Is Safer in Britain Than in the U.S.” ProPublica,

ProPublica, 31 Aug. 2017, www.propublica.org/article/why-giving-birth-is-safer-in-

britain-than-in-the-u-s. Accessed November 17 2018.