SALT LAKE CITY — The number of deaths related to childbirth and pregnancy has dropped by nearly half worldwide over the last quarter century. But in the United States, the number has doubled since 2000. And the news is even worse for black women, who are at three to four times higher risk than other racial groups.
Experts recently gathered at Harvard's T.H. Chan School of Public Health to consider how health care providers can change that trajectory. Panelists called out rural challenges, racial inequities and the high rate of cesarean sections in America as contributors to maternal mortality that could be prevented.
And they're not the only ones who are worried and wondering why the trend is moving in the wrong direction in one of the richest countries in the world, which also has one of the most advanced health care systems.
The concern is so great that Congress last year passed and the president signed legislation to provide states with grants to investigate pregnancy-related deaths.
The Centers for Disease Control and Prevention and other experts define pregnancy-related death as occurring while a woman is pregnant or within a year of the end of the pregnancy, whether it resulted in a healthy live birth or not, as long as the causes was "related to or aggravated by the pregnancy or its management."
According to the CDC, the maternal mortality rate for white women in the United States from 2011 to 2014 was 12.4 deaths per 100,000 live births, compared to 40 per 100,000 for black women (similar to the rate in developing countries). The overall figure for 2014 was 18 deaths per 100,000 live births, up from 7.2 in 1987.
By comparison, according to United Nations estimates, Canada's maternal mortality rate is exactly half that of the United States,' and some other developed countries, such as Sweden, Norway and Switzerland, have even lower rates.
And those numbers only include the complications that result in death.
"For every maternal death, there are about 60 near misses," said Dr. Haywood Brown, past president of the American College of Obstetricians and Gynecologists and one of the Harvard forum panelists. "And those near misses include things like hemorrhage that didn't lead to death, heart failure that didn't lead to death, a blood clot that didn't lead to death and infection that didn't lead to death."
An estimated 60 percent of America's pregnancy-related deaths are believed to be preventable. The top three preventable causes are severe hypertension (even beyond the hospital stay), postpartum hemorrhage and blood clots, said Dr. Susan Mann, OB/GYN with Beth Israel Deaconess Medical Center and a clinical assistant professor at Harvard Medical School.
What's going wrong?
A Commonwealth Fund report released in December said maternity complications are just one example of how women's health care in America is falling behind.
"Women in the United States have long lagged behind their counterparts in other high-income countries in terms of access to health care and health status," the report said. Among the 11 countries it compared, the report found that Americans have the highest rate of maternal mortality and complications from pregnancy or childbirth. And one-third of women in America said they skip the care they need because they can't afford it, which is the highest rate among the countries included in the study.
Overall, the maternal mortality trend in America has been going up since 1987, according to the CDC. The causes are unclear, but one factor could be how data is collected, making it likely more cases could be identified as pregnancy-related than in years past. Other factors could be an increase in chronic conditions like heart disease and diabetes, which can contribute to pregnancy-related complications. And the age at which women have children, especially a first child, has been increasing, too.
Among pregnancy-related deaths in which the cause is known, causes include cardiovascular disease (15.2 percent), other diseases (14.7 percent), infection (12.8 percent), hemorrhage (11.5 percent), cardiomyopathy (10.3 percent) and blood clots (9.1 percent), the CDC reports.
The Commonwealth Fund report also pointed out America's high rate of C-sections, which are more costly and have higher risk than vaginal delivery, though when they are medically necessary they're credited with saving lives.
"Some research suggests it is a combination of a country's specific health system, physician and patient preferences, cultural factors, population characteristics and payment incentives" that determines whether women deliver by C-section, the report said. Other experts suggest the culture surrounding childbirth at specific hospitals can have great impact on whether women have C-sections.
Implementing best practice in pregnancy-related care is essential to reduce complications and death. Around 2012, the National Partnership for Maternal Safety, the American College of Obstetricians and Gynecologists and several dozen community and health organizations collaborated on "bundles of care" recommendations that identify and explain best-practice treatments to handle challenges like postpartum hemorrhage.
But making information available doesn't ensure that those who provide care consistently use it, a fact that Mann said "really shook Dr. Haywood and I to the core."
About half of babies nationwide are delivered in rural hospitals that see three or fewer births a day, Brown said, while half of U.S. counties "do not have a practicing OB/GYN or a midwife."
That makes it crucial that everyone providing care in a rural hospital be on the same page about what's happening there at a given time so they can use limited resources to the patients' advantage, said Mann. "You can't go and start an elective C-section if somebody else is having a hemorrhage. The time of practicing in individual silos is really over. Our care absolutely needs to be coordinated across the board."
She also recommended hospitals that don't deliver babies regularly do simulations so when crisis occurs they know how to handle it and have confidence because they've practiced.
"You have to make sure that you have ways of delivering the same quality to individuals, whether they're in rural Montana or rural South Dakota, as they are in urban Boston," said Brown.11 comments on this story
She also noted that health care access and affordability are crucial to preventing pregnancy-related complications and death. Women who don't have insurance may not get prenatal care in a timely fashion, or they may not have care available within a reasonable distance, which also leads to receiving inadequate prenatal care.
Rear Admiral Wanda Barfield, director of CDC's Division of Reproductive Health Services, expressed hope that maternal mortality review committees will help reverse the uptick in pregnancy related deaths by showing what goes wrong and identifying ways to prevent them. Such review, she said, is "really our opportunity to truly understand what is going on around the circumstance of a woman's death," including clinical and social factors.