The scandal behind the scandal of US maternal mortality

5FAB2135-1485-443C-8A18-11CB6507EA0D

The US maternal mortality rate has become a scandal. Too many women, particularly women of color, die of pregnancy related causes or in the year after giving birth.

But a comparable scandal, in my view, is how we let maternal mortality rise so high. We deliberately ignored the actual data about maternal mortality in favor of a conventional wisdom that blamed C-sections rates, obstetric technology and obstetricians.

We ignored the actual data about maternal mortality in favor of a conventional wisdom that blamed C-sections rates, obstetric technology and obstetricians.

A new report from the CDC, Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths, confirms the scandalous truth.

An article from CBS explains the findings:

Maternal mortality is much higher among black women.

The maternal death rate among black women was 37.1 deaths per 100,000 live births, a rate up to three times the rates for non-Hispanic white and Hispanic women, the report said.

Maternal mortality is not, by and large, a problem of death in childbirth; it’s a problem of women dying AFTER being discharged from the hospital.

Maternal mortality is not a problem of pregnancy complications; it’s a problem of pre-existing chronic conditions exacerbated by pregnancy.

Heart disease and stroke caused more than 1 in 3 pregnancy-related deaths between 2011 and 2015 in the United States, according to the CDC.

Maternal mortality reflects the increasing age of pregnant women.

The data also showed the maternal death rate among women 40 and older was 81.9 deaths per 100,000 live births, almost eight times the number for women under 25.

Maternal mortality has NOT been rising precipitously as has been claimed repeatedly. The new report has finally eliminated the errors due to disparate methods of reporting in different states. The maternal mortality rate in 2018 is almost exactly the same as it was in 2007.

The US maternal mortality rate did NOT double from 1991 to 2015 as activists repeatedly claimed. Nearly all of the purported increase was due to better reporting, not increased deaths.

From the actual report:

Without the adoption of the checkbox item, maternal mortality rates in both 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births compared with 8.9 in 2002. With the checkbox, the maternal mortality rate would be reported as 20.9 and 21.8 deaths per 100,000 live births in 2015 and 2016.

I feel justified in saying ‘I told you so.’

Nearly 10 years ago I made many of these points in an article for Salon Magazine, Is there really a “maternal mortality crisis?”.

…[I]t is not clear that maternal mortality is even rising, let alone rising because of decreased access to care or increases in the C-section rate. Review of the data suggests that changes in the way that maternal mortality is assessed may be leading to a spurious “increase” in maternal mortality. Moreover, a detailed analysis of the causes of maternal mortality casts serious doubt on either access or interventions as the reason for any rise.

Over the years I’ve continued to question the conventional wisdom:

The rise in US maternal mortality: the cause will surprise you
Is US maternal mortality rising? Maybe not.
Latest data on US maternal mortality confirms it is a problem of race and healthcare disparities
Experts acknowledge MORE interventions are needed to reduce maternal mortality
Surprise! CDC confirms US maternal mortality rate is high because pregnancy is inherently dangerous.

In 2017, in the wake of a blockbuster report from ProPublica and NPR that advanced the conventional wisdom, I noted:

The take home message about maternal mortality in the US is a lot more nuanced than the ProPublica/NPR piece implied. It’s not a problem of privileged white women who are victims of malpractice. It is a problem with profound racial disparities and changing causes of death. And it’s also a story about what happens when people forget that pregnancy is inherently dangerous and demonize technology instead of using it to save lives.

The problem of maternal mortality persists because we refuse to recognize the nature of the problem and refuse to take the steps necessary to reduce it:

We must stop demonizing C-sections and interventions; they are lifesaving and it is the LACK of interventions that kills pregnant and postpartum women.

We must acknowledge the critical role of race/ethnicity including the fact that international comparisons of maternal mortality are invalid if they don’t correct for race/ethnicity.

We must stop pretending that more midwives and doulas (promoted because they are less expensive) can reduce maternal mortality. The problem is lack of perinatologists and obstetric intensive care units and midwives and doulas cannot fix that.

We must stop pretending that pregnancy is inherently safe when it is inherently dangerous and becomes more dangerous still when women are older or have pre-existing chronic conditions. We should never “trust” birth but should drill endlessly on quick response to hemorrhage, pre-eclampsia and other deadly complications.

In my view, the most important fact about US maternal mortality is this:

…[A]lthough Washington, DC, has the highest maternal mortality ratio in the nation, non-Hispanic white patients in this district have the lowest mortality ratio in the United States…

We are capable of providing excellent, life saving care for those who can afford it. If we want to reduce maternal mortality, we must ensure that all pregnant women — regardless of ability to pay — have access to the highest quality obstetric care.

  • demodocus

    Sometimes it seems like being a person of color is a pre-existing condition, at least so far as how others are more likely to act towards you. if that makes any sense….

    • fiftyfifty1

      The perfect storm: less likely to be listened to, less likely to be believed, less access to a wide variety of resources, less scientific research into conditions that affect you more. More stress, more bullshit.

  • fiftyfifty1

    So let me clarify, when you said in the 2010 Salon piece that maternal mortality was not a problem of “access”, you meant access to standard obstetric services, right? Because I agree, women do have access to standard services in most locations. But what women DON’T have consistent access to is specialty care for high risk maternal medical conditions. We have plenty of NICU beds and neonatologists, but almost no dedicated maternal ICU beds or maternal intensivists. If we are going to save women, we are going to have to recognize the dangers, take them seriously, and have this specialized high risk care ready to go. People say “pregnancy is not a disease” and obviously that is the case. But the physiology of pregnant and postpartum women is profoundly different that usual physiology, and these differences have serious risks.

    • mabelcruet

      In the UK, technically every woman has access to the same standard of care, regardless of income, but we still have higher maternal morbidity and mortality in women of colour, and there are variations between the ethnic groups with Black women getting more sepsis, and Bangladeshi and Indian women getting more haemorrhagic problems and increased risk of placenta accreta. So its not simply equitable access to care, there’s other issues in play. Some of the potential reasons are low health literacy, language barriers, non-familiarity with how the NHS operates (especially for immigrant mothers), and it might be that women of colour find it difficult to advocate for themselves, and when they do, their concerns are dismissed. Look at Serena Williams-confident, intelligent, capable woman who could potentially have died because the staff dealing with her didn’t take her seriously at first about her symptoms of her pulmonary embolus.