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Is maternal mortality in the United States as bad as we think?

Every day around the world 1,500 women die in child birth. In 2005 more than 500,000 women died giving birth. This is, of course, a double tragedy – a woman dying early from something that should be a joyful event and a baby left without a mother.

WHO maternal mortality by country, 2005

There is a big difference in the rate of maternal mortality based on country. The reason appears to be primarily economic: those who are more disadvantaged and do not have access to a skilled birthing attendant or life saving medications to stop bleeding or halt an infection die from what is preventable in a full-staffed hospital.  In addition, extreme poverty affects nutritional status, another co-factor in mortality.

The goal is obviously to have the lowest maternal mortality, fewer than 10 deaths per 100,000 live births. This rate has been achieved in Canada, Northern Europe and the United Kingdom, Australia, New Zealand, and Japan. But not here in the United States. A study published in 2010 in Obstetrics and Gynecology by Berg et. al. evaluated maternal mortality during the eight-year period from 1998-2005. The rate was 14.5/100,000 live births (it was at an all time high of 16.8 in 2003, the year I delivered my babies).

There is a lot of talk that this high rate is due to problems with obstetrical care, when in fact the exact opposite is true. This same study looked at demographics and social factors. We know in third world countries these factors affect maternal mortality, so why not in the United States as well?

The results? If you have any prenatal care in the United States the pregnancy related mortality is 7.6/100,000, which is in the target range. However, for women with no prenatal care at all, the rate sky rockets to 39.1/100,000. In the United States, as everywhere else, poverty and lack of prenatal care are killers.

When the data are teased apart even more we see sad racial inequities. A white woman with prenatal care has a maternal mortality rate of 5.4/100,000 and for an African-American woman it is 18.9/100,000. Among other non-white women the mortality rate is 7.6/100,000, so African-American mothers are dying disproportionately in this country. Among those with no prenatal care the maternal mortality is on par with Eastern Europe (or worse): white women with no prenatal care in the U.S. have a mortality rate of 30.9/100,000 and African-American women, a staggering 56.1/100,000.

Why are African-American women dying at disproportionately higher rates? Many experts cite high rates of obesity and high-blood pressure (conditions more common among African-American), but there also appears to evidence of disparities in care.

So the United States is a microcosm of the world. Women in better health with access to the best prenatal care have the best outcomes. The low rates of maternal mortality among white and other racial groups with prenatal care show us it can be done, but we still have a lot of barriers to overcome. We also need to re-bouble our efforts with African-American women to address the higher rates of mortality for these women.

And as an aside to all those pro-life politicians who disparage universal medical care? Access to prenatal care clearly saves the lives of women, regardless of race. Universal prenatal care doesn’t address the racial inequities in this country, but it would reduce the risk of women of every racial and ethic background dying in childbirth. That’s pretty pro-life, don’t you think?

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Discussion

7 thoughts on “Is maternal mortality in the United States as bad as we think?

  1. I really like this post, but I can’t help feeling like the title is a bit misleading. It’s not that we don’t have a serous maternal mortality problem but that it’s a healthcare access issue (esp for prenatal care) much more than it’s an obstetrics issue.

    Posted by Emily | July 7, 2011, 3:39 pm
    • That is the point I am trying to make. There is much insinuation that the ,maternal mortality rate in the US is the result of poor maternal care, but thatis not the case. Women who are healthy with good OB care have similar rates of mortality compared with England, Canada, etc. Those that do not have a higher rate, much more so for African-American women.

      Posted by Dr. Jen Gunter | July 7, 2011, 10:41 pm
  2. Thanks for this post – I couldn’t agree more.
    I think we already do have pretty close to universal prenatal care. That’s one thing public aid programs are pretty good about paying for. The huge black-nonblack disparity with regard to prenatal care exists, at least in part, because so many black women don’t/can’t take advantage of this service. Public policy experts will know better than me why this is the case but some factors include things like drug abuse issues, teen pregnancy and simple transportation issues.
    The upshot of this and many other similar discussions is that we need universal health care. I think the Affordable Care Act is an important first step, but not the final answer.

    Posted by James Logan | July 7, 2011, 5:04 pm
    • Sadly many women with Medicaid do not get prenatal care. And unfortunately there are many women who still get no prenatal care. My first night on call in the United States not one of the 4 women I delieverd has seen any OB provider during her pregnancy. I was amazed as coming from Canada the only women without prenatal care were young girls who were hiding their pregnancies from their families. The residents could not belive that I had never seen so many women who had never had prenatal care. It shicked me then and still shocks me to this day.

      Posted by Dr. Jen Gunter | July 7, 2011, 10:43 pm
  3. I was a “near miss” due to eclampsia and HELLP syndrome. I had good prenatal care, but I was not aware of HELLP syndrome. There is a bit of an education gap too – if I had known the warning signs I might have caught it before it got all the way to eclampsia. But it happened very quickly – between appointments. Still, I am shocked at the statistics and the gaps shown in the above post. I can think of nothing more ‘pro-life’ than good, affordable, and universally accessible prenatal care. There is no good excuse for the disparities in care.

    Posted by jbcarney | July 8, 2011, 2:25 am
  4. Nice Post, I’m a bit confused though. I thought Medicaid (pre-ACA) covered prenatal care for uninsurered women? i.e. if you’re an un-insurered woman and you get pregnant, you can then immediately enroll in medicaid. Do you know if this true? I know Medicaid covers at least the delivery itself, right?

    Is it just that many of these women do not know about their ability to enroll in Medicaid, or is there really a coverage gap that will hopefully filled with the ACA?

    Posted by danbeachler | July 8, 2011, 3:18 am
    • Many women do not know how to enroll in Medicaid. The sad thing is if they just show up for care, the hospital will help them. And then cans tart accessing care because they are presumed Medicaid eligible until proven otherwise and you can’t bill someone who is Medicaid eligible.

      Even with Medicaid, many women choose to not access care. In Parkland in Dallas COunty they changed their program by adding many community clinics and dramatically improved access and their prematurity rate dropped to less than 10% (best in nation).

      But there are women who are uninsured because they work for small companies that don’t offer health care but their income may be too high to qualify for maternal coverage and then of course all the women here illegally.

      Posted by Dr. Jen Gunter | July 9, 2011, 5:50 pm

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