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Too many new mothers are dying in the US
How much exactly, however, is more difficult to determine.
After years of neglect, the issue of maternal mortality is finally getting attention policy and politicsas well as in the media, with headlines highlighting figures showing that the maternal mortality rate, at least according to some measures, doubled in the past two decades.
But some recent newspapers and media stories have questioned whether the crisis is more of a crisis perceptionwhich raises concerns about whether overcounting and bad data has led to fear mongering. An essay published in The Atlantic Oceanwho criticized the “doom and gloom” attitude towards maternal health status in the US, argued: “It’s not getting worse for women; we’re getting better at following what’s going on.
It’s true that data varies: Various sources estimate that the maternal mortality rate per 100,000 live births in 2020 was 23.8 (according to figures from the Centers for Disease Control and Prevention). National Vital Statistics System); 24.9 (according to the CDCs Prevention’s Pregnancy Mortality Surveillance System); and 18.4 (according to the 38 states reporting to the CDCs Maternal Mortality Assessment Committee). Some data sources classify deaths as maternal deaths only up to 42 days after delivery, while others categorize them as such up to a year after the person gives birth. Variations in death records over time make accurate historical comparisons impossible. And the absolute number of maternal deaths is so small (typically less than a thousand per year, and 861 in 2020) that even one or two miscategorized deaths make a difference.
But even without definitive data, there are undeniable facts. The maternal mortality rate in the US is several times higher than in comparable countries. Racial inequality plays a major role in maternal health outcomes. And black women in particular are three to four times more likely to die from pregnancy-related causes than their white counterparts, regardless of their income or educational status.
The result: Improving the collection and analysis of maternal data is important. But experts studying the issue say this should not overshadow the fundamental work of understanding why maternal deaths occur and how they can be prevented.
“We can’t let discrepancies around data distract us from how poorly we are performing in the United States, as well as the extent to which there are disparities between different racial groups, payer groups, and language groups,” says Amanda. Williams, clinical innovation advisor at the California Maternal Quality Care Collaborative, an organization co-founded in 2005 by the state of California and Stanford University to improve maternal health.
“Either way, we really have a problem,” said Eugene Declerq, a professor of community health sciences at Boston University School of Public Health and a leading expert on maternal mortality data. “And you can’t solve it by ignoring it.”
The qualitative side of maternal mortality
While data is important, experts say, so is the qualitative side of maternal mortality — meaning not just whether or not a new mother died, but how, and why, and what led to such an outcome.
This side of the issue is perhaps best represented by the work of national maternal mortality review boards, which act as medical and social research teams and consider every reported case as a potential maternal death in a state – even in very large statesthe number of deaths rarely exceeds 100 per year – and research is underway to determine whether this can be considered a maternal death and whether it could have been prevented.
The key question is whether the person would have died if she had not become pregnant within the past year. “And trying to determine that in a death that occurs five months after the baby’s birth is really challenging,” said Declercq, a member of the Massachusetts review board. “Then we also have to wrestle with: ‘was it preventable?’ And you often end up with this dilemma: It could be prevented if we had a functional social system that helped take care of her when she was seventeen and first developed a drug problem.”
Such questions apply to many other possible causes of death. A woman murdered by her domestic partner: was her pregnancy or being a new mother a factor? A new mother falls asleep at the wheel after work: could parental leave have prevented her death?
Maternal health care advocates believe that one reason it took so long for these deaths to be recognized as a serious health problem is that maternal mortality sits at the intersection of many systemic diseases: racism, economic inequality, poor access to healthcare and misogyny.
Addressing maternal mortality “has never been about one thing: it’s about a revolution,” says Joia Crear-Perry, the founder and president of the National Birth Equity Collaborative, one of the leading maternal health advocacy and policy organizations in the country.
Focusing on the accuracy of data to argue that concerns about maternal mortality are overblown could even be seen as a response to the maternal health movement, said Michelle Drew, a midwife and maternal health advocate and the director of Ubuntu, a collective focused on maternal care. of health care and community workers serving Black families in Delaware.
Black women are at the forefront of the movement to recognize and address the maternal mortality crisis, Drew points out, and the nature of the issue makes it inherently political. “Each [case] indicates some form of bias,” she said.
The history of maternity care in the U.S. is inextricably linked to issues of white supremacy, Drew said. For example, in the early 20th century, white doctors used this racist stereotypes to question the competence of black midwives, with the intention of profiting from childbirth.
Those who aren’t convinced there is a crisis now wouldn’t be swayed by stronger data either, Crear-Perry said: “I don’t know what number the crisis is going to make [them] care.”
There is no way to successfully improve maternal health status in the U.S. without embracing larger reforms, which ultimately makes the issue controversial, Crear-Perry and Declercq said.
This is especially evident when making international comparisons. “The difference in those other countries is very often that they have universal health insurance, paid leave, and all those other things that make life more livable for a pregnant woman and her family,” Declercq said. “That is right in the wheelhouse of policymakers, and then that is uncomfortable, because that is real expenditure.”
Some of the advocacy for better maternal health in recent years has already yielded important policy progress, Williams noted. “Expansion of Medicaid, paid family leave, increased funding for maternal health care, better funding for pregnancy mortality review boards – these are steps that are being taken and are meaningful steps in the right direction,” she said.
Near misses and avoidable deaths
Too much focus on quantifying maternal deaths also risks overshadowing another important problem: the much larger number of women who almost die or become seriously ill during and shortly after pregnancy.
Data on this problem is even more elusive. Estimates indicate that there are between 50 and 100 near misses per maternal death, and that approximately 60,000 cases of severe maternal morbidity cases — unexpected labor and delivery outcomes with serious short- or long-term consequences.
Focusing on near misses will provide a better understanding of what else can be done, both medically and beyond, to save the lives of mothers. A large majority of maternal deaths, or more than 80% of casesare preventable.
“I have been an obstetrician for over 20 years and I can count on one hand the number of maternal deaths I have been associated with,” Williams said. “But when it comes to serious maternal deaths, it happens once or twice a month. It is 1% to 2% of births.”
Conditions Williams sees in her patients include eclampsia, seizures and sepsis, all of which can result in death if, for example, they occur in a hospital with fewer resources, or where the staff is less skilled. Every near miss, Williams said, offers an opportunity to understand how a death was prevented — and what goes wrong if the mother can’t be saved.
In many cases, “if the patient had someone to call, or knew the warning signs, or did not feel stigmatized about getting care for her drug treatment, or if she lived in a city closer to a major hospital, she would don’t do that.” lost her life,” Williams said. “These are all issues that can be solved if we have the political will to do so.”