Introduction
In the United States today, pregnant women carry a higher risk of dying during or shortly after pregnancy than in any other developed country in the world. In the past, pregnancy and childbirth have always been associated with inherent dangers for the mother; indeed, recorded evidence up until the nineteenth century of the death of women during childbirth tell the story that if a woman was to perish during birth or in the period afterwards, then it was no great surprise. Fortunately, maternal health care has come a long way, and today in the United States, women should theoretically enjoy the best maternal health care the modern world can offer. However, the risk of morbidity and death amongst American women during pregnancy, birth, and post-partum are still present. The question remains: why are women still dying during and after childbirth in America despite first-class health care? From the 1600’s through to the 1800’s, it was common for women who gave birth in hospital to die.
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"Severe Maternal Morbidity and Mortality in the United States".
Today, it is understood that the reason for this so-called ‘child-bed fever’, now called puerperal fever, was lack of hygiene. It was usual for doctors to conduct frequent vaginal examinations on patient after patient, without washing their hands or cleaning their instruments. By the 19th century, physician Ignaz Semmelweisz realized that women who gave birth at home had a better chance of survival than those who labored in hospitals, and he subsequently discovered that by washing his hands with antiseptic reduced the instance of childbed fever by a staggering 90 percent. Since then, childbirth in the Western world occurs in a sterile environment, to negate the impact of bacterial infection. There are however, other contributing factors to why women die or come close to dying after giving birth in modern America.
According to Creanga et al (2014), “a pregnancy-related death is defined as the death of a woman during or within 1 year of pregnancy that was caused by a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.” The World Health Organization (WHO) state that postpartum deaths are associated with substandard care. Therefore, if high quality pre- and post-natal care was offered to all women, then the rates of sever maternal morbidity and mortality in the United States would be reduced.
Section I
Centers for Disease Control and Prevention’s Division of Reproductive Health (CDC’s PDH) conducted a longitudinal study spanning the years 1987 to 2009. Their findings demonstrated that for every 100, 000 live births, the numbers of associated deaths consistently rose each year – 7.2 to 17.8 respectively. This begs the question, why? In 2009, there was an influenza epidemic in the United States, hence the dramatic rise in that year from the previous year. In 2003, death certificates added a pregnancy checkbox, which may explain the increase. This study highlighted the discrepancies between white woman and all other groups; there were higher rates of death in these groups with African American being the highest. Certain causes of death had decreased, such as haemorrhaging and sepsis, but cardiovascular causes had risen, according to this study (Creanga, 2014.)
In their 2011 study, Kuklina and Callaghan report that “heart disease is the leading cause of maternal mortality in developed countries”. Their study demonstrated that in the years 2004 to 2006, there was a noticeable increase in the four categories of heart disease (rheumatic valve disorders, congestive heart failure, congenital heart disease, and chronic heart disease.) In the same study, several reasons for the deaths that occurred amongst pregnant women in the United States during delivery due to heart problems were: 1) lack of established protocol in the management of these types of pregnancies, and 2) clinical decision-making based on the experience of a single institution. Suggestions made by the study to remedy this situation are that doctors remain vigilant for complications when treating pregnant women with heart disease, using a low threshold in order to begin investigation to exclude complications, and a registry of clinically detailed data.
When these statistics are compared to other developed nations, a frightening picture emerges. The maternal morbidity rate, or MMR, dropped markedly in Australia, New Zealand, The Netherlands, Canada, Germany, Switzerland and Singapore in the years 1990 to 2013. In the United States, however, this number went up.
Section II
Coeytaux, Bingham and Strauss (2011) assert that the reasons behind these deaths are lack of decent medical care. As previously discussed, mortality is more prevalent in African American woman (40 percent), compared to 12 percent for white women and 16.5 percent of woman of other ethnicities. These women do not have a higher rate of pre-existing conditions than any other group (conditions such as eclampsia, pre-eclampsia, haemorrhage, placental abruption and placenta previa.) Coeytaux et al assert that many of these women are falling through the cracks of the healthcare system because they cannot afford prenatal care right at the start of their pregnancy, when these problems could be detected early on. Discrimination also plays a part; these women are not afforded the same high degree of care that other American women are. These issues are all solvable. Coeytaux et al refers to this crisis as “a human rights failure”, and in direct conflict with the Universal Declaration of Human Rights”. More American women will die unnecessarily if these issues are not addressed.
Section III
Severe maternal morbidity is considered to be highly preventable. Hounton et al (2013) examine a program called maternal death surveillance and response (MDSR), aimed at reducing the number of maternal morbidity cases in the United States. Their article highlights several responses to this serious issue. These responses are: the compilation of accurate data to ensure accountability, methods of improving the accuracy of education, counting and reporting of deaths, providing more accurate estimations of maternal mortality rates, and offering actions to improve quality of care and reduce maternal deaths. Criticisms of the MDSR model that are applicable to the United States include lack of budget and lack of commitment from overloaded and time-poor clinicians.
Conclusion
Women living in the United States are at an increasing risk of maternal morbidity today, more so than in any other developed nation. Cardiovascular complication is one of the leading reasons for this. In America, African American women are four times more likely to succumb to this than women from any other groups, despite this group not having higher rates of pregnancy complications such as pre-eclampsia. This morbidity and mortality could be avoided in most cases, if women had access to proper prenatal and postnatal care. The maternal death surveillance and response program (MDSR) highlights the need for a systematic approach to recording post-partum deaths so that accurate figures can be ascertained, and the need for procedures to be put into place to ensure that every woman in the United States has equal access to the best medical care available. If high quality pre- and post-natal care was offered to all women, then the rates of severe maternal morbidity and mortality in the United States would be reduced.
- Coeytaux, F., Bingham, D. and Strauss N. (2011). “Maternal Mortality in the United States: a Human Rights Failure”. Contraception Journal, 83, pp. 189-193.
- Hounton, S., Bernis, L., Hussein, J., Graham, W., Danel, I., Byass, P. and Mason, E. (2013).
“Towards elimination of maternal deaths: maternal deaths surveillance and response.” Reproductive Health, 10 (1). - Jones, R., Baird, S., Thurman, S., Gaskin, I. (2012). “Maternal Cardiac Arrest: An
Overview”. Journal of Perinatal and Neonatal Nursing, 26 (2), pp. 117-123. - Kukilna, E. and Callaghan, W. (2011). “Chronic heart disease and severe obstetric morbidity
amongst hospitalisations for pregnancy in the USA: 1995-2006.” BJOG. 118 (3), pp. 345-352. - Sofer, Dalia (2016). “Maternal Mortality in the United States is on the Rise”. American Journal of Nursing. 116 (11), p. 14.
