In honor of Mother’s Day, we take a closer look at the current state of maternity care in the U.S.
Mother’s Day is traditionally observed in the U.S. on the second Sunday of May, and what originally began as a peace movement is now a day to honor and celebrate mothers around the globe. Mother’s Day is also a time to look at the current state of maternity care, maternal health, and maternal mortality rates.
Recent reports have shown that despite all the gains that have been made in the health and mortality rates of children, the United States’ maternal mortality rate (the rate of mothers who die from pregnancy and childbirth-related complications) is not only much higher than many other developed countries, it has doubled in the past 20 years.
There is hope, though. At the end of last year, new laws were passed that should help reverse this trend by establishing review boards and expanding access to maternity care services. This past fall, two senators introduced additional legislation to address gaps and disparities in maternity care for women of color and women living in rural areas. Just this week, Senators Cory Booker and U.S. Representative Ayanna Pressley introduced legislation to help improve access to maternity care by extending Medicaid coverage for new moms and provide more options in order to address systemic racism. Clearly, lawmakers, at least, are starting to pay attention.
Maternal Health And Mortality Rates In Context
To understand what this legislation hopes to accomplish, we need to know how we got to where we are. In days past, women preparing to give birth also commonly prepared for death. Maternal mortality rates in the early nineteenth century averaged 500 to 1,000 women per 100,000 births. Many of these deaths were from puerperal fever (“childbed fever”). Once the practice of washing hands and other hygienic practices, and later, the widespread use of antibiotics, were introduced, this rate declined markedly.
The countries with the lowest mortality rates have an average of only 10 deaths per 100,000 births, with the lowest being Finland, with an average of 3.8 as of 2015. Worldwide, maternal mortality rates have declined overall, most notably in developing countries where rates were still high in 1990. Some countries have succeeded in halving their mortality rates, according to the World Health Organization (WHO), which estimated a global maternal mortality rate of 289,000 mortalities in the year 2013.
The United States, despite having one of the most expensive healthcare systems in the world, has an abysmal mortality rate compared to other developed countries. With a rate of 22 maternal deaths per 100,000 births, it’s four to five times higher than other comparable countries in Europe; the U.S. ranks higher for maternal death rates than many Middle Eastern and Asian countries. While the higher rate of complications and mortality can be partially attributed to a higher number of older mothers giving birth, the average age has similarly risen in many countries where the rates are the lowest.
In 2010, Amnesty International USA published a report on the alarming situation, noting the wide disparities across different states, with women in Washington, DC, dying at a rate 30 times higher than those in Maine.
What’s Wrong With U.S. Maternity Care?
Katy B. Kozhimannil, an associate professor of health policy at the University of Minnesota’s School of Public Health, blames this spike in mortality rates on “the policies and systems that do not support the health of women before they become pregnant, during pregnancy, at the time of childbirth, and postpartum.”
The rise in rates correlates with decreased access to reproductive health because of a rising number of uninsured women and overall less access to healthcare services due to hospital closings and consolidations. Indeed, with the expansion of Medicaid under the Affordable Care Act since that period, more women have been able to obtain free or low-cost healthcare and maternal mortality rates have gone down.
Some of the reasons women are dying are also because warning flags have been ignored — or hospitals simply don’t have the right protocols in place, according to an in-depth investigation by National Public Radio and Pro Publica.
More recently, reports have been emerging that women of color are especially at risk. Last year, a New York Times story highlighted the high rates of both infant and maternal mortality for African Americans, with black women’s rates of death in the U.S. from pregnancy or pregnancy-related causes three to four times that of white women’s. And should this statistic be dismissed as being connected to economics (with an estimated 25 percent of black women more likely to live in poverty), the story of famous tennis star Serena Williams’s life-threatening birth experience underscores that there’s something much more insidious going on.
A Technocratic Model Of Birth
The U.S. healthcare system still relies on what medical anthropologist Robbie Davis-Floyd has referred to as a “technocratic” model of birth.
“We spend four times the amount on healthcare than other countries, yet our system still fails women,” says Jennifer Houston, a certified nurse midwife (CNM) in the Hudson Valley in upstate New York, who has been working with mothers since 1972.
“We still have a healthcare system that overuses unproven technologies that don’t help outcomes — like fetal heart monitoring — and that continues to communicate to women that they need the fear-based, impersonal, machine –reliant dominant model,” Houston adds.
Another reason for these dismal rates is undoubtedly the high rate of Cesarean sections. North America had a C-section rate of 32 percent in 2015 — much higher than the WHO (World Health Organization) recommendation of between 10 to 15 percent. Experts blame financial incentives, legal fears, and convenience for the high rate of C-sections.
“As the discipline of obstetrics formalized, the medical profession entered the birthing sphere with an explicit recognition of the pathologic outcomes associated with labor and delivery … However, for the average healthy American woman, we have seen the medicalization of childbirth lead to certain trends,” explain Dr. Chitra P. Akilaswaren, an OBGYN at Beth Israel Medical Center in Boston, and Margaret Hutchison, CNM, a clinical professor at University of California, San Francisco, in a 2016 commentary published in the journal Obstetrics and Gynecology.
Akilaswaren and Hutchison identify the frequent use of technology (like fetal heart monitoring) and interventions (like labor induction) as leading to higher rates of risky births and Cesarean sections. These are the hallmarks of what has become known as the “medicalized model” of birth.
Solutions To Solve The Crisis In Maternal Mortality
The epidemic of rising maternal mortality rates in the U.S. is not irreversible; we’ve already seen that expanding Medicaid and other health insurance coverage can have an impact.
Experts in the field point to other countries with healthier outcomes for some possible solutions. One place to start, many agree, is a federal-level review board of maternal mortality in order to better assess the situation, collect key data, and understand better what needs to improve. While some states have these boards, too many still do not.
The good news: in December 2018, the president signed into law the Preventing Maternal Deaths Act, which directs more funding for all states to either establish or strengthen their maternal mortality review committees. The information that will eventually come out of these committees “is essential to driving a necessary sea change in the abhorrent maternal mortality and morbidity rates in the United States. It is especially critical for women of color,” said Dr. Susan Stone, the president of the American College of Nurse-Midwives.
The Midwifery Model Of Care
Many researchers argue that turning to a midwifery model of care for healthy pregnant women also can help prevent unnecessary maternal deaths. In the past decades, midwives have come out of the closet, emerging from outdated images as lay healers that use superstition and folk practices. While in the past obstetricians often viewed midwives as competitors, or as risky alternatives, many in the field are now acknowledging the critical importance of working with midwives and incorporating a model that is more mother-friendly.
According to the Midwives Alliance of North America, the best outcomes for women are places where “midwifery is a valued and integral pillar of the maternity care system. The midwifery model is a low-tech, high-caring model that produces excellent outcomes not only for low risk women, but for vulnerable and at-risk women as well.” Obstetricians, by contrast, are trained in high-risk birth, which can lead to an over-reliance on technology for even healthy, low-risk women.
Undoubtedly, obstetricians’ skills are very valuable for women who need them, especially in instances where their specialties are required during a compromising childbirth, but many agree that a midwifery model is linked to best outcomes for most women. The countries that have the best maternal and infant mortality rates are also countries where mothers use midwives at higher rates. The World Health Organization asserts that as much as 83 percent of the deaths of mothers and infants could be prevented by ensuring more access to midwives.
If we want to save more women’s lives, then “we need more midwives trained in the midwifery model of care,” says Houston. In the midwifery model, a woman’s social and emotional context as well as her physical condition is taken into consideration; there is more emphasis on prenatal care and establishing a system of support around birthing women. Midwives work in a variety of settings, including hospitals, birth centers, and in the home.
In their commentary, Akilaswaren and Hutchison advocate a team-based approach to care where midwives, nurses, and obstetricians work together as partners for care. The Access and Integration Maternity Care Mapping (AIMM) Study, a project run out The Birth Place Lab at the University of British Columbia, found a high correlation between healthy outcomes and access to midwives in the U.S. The study’s authors looked at how well midwives were incorporated into existing healthcare systems, building on previous research which demonstrated that “when professionals collaborate on decision-making and when coordination of care is seamless, fewer intrapartum neonatal and maternal deaths occur during critical obstetric events.”
Further, in 2017, the American College of Obstetricians and Gynecologists issued a set of recommendations for low-risk birth that advises more restrained use of interventions — something that advocates for the midwifery model have been pushing for for years.
Not Enough Midwives Or Doctors
Another piece of legislation, the Improving Maternity Access to Care Act, was also signed into law in December 2018. This law helps provide funding for areas where there is a critical lack of maternity care services.
These new laws are all promising strides to help improve maternal health and lower mortality rates, but there is one missing key: there are not enough healthcare professionals to give mothers the kind of care they need. According to WHO, there’s a global shortage of both nurses and midwives, and there is a declining number of OBGYNs who attend births, which means access to proper maternity care is a potential issue for mothers. While many observers have encouraged the use of midwives not only for healthier outcomes but also to solve the problem of physician shortages, how do we solve the problem of not enough midwives?
It may come down again to how we allocate money and resources – and, chiefly, paying existing midwives to train more midwives: according to the American College of Nurse Midwives, “62 percent of midwives who precept students receive no remuneration.” By contrast, physicians usually get their training from well-funded graduate medical education programs.
Perhaps, with the recent and pending legislation that acknowledges the crisis and proposes solution, this will be the next step in saving mothers’ lives.
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