Fixing the US Maternal Health Problem: Signs of Hope?

Kathleen Doheny

December 14, 2021

In the US, nearly 4 million women a year prepare to give birth, looking forward to the joy to come. But for some, the dream turns tragic. About 700 women die each year either during their pregnancy or in the weeks after the birth. And another 60,000 have pregnancy-related or childbirth-related health issues.

Causes of death vary greatly, including hemorrhage during pregnancy or during delivery, heart conditions, and mental health issues such as substance abuse and suicide after the birth.

In 2019, the US maternal death rate was 20.1 per 100,000 women, according to the CDC, significantly higher than the 17.4 per 100,000 recorded in 2018. For Black women, the maternal death rate was more than double the overall — 44 per 100,000 in 2019.

"We have to address our horrendous maternal health care system and also need to address the inequities," says Laurie Zephyrin, MD, vice president for advancing health equity for the Commonwealth Fund, a foundation supporting independent research on health care issues. "This is an issue that has needed national attention for a long time."

"If we look overall, our maternal death rate is more than twice that of more than 10 other high-income countries," she says.

As sobering as the problem is, recent developments have sparked hope that reversing the course is possible. Among them:

  • U.S. News & World Report, long known for its rankings of hospitals, issued its first ever "Best Hospitals for Maternity" rankings Dec. 7, highlighting facilities that perform well on key quality indicators. It plans to update the report annually.

  • At the first ever White House Maternal Health Day of Action on Dec. 7, Vice President Kamala Harris urged a call to action to reduce maternal deaths and pregnancy-related health problems, with extension of postpartum coverage through Medicaid programs, among other actions.

  • A new hospital designation called ''Birthing Friendly" will be established by the Centers for Medicare & Medicaid Services. The label will be given to facilities that take part in a program aimed at improving maternal outcomes and that use patient safety practices.

  • President Joe Biden's proposed Build Back Better plan includes maternal health provisions, including $3 billion in new maternal health funding. The money will aim to grow and diversify the workforce caring for pregnant women, coordinate care better, and step up research on maternal health, among other projects.

  • Ongoing efforts in Congress are aimed at fixing the wide disparities in maternal health affecting Black women. Regardless of income level or education, Black women are at a higher risk of maternal death and other health issues than are white women. A Black woman with a college education is at 60% higher risk of maternal death than a white or Hispanic woman who didn't graduate high school, according to the Commonwealth Fund.

Best Hospitals for Maternity

For its rankings, U.S. News & World Report reached out to the 2,700 US hospitals that offer maternity services, says Ben Harder, chief of health analysis and managing editor at the publication.

To be recognized, a hospital had to submit data from 2019 and meet the publication's maternity care standards. The publication received responses from just 571 hospitals, representing about 2 of every 5 births in the country.

Of those, 237 were identified as best for maternity.

As to why the response rate was not higher, Harder cites the reporting burden and says it is understandable. Some hospitals likely did not have the staff available, especially during the pandemic, to gather the data needed to be evaluated by U.S. News & World Report.

On their other evaluations, the rankings are based on Medicare data, ''so hospitals don't have to lift a finger." He expects more hospitals will respond for their future evaluations of maternity care.

The evaluators focused on five quality measures, making a score based on the cesarean section delivery rate among first-time mothers, early elective delivery rates, unexpected newborn complication rates, breastfeeding rates, and option for vaginal birth after C-section (VBAC).

A Call to Action: Expand Coverage

Speaking at the White House Maternal Health Day of Action, Harris told participants: "The challenge is urgent, and it is important, and it will take all of us."

Being pregnant and giving birth, she said, should not carry such great risks. She zeroed in on systemic inequities in the way women are treated and the dramatic impact maternal death and health issues have on the economy.

"A healthy economy requires healthy mothers and healthy babies," Harris said.

"Before, during, and after childbirth, women in our nation are dying at a higher rate than any other developed nation in our world," she said, noting that research shows that Black women, Native Americans, and women in rural America more likely to suffer.

A major strategy in the call to action, according to Harris, is encouraging states to expand postpartum coverage to pregnant women enrolled in Medicaid or the Children's Health Insurance Program (CHIP) from the existing 60 days to a full year. Together, these two programs cover over 42% of births in the country, so expanding the coverage is expected to have a great impact.

The 60 days of coverage is not enough, as many deaths and complications happen more than 60 days after childbirth, Harris said. The logistics for states to extend coverage were established by the American Rescue Plan and will become available by April 2022, she said. Some states have already extended the postpartum coverage.

According to the Centers for Medicare & Medicaid Services, if every state did adopt an extension, as the Build Back Better Act proposes, the number of Americans getting coverage for a full year after childbirth would about double, extending the coverage for about 720,000 each year.

Congressional Actions

Congress is working on the issue as well. The Black Maternal Health Momnibus Act of 2021, for instance, proposes several measures, including improving maternal nutrition, expanding affordable housing, and extending the maternal workforce to include more doulas and midwives.

"And for so many women, let's note doulas are literally a lifeline," Harris said at the White House event.

Doulas are trained to offer women physical, emotional, and informational support before, during, and after childbirth. No reliable statistics are available on their numbers in the US, but a March of Dimes report estimates that about 9,000 were included in a registration database in 2018.

Explaining and Fixing the Disparities

No one can explain for sure why Black women, in particular, are at higher risk of dying from pregnancy-related complications. Systemic inequity is one likely reason, Harris said, noting there are differences in how people are treated based on who they are.

Inherent and unconscious bias in offering women treatment plays a role, experts say. Training could reverse or reduce that bias. Some women of color also may have less access to care, as do women in some rural areas.

According to Harris, more than 20 companies and nonprofits have pledged to invest more than $20 million in maternal health efforts in the US and more than $150 million globally. Among the proposed programs: remote-care monitors in rural areas, better care models for the postpartum period, and improved education programs for maternal health providers.

When Statistics Hit Home

Many who work to improve maternal health have gone through issues themselves or had loved ones who did.

Jill Arnold, founder of the Maternal Safety Foundation in Bentonville, Arkansas, became a consumer advocate after giving birth to her two daughters, now teenagers. With the first birth, Arnold says she was intensely pressured at the last minute to have a C-section. She held out, resisted, and delivered a healthy baby vaginally.

For her second childbirth, she chose an accredited birth center that allowed her to have a doula and a midwife.

"The care I received was night and day," she says. "The overwhelming pressure to consent to a C-section wasn't there."

She welcomes the information provided by the new U.S. News & World Report rankings as well as the upcoming "Birthing Friendly" designations.

"The onus shouldn't be on patients, on individuals, on pregnant people to do the research," Arnold says.

Rather, women and their partners need information at their fingertips so they can make an informed decision about how to give birth and where.

US Rep. Lauren Underwood (D-IL), who co-founded the Black Maternal Health Caucus in April 2019, with Rep. Alma Adams (D-NC), wrote a touching blog in the journal Health Affairs to explain her passion in improving maternal health.

Her former classmate, Shalon Irving, who went on to become a CDC epidemiologist, died in February 2017 at age 36, just 3 weeks after giving birth, when she developed complications from high blood pressure.

In the blog, Underwood cites statistics and provides details of the Black Maternal Health Momnibus Act of 2021, then ends the blog, published in 2020, with an update on how Shalon's then 3-year-old daughter, raised by her grandmother, is doing. While Soleil is ''curious, joyful, and brilliant," the grandmother told Underwood that she has also walked into a room and found the little girl clutching a framed photograph of her mother.

The child's question is understandable and heartbreaking: She wants to know where her mommy is.

"Soleil's question is my motivation," Underwood writes. "To honor Shalon, and all the women like her who we have lost, let us take the serious and urgent action that is required to save our moms."

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