Part Two in a Three-Part Maternal Health Series
An estimated 60% of United States pregnancy- related deaths are preventable (AJN, 2019). Not only is the U.S. maternal mortality rate the highest in the world, but it continues to rise while other developed countries’ rates are decreasing each year. Death rates in the U.S. related to pregnancy and birth have more than doubled in the last twenty years, matching the mortality rates of women lacking access to healthcare who deliver babies in developing countries (Kaplan, 2019). There is a racial disparity as African American, Native American, and Alaska Native women die of pregnancy-related causes at a rate three times higher than white women (Rabin, 2019). All of these statistics are from the Centers for Disease Control and Prevention reports written in 2019.
Why is the United States losing pregnant and postpartum women at a rate equal to countries with no access to hospitals and organized healthcare? The concern has become a focus of the upcoming 2020 U.S. Presidential Election, as candidates have made this topic part of their platform (Rabin, 2019). Dr. Lisa Hollier, the former president of the American College of Obstetricians and Gynecologists, states that “we are missing opportunities to identify risk factors prior to pregnancy… during pregnancy, and postpartum, particularly for black women” (Rabin, 2019). The implication is that African American women have higher rates of obesity, cardiac disease, and hypertension, which can be causes of prenatal and postnatal complications. Dr. Elliott Main, medical director of the California Maternal Quality Care collaborative, argues “That’s not the driver… you shouldn’t die of obesity. You shouldn’t die of hypertension,” indicating there is more to blame than a pregnant person having these conditions (Rabin, 2019).
While there are documented conditions leading to maternal mortality, Kaplan (2019) notes one of the biggest factors are complications linked to Cesarean sections, which occur in one in three deliveries. In the world, Sweden has one of the lowest rates of maternal mortality, and one of the lowest C-section rates (Kaplan, 2019). C-sections are performed more in the United States than in any other country (Kaplan, 2019). Dr. Neel Shah, a professor at Harvard Medical School, and director of the Delivery Decisions Initiative, states a woman should pick a hospital to birth her baby according to the C-section statistics of that facility (Kaplan, 2019). Dr. Shah conducted a national study on C-section rates by hospital, and found “a woman’s chances of having a surgical deliver had less to do with her health, the health of her baby, or her doctor, and more to do with the hospital she delivered in” (Kaplan, 2019).
There is a lack of education in discharge, and an inadequate schedule of follow-up doctor appointments. Most new mothers go home without knowing they should return to the hospital if they develop chest pain, shortness of breath, increased bleeding, signs of infection in the C-section incision, swelling or redness on the lower legs, fevers, headaches, etcetera. A headache may be dismissed, when it could be a symptom of something more serious, such as hypertension or a stroke. Currently, a postpartum appointment is scheduled for six weeks after delivery, as a single appointment. Research shows recovery is an ongoing process and should be standardized to include an appointment within in the first three weeks, at twelve weeks, and then on a case by case basis, include more frequent and continued appointments as needed (Kaplan, 2019). This is difficult for women with Medicaid who lose coverage sixty days after giving birth (Kaplan, 2019).
There is a marked lack of research within the United States to explain why the maternal maternity rates are so high, and therefore it is difficult to initiate protocols to prevent prenatal and postnatal deaths. Dr. Shah states that the lack of standardized protocols for pregnancy-related conditions is a major factor in maternal mortality (Kaplan, 2019). He notes that if a man goes to the ER with chest pain, there is a rule to how quickly they are seen, and there is a national goal for door to catheterization lab times. (Kaplan, 2019). There are no such protocols for pregnancy-related complications. There is also no explanation for the causes cited for maternal death. For example, if a death is listed as being caused by postpartum hemorrhage, was it because there was no blood available, lack of nursing assessments within the hospital, or an untreated prenatal anemia (Kaplan, 2019)?
States are responsible for overseeing medical regulation and surveillance, as opposed to other countries (with better maternal mortality rates) where the national government is in charge. For this reason, Congress passed a new federal law in 2018 called the Preventing Maternal Deaths Act (PMDA, 2018). This provides federal grants to states in order to investigate deaths of pregnant women, and women who die within a year of their pregnancy. This has been a positive step in the right direction as evidenced by new guidelines being developed by the American College of Obstetricians and Gynecologists, including one released in May of 2019 regarding treating heart disease during pregnancy (Kaplan, 2019). As more statistics are compiled since the passing of this law, it will allow for better directed and funded research studies with the goal of decreasing maternal mortality. In the meantime, it is up to the medical professionals who see pregnant and postpartum women to fully educate their patients on potential signs and symptoms that can indicate life threatening complications.
AJN. (2019). An estimated 60% of U.S. pregnancy-related deaths are preventable. AJN, American Journal of Nursing,119(8), 17. doi:10.1097/01.naj.0000577400.99328.ca
Kaplan, E. K. (2019, March 5). Reducing maternal mortality. The New York Times. Retrieved from https://www.nytimes.com/2019/03/05/well/family/reducing-maternal-mortality.html?action=click&module=RelatedLinks&pgtype=Article
Preventing maternal deaths act of 2018, H.R. 1318, 115thCongress. (2018).https://www.congress.gov/bill/115th-congress/house-bill/1318/text
Rabin, R. C. (2019, May 7). Huge racial disparities found in deaths linked to pregnancy. The New York Times. Retrieved from https://www.nytimes.com/2019/05/07/health/pregnancy-deaths-.html?linked=google&auth=linked-google