Every day 830 women around the globe die from pregnancy or childbirth-related causes. Almost all of these deaths occur in the developing world, but over the past sixty years this global problem has made waves at home. While worldwide maternal mortality rates are decreasing, the rates are rising in three countries: Afghanistan, Sudan, and the United States. Between 2000 and 2014, the number of women who died in the United States from pregnancy-related causes while pregnant or within 42 days postpartum increased by almost 27 percent, from 18.8 per 100,000 deaths in 2000 to 23.8 in 2014.

Each year, more than 700 women die in the United States due to pregnancy or causes related to childbirth. Some 3.8 million births occur annually and more than 50,000 women experience pregnancy-related complications. Women are vulnerable to pregnancy-related deaths and complications during pregnancy or up to one year after the end of her pregnancy.  According to the Centers for Disease Control and Prevention (CDC), between 2011 and 2015 more than 31 percent of deaths occurred during pregnancy, 36 percent during delivery or within the week after birth, and 33 percent occurred one week to a year after birth.

Despite the statistics, in the United States, nearly 60 percent of all maternal deaths are preventable.

But they aren’t prevented.

Postpartum Care Gets Short Shrift

One of many factors behind the numbers is uneven quality of care in the United States, where many hospitals lack standardized protocols or guidelines to prevent common causes of maternal deaths. U.S. maternal care tends to focus on the prenatal and birthing periods of a pregnancy, giving little attention to postpartum care or the mother’s health.

However, care for women should not end upon delivery. The World Health Organization (WHO) recommends that pregnant women have eight prenatal visits and four postpartum visits up to six weeks following delivery. Ideally, the woman should be questioned about her emotional well-being and assessed for postpartum complications.

What about women who cannot afford or lack access to quality care? Women who do not receive adequate prenatal care are up to four times more likely to suffer pregnancy-related death. In the United States, $4 out of every $5 spent on pregnancy and childbirth revolves around labor and birth. Leaving little resources for prenatal and postpartum care, including screenings for non-communicable diseases, mental health screenings, educating women about warning signs, and more. On top of that, across the nation, there is a scarcity of healthcare providers, as rural and urban areas are seeing an increase in closing hospitals and maternity units.

Nearly half the counties in the U.S. have no obstetrics or gynecological care and more than half have no nurse-midwives. In 2017, certified nurse-midwives and midwives attended about nine percent of all pregnancies in the U.S. and there is growing evidence that midwives help reduce global maternal mortality rates in numerous ways. A recent study found that states with higher densities and integration of midwives had better birth outcomes.

Race and Bias in the U.S. Medical System

Who you are can affect the quality of care you get as a woman in the U.S. healthcare system. Maternal mortality numbers reflect racial and ethnic disparities within the U.S. medical system.  Black women are 3.3 times more likely to die from pregnancy-related causes and American Indian/Alaska Native women are 2.5 times more likely to die than white women with the same education and socioeconomic status.

For example, despite their fame and fortune, both professional tennis player, Serena Williams, and artist, Beyoncé Knowles-Carter, have spoken out about their less than ideal experiences as black women giving birth in the United States. Both women underwent emergency C-sections and experienced preventable life-threatening pregnancy complications.

Black and American Indian/Alaskan Native women also experience more pregnancy-related complications than any other ethnic group in the United States. For example, black women are three times more likely to die from preeclampsia than white women in part due to being disproportionately affected by associated risk factors (e.g., diabetes, obesity, chronic hypertension) and inequalities in access to prenatal care. Even before pregnancy, women of color face chronic stress and weathering, a hypothesis that the health of black women may decline during early adulthood because of cumulative socioeconomic and racial disadvantage.  

Closing Gaps

Legislation is a tool that can address the inequalities of care and structural and implicit bias evident in the U.S. maternal care system. In a historic action, the passing of H.R.1318, The Preventing Maternal Deaths Act of 2018, allowed states to create and or strengthen Maternal Mortality Review Committees, which identify trends in maternal mortality, increase research, and implement strategies for preventing pregnancy-related deaths. Nearly 30 states in the U.S. have a committee or are in the process of developing committees. These types of review committees can have positive outcomes, for example, since the convening of California’s review board, the state has seen a 55 percent decline in maternal mortality rates.

Many other bills have since been introduced to close the gaps in the U.S. medical systems’ treatment of mothers. Women using public insurance account for almost half of all U.S. births and in most cases, insurance does not kick-in until late into the prenatal period and ends shortly after childbirth. Rep. Eliot Engel (D-NY) and Rep. Steve Stivers (R-OH) introduced, H.R.1551 – Quality Care for Moms and Babies Act, which amends the Social Security Act to improve maternity care under public funded programs, Medicaid and Children’s Health Insurance Program. From Illinois, Rep. Robin Kelly (D-IL) and Sen. Dick Durbin (D-IL) passed H.R.1897/S.916 – “MOMMA’s Act” (Mothers and Offspring Mortality and Morbidity Awareness Act), which helps states determine best practices in maternal mortality identification and review; extends Medicaid coverage from two months to a year after childbirth; and establishes “Centers of Excellence” for implicit bias and cultural competency training.

Additionally, three U.S. democratic presidential candidates have introduced legislation addressing related issues. Sen. Corey Booker (D-NJ) and Sen. Kirsten Gillibrand (D-NY) have introduced or re-introduced different bills aimed at expanding Medicaid coverage and pilot programs for quality of care and providing states and hospitals with access to new resources for best practices to prevent and respond to maternal deaths. Sen. Kamala Harris (D-CA), has reintroduced a bill aimed at creating a grant program to address implicit bias in provider care.

To address racism and bias in maternal care, a few days before 2019’s Black Maternal Health Week (April 11–17) Rep. Alma Adams (D-NC) and Lauren Underwood (D-IL) launched the Black Maternal Health Caucus to improve black maternal health outcomes across the country and signal to Congress to make the maternal health care of black women a national priority. Sen. Holly Mitchell (D-CA), introduced California Bill 464 making California the first state in the nation to make implicit bias training a requirement at hospitals and birthing centers and require coroners to list if a woman was pregnant within a year prior to death. 

Legislation to address bias in the treatment of Black or Native Indian/Alaska native women is critical for a systematic shift in how we care for American women.

The nation’s capital, Washington, D.C., has the highest maternal mortality rate in the country, with a rate of 40.7 deaths per 100,000 live births. In 2017, Washington, D.C. closed two maternity wards, one of which primarily served black women and one-third of D.C.’s total births.

In 2018, black female elected officials from across the country, D.C. residents, and health experts gathered at the capital’s first national maternal and infant health summit, hosted by D.C. Mayor Muriel Bowser. They examined not just D.C.’s maternal mortality rates, but the nation’s as a whole. With the second annual summit scheduled for September 10, 2019, it is a crucial time for the country to explore best practices for improving perinatal health and tackling racial disparities in birth outcomes.