Report cites staggering level of US maternal mortality

By Natascha Grimmelshausen and Kate Randall

14 April 2010

Women in the US have a greater chance of dying from complications of pregnancy and childbirth than women in 40 other countries. A report from Amnesty International (AI), “Deadly Delivery: The Maternal Health Care Crisis in the USA,” shows that US maternal mortality ratios have soared in recent years, rising from 6.6 deaths per 100,000 lives births in 1987, to 13.3 deaths per live births in 2006.

The AI report says that “half of these deaths could be prevented if maternal health care were available, accessible and of good quality for all women in the USA.” Poverty and discrimination play a key role in denying women access to decent care related to pregnancy, delivery and in the days following birth, the report notes. So-called near-misses—severe pregnancy-related complications that nearly cause death—have also risen by an alarming 25 percent since 1998.

Deaths from pregnancy and childbirth-related complications in the US are five times more likely than in Greece, four times more likely than in Germany, and three times more likely than in Spain. These differences are likely even more severe, because only six states—Florida, Illinois, Massachusetts, New York, Pennsylvania and Washington—are legally bound to record maternal deaths.

Every year, one-third of all pregnant women in America, or some 1.7 million women, suffer from some sort of pregnancy-related complications. Although women are at risk of death for a whole host of reasons during pregnancy and childbirth, according to the Centers for Disease Control half of all maternal deaths are preventable either by proper prenatal and postnatal care or by adequate responses to warning signs by health care professionals.

The four most seen causes of maternal death in the US are embolism, a blood clot that blocks a major blood vessel (20 percent); hemorrhaging, severe bleeding (17 percent), pre-eclampsia and eclampsia, disorders associated with high blood pressure (16 percent); infection (13 percent); and cardiomyopathy, heart muscle disease (8 percent).

Major discriminatory factors blocking women from access to quality care include poverty, ethnicity and immigration status. African-American women are four times more likely than white women to die of childbirth-related complications; in high-risk pregnancies, they are 5.6 times more like to die.

The report notes: “Native American and Alaska Native woman are 3.6 times, African-American women 2.6 times and Latina women 2.5 times as likely as white women to receive late or no prenatal care.”

An average of 45,000 people die each year in America because they do not have health insurance. Millions of others are burdened by enormous medical bills and a disturbingly large proportion of bankruptcies, about 62 percent, are caused by the inability to pay medical bills. These are contributing factors to the poor state of maternal health in the US.

Some 42 percent of low-income women are covered by Medicaid, the government-run health care program for the poor. Under Obama’s health care proposals, about 16 million people will be added to the Medicaid rolls, further burdening states that are struggling to fund the program in the face of budget crises.

While the White House touts this increase in Medicaid coverage as an improvement in medical care for ordinary Americans, in reality it will result in substandard, inferior care for a new section of the population. Increasing numbers of doctors turn Medicaid patients away because they are not being paid by the states. Pregnant women in the Medicaid program also face specific problems.

The Amnesty International report quotes Jennie Joseph, a certified professional midwife from Florida, who relates an example of the bureaucratic hurdles facing women on Medicaid: “If you go to apply to the Medicaid system, you need a ‘proof of pregnancy’ letter, with the due date, the date of your last period, and the gestational age of the baby. Where do you get that kind of a letter?—a doctor. If you have no Medicaid, how are you going to get to the doctor to get that letter?’

Women insured through their employer, or who purchase their own coverage, also face difficulties obtaining quality care. Though insurance does cover half of all births, policies that omit maternal care are not a rarity and women that are already pregnant have a harder time finding any policies that will cover them because a pregnancy is considered a “pre-existing condition.” While the new health care legislation has restrictions on barring coverage for pre-existing conditions, insurers can be expected to try to get around this by raising premiums or by other maneuvers.

Poor women and women without insurance are far more likely to receive little or no pre-natal care. Twenty-five percent of women do not receive any prenatal care, making them three to four times more likely to die of complications during and after births. For high-risk pregnancies the rate is 5.3 times more likely.

By law, women in active labor cannot be turned away, regardless of their ability to pay. But after the labor is over and the mother returns home she may be billed for thousands of dollars, especially if she had a cesarean section.

Cesarean deliveries have increased by 71 percent from 1996 to 2007, rising from 797,119 to 1.367 million. The use of cesareans in the US is driven by many factors, including their profitability for doctors and hospitals and because they reduce an obstetrician’s chance of being sued for malpractice.

The AI report also notes that many women are not given a say in decisions concerning their medical care, and are not properly informed about the risks of interventions such as inducing labor or cesareans.

Larry Cox, executive director of Amnesty International USA, commented on the release of the “Deadly Delivery” report: “Good maternal care should not be considered a luxury available only to those who can access the best hospitals and the best doctors. Women should not die in the richest country on earth from preventable complications and emergencies.” The reality is that rising social inequality in the US, compounded by the deepening recession, have been translated into what can only be termed skyrocketing rates of maternal mortality.

Rachel Ward, one of the authors of the Amnesty International report, also stressed that the new health care legislation would not address this crisis in maternal care.“Reform is primarily focused on health care coverage and reducing health care costs,” she said, “and even optimistic estimates predict that any proposal on the table will still leave millions without access to affordable care.” Ward also said the legislation “does not address discrimination, systemic failures and the lack of government accountability documented in Amnesty International’s report.”