Medical Examiner

Why Is U.S. Maternal Mortality So High?

The main reason is not medical errors. It’s poverty and access to health care.



ProPublica and NPR’s recent story “The Last Person You’d Expect to Die in Childbirth” brought much needed attention to a serious problem: The U.S. has an unacceptably high rate of maternal mortality. The story, which focused on Lauren Bloomstein’s pregnancy-related death, was particularly frightening because Bloomstein was a neonatal intensive care nurse. As the headline suggested, if it can happen to Bloomstein, it could happen to anyone. We’re maternal-fetal medicine specialists, so the story hit us like a freight train. This kind of death is what we’ve trained our whole lives to prevent.

Maternal-fetal medicine specialists like us are tasked with caring for women with “high-risk” pregnancies, usually defined as pregnancies complicated by chronic or acute maternal illness, fetal concerns, or problems related to pregnancy itself (e.g. preterm labor). Our nuclear event—one of the worst things that can happen when we practice—is a mother dying. Maternal mortality in the United States is rare but, sadly, nowhere near rare enough: Data collected from 1990–2015 show that the number of maternal deaths per 100,000 births has increased from 16.9 1990 to 26.4 in 2015. Not only are more American mothers dying than in our peer countries, but we’re one of the only developed countries where the death rate is increasing, not decreasing. That’s a frightening trend, and it’s part of why we were thrilled that the ProPublica piece threw new attention at this issue.

For women who are now facing pregnancy with fear, we would like to offer more context. It’s important to recognize that even though our country’s numbers are higher, maternal death following birth is still very, very rare—your chances of dying in childbirth are still lower than your chances of being killed in a car accident or being struck by lightning.

Are maternal deaths in high-resource countries always due to medical error? It is true that many maternal deaths are preventable and result from suboptimal care, as described in the ProPublica piece. But human technology hasn’t gotten far enough to guarantee no level of maternal death, and it probably never will. Even with the best medical care, there are still catastrophic events—events in which disease moves too far, too fast—and no matter how quickly we act, how well we train, or how much we do, in those cases, outcomes are still dire.

To combat the United States’ outsize rate of maternal mortality, national and international health organizations have been working on maternal mortality by introducing evidence-based “toolkits” and protocols, which aim to standardize and improve care for common obstetric complications. Beyond that, as individual providers, we care for every patient with the knowledge that quality improvement committees are assessing what we’ve done, when we’ve done enough, when we’ve done too much. When we make mistakes, we must take responsibility, and increased attention will help ensure we do.

But this won’t help us address the real problem, the problem that the ProPublica piece doesn’t even ask, that huge and ugly central question of maternal mortality in America: Why are more women dying in the United States during pregnancy? There are many answers, but here’s a big part of it: poverty. Here’s another large part: access to health care. And here’s a third large part: access to family planning, including contraception and abortion services.

According to the U.N. Population Fund, “the poorer and more marginalized a woman is, the greater her risk of death. … Within countries, it is the poorest and least educated women who are most vulnerable to maternal death and disability.” Maternal mortality in the U.S., for example, disproportionately affects black women, who die in childbirth more than three times as often as white women. Medical studies show that planned pregnancies are safer for women, especially those with underlying health problems or previous pregnancy complications. That’s because a planned pregnancy is more likely to allow the woman to understand and address her health issues prior to conception. This is vital to the success of any pregnancy.

In many cases of maternal mortality, what happens in the hours before or after birth matters greatly. But what happens in the months before birth and even before conception matter too. Unfortunately, many recent policies put forth by both state legislatures and our current federal government will greatly decrease the access to this kind of health care. The loss, or forced dysfunction, of Obamacare will only increase the problems that lead to maternal mortality; Trumpcare will likely make those changes dramatic and sustained. The new budget coming out of the White House limits funding for health care and women’s health care in particular. These changes will widen the gap between the healthy pregnant woman and sick pregnant woman.

As part of those policies, decreased access to contraception will mean that fewer pregnancies will start at times when women have planned—financially, emotionally, and yes, medically—to have the best pregnancies they can have. This will be especially true for women at the margins, women who can’t afford contraception, and women who have not had regular access to medical care throughout their lives. It is the poorest and most vulnerable women who will come into pregnancy sick and leave sicker than ever.

And that brings us to another vital aspect of reducing maternal mortality: abortion. As maternal-fetal medicine doctors, we have both had many patients whose pregnancies have become high risk, higher risk, and ultimately catastrophically risky, only after conception. In those situations, as experts in saving women’s lives in pregnancy, we have been able to offer termination of the pregnancy as an option. We do so with grief, in any desired pregnancy; we do so with tremendous responsibility and humility. We have both seen what has happened when a woman continues a dangerous pregnancy; we both know first-hand that sending a woman home safe from a pregnancy that might have killed her is a gift of irredeemable value. Abortions can, and regularly do, save women’s lives.

It is disingenuous of us as a society to claim to care about reducing maternal death and disability while at the same time limiting women’s health care, including routine health care, contraceptive care, and abortion care.

The ProPublica piece was important and influential; Bloomstein’s story and other stories of this kind of tragedy must be told. But they can’t fix the systemic problem. The way we affect large-scale change is with research and with policy—research that investigates maternal mortality, policy that increases access to care. Instead, as a nation, we are heading in the opposite direction. Ultimately, we must recognize that there are some very difficult reasons why our maternal mortality rates are higher than our peer nations and that correcting these differences ought to be our first order of business.

So read that ProPublica piece. Let it break your heart. Lauren Bloomstein deserved better. And so do you, and so does the rest of this country. And after you read it, remember there is at least one simple thing you can do to limit maternal mortality in this country: Call your representatives and tell him or her what we all deserve—access to care, which includes health care, contraceptive care, and abortion care. It won’t solve every single problem, but it’s a big step toward saving the lives of American mothers.