Risky Business: Pregnant in America

Amie Newman

Pregnant women in the U.S. have a greater risk of dying from pregnancy or childbirth related complications than women in 40 other countries around the world.  It's past time to fix this.

Pregnant? Or think you’d like to be pregnant sometime and give birth in the United States?

You may be taking more of a risk than you realize.

Pregnant women in the United States have a greater risk of dying from pregnancy- or childbirth-related complications than women in 40 other countries around the world – and this risk is increasing. If you’re African-American – regardless of income level –  your risk of dying from pregnancy- or childbirth-related complications is nearly four times higher than for white women in this country.

According to a new report from Amnesty International, Deadly Delivery, the state of maternal health in the United States is nothing short of a violation of women’s basic human rights. 

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Two women die every day “from pregnancy-related causes” but as the report notes this statistic doesn’t begin to address the 68,433 women in 2004 and 2005 who experienced “near misses” – the women who skirted death during pregnancy or childbirth. Or the 1.7 million women from 1998 – 2005 who experienced “adverse effects” on their health from a complication arising from pregnancy or childbirth.

Because the United States does not have any federal reporting requirements on maternal deaths, the report notes that “the number of maternal deaths may be twice as high.” The United States goal to reduce maternal deaths to 4.3 deaths per 100,000 live births by 2010, codified in the U.S. Healthy People 2010 objectives, has been met by only five states thus far. The national average now stands at 13.3 deaths per 100,000 live births. Being a pregnant woman in New York City may mean putting ones’ life in the hands of the maternity care business –  83.3 women die for every 100,000 live births. And California? It is now more dangerous to give birth in California than it is in Kuwait or Bosnia according to trends tracked by the state’s Department of Public Health.

Perhaps one of the most chilling bits of information in the report is that, according to the Centers for Disease Control and Prevention, approximately half of these deaths are preventable – a truth that leads Amnesty to declare that what we’re talking about “is not just a public health issue, it is a human rights issue.”

The five main causes of maternal death in the U.S. are: embolism, hemorrhage, pre-eclampsia and eclampsia (diseases associated with high blood pressure), infection and cardiomyopathy (heart muscle disease) but many of these can be treated if detected early on, even before a women becomes pregnant in certain cases, with adequate access to quality, non-discriminatory health care. In some cases, these conditions can be warded off completely.

As Jennifer Block writes on Time.com these preventable deaths are:

“…the result of systemic failures, including barriers to accessing care; inadequate, neglectful or discriminatory care; and overuse of risky interventions like inducing labor and delivering via cesarean section. “Women are not dying from complex, mysterious causes that we don’t know how to treat,” says Strauss [Nan Strauss, a co-author of the report]. “Women are dying because it’s a fragmented system, and they are not getting the comprehensive services that they need.”

These “risky interventions,” such as delivering via c-section when it’s not necessarily needed, have led to a rising cesarean section rate in this country – a rate which has far surpassed being risky, actually. One out of every three births or 30 percent are via c-section placing this country’s rate firmly in the realm of “harmful” as per the World Health Organization, which recommends that no more than 5-10 percent of all births result from c-sections. In addition, as Block notes in her article, the NIH recently convened a panel of experts on maternal health – a panel which came to consensus on the importance of allowing women increased acess to VBACs or vaginal birth after cesarean sections. Current policies too often bar women from a vaginal birth after a previous c-section, increasing the number of c-sections, which lead to more maternal health complications.

On the cusp of comprehensive health reform efforts, the Amnesty report’s focus on the disparity in access to care between women who have insurance and those who do not is timely. Universal health care access is, for all purposes, off the table but Amnesty International sees the provision of care to all Americans as integral to a government’s role in preserving human rights:

Governments have an obligation to respect, protect and fulfill these and other human rights and are ultimately accountable for guaranteeing a health care system that ensures these rights universally and equitably.

Though Medicaid covers 42 percent of all births in the U.S. bureacratic barriers stand in the way of accessing care:

‘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?’ Jennie Joseph, certified professional midwife, Winter Garden, Florida

Even a woman with insurance is not immune to discriminatory practices by insurance companies, with policies that exclude maternal care or do not provide coverage unless the pregnant woman had insurance prior to the pregnancy.

The crisis only deepens for African American women. Far from being a question of income level or socio-economic status, the health disparity that exists between White and African American women when it comes to maternal mortality is more insidious. The disparity between white and African American women hasn’t changed in more than twenty years.

Womens enews, in their ongoing series on Black Maternal Health notes that,

African American women are three-to-six times more likely to die during pregnancy and the six weeks after delivery than U.S. white and Latina women. That holds true across various levels of income and education. In fact, some studies find middle-income and highly educated African American women at higher risk.

While women of color are less likely to enter pregnancy healthy and far less likely to receive any prenatal care than white women because of issues of access, many are now beginning to acknowledge the effect “chronic racism” has on a woman of color’s physiologic system, creating an environment ripe for physical problems such as high blood pressure and obesity.

For Native American and Alaska Native women, the issue may be more economically rooted. The report notes that while the U.S. spends $5, 775 per person on health care, the Indian Health Services spends only $1,900 per capita.

The report recommendations for addressing the state of African American, Native American and Hispanic women’s maternal mortality rates include “ensuring equitable access to health care without discrimination” by, among other things, increasing funding for the Office of Civil Rights within the Department of Health and Human Services. 

The Amnesty International report is not the only call-to-action released this year on our crumbling maternity care system. According to the “2020 Vision For A High-Quality High-Value Maternity Care System” which was released in January of this year to address ways in which our maternity care system must be overhauled to address our maternal mortality rates,  the United States spends $86 billion a year on maternity care, and more money per person on health care than any other nation in the world. The report and accompanying “Blueprint for Action” calls on the U.S. government and our health care system to question what kind of return-on-investment we’re really getting for all of the money spent and makes key recommendations including: confronting payment reform; disparities in access and outcomes of maternity care; coordination of maternity care; clinical controversies (such as homebirth, VBACs and elective induction), and consumer choice.

To confront the crisis Amnesty International is calling for a major U.S. government intervention. Some of these recommendations include: removing “barriers to timely, appropriate, affordable” maternal health care; ensuring access to family planning services (which would also mean increasing funding for the federal Title X program which funds our community health clinics); ensuring women receive quality postpartum care; improving accountability in reporting requirements and, most timely of all, integrating a “human rights” perspective into our health care system – a step which would require a tremendous overhaul to our current, national health care reform proposal which includes no provisions for universal health care.

Finally, as Block notes, “Amnesty is calling on Obama to create an Office of Maternal Health within the Department of Health and Human Services to improve outcomes and reduce disparities, among other recommendations.”

With two in-depth reports released within one month of each other calling on our federal government to act quickly, this is our hour of decision. Our advocacy and health care experts have done the prep work. Now, President Obama and our congressional representatives must lead the charge.

Our maternity care system is broken and we’re paying for the damage with womens’ lives.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.