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.

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