Human Rights-Based Approaches to Maternal Death in the U.S.

Cristina Finch

The U.S. has shockingly high rates of maternal death, especially among marginalized communities such as women of color. The human right to health care, particularly maternal health care, is not being met in the US. But we can change this.

This article is part of a series published by Rewire in partnership with the Center for Reproductive Rights. It is also published in recognition of International Human Rights Day, December 10th, 2010. Read more International Human Rights Day 2010 posts here.

Amnesty International released a report last spring entitled Deadly Delivery concerning the maternal health care crisis in the United States including how this crisis disproportionately affects marginalized communities.  This report is part of a series of reports that we are issuing as part of our Dignity campaign which is focused on fighting poverty with human rights.  The statistics are shocking; every 90 seconds a woman dies from pregnancy related causes.  Although the vast majority of these deaths are in the developing world, it is also an issue in the United States which spends more on health care than any other country in the world. On November 2, I presented Amnesty International’s findings during a panel discussion at the UN.

The Universal Declaration of Human Rights says, “Every human being has the right to health, including healthcare.” Unfortunately, the human right to health care, particularly maternal health care, is not being met in the US. The problem is especially severe in marginalized communities such as women of color. Since the vast majority of maternal deaths in the United States are preventable, maternal mortality is a human rights issue. Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists, once said, “Women are not dying of diseases we can’t treat. […] They are dying because societies have yet to make the decision that their lives are worth saving.”

Two to three women die each day in the US because of pregnancy-related causes. A further 34,000 more women experience “near misses” each year. Women in the US are more likely to die of complications resulting from pregnancy or childbirth than women in 49 other countries, including South Korea, Kuwait, and Bulgaria. In fact, according to recently released UN numbers, the maternal mortality rate nearly doubled between 1990 and 2008.

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There are shocking inequities in maternal health in the US. Women of color, low-income women, Indigenous women, immigrant women and women with limited English proficiency all face additional risks. For example, black women are nearly four times as likely to die from pregnancy related causes as white women. In high risk pregnancies, black women are five and a half times more likely to die. The inequalities are also geographical; risk is not uniform across the 50 states. Women in DC are almost 30 times more likely to dies than women in Maine.

These inequities are a result of systemic barriers to maternal care in the US. One of the largest problems is the lack of access to care caused by discrimination, language barriers and financial troubles. Women have been turned away because they couldn’t speak English and subjected to racial stereotyping and disrespect which affected their treatment. There are also problems with shortages of medical providers, a lack of culturally appropriate care, inadequate implementation of protocols, and a severe lack of accountability.

Take, for example, Linda’s story. Linda Coale died of a blood clot a week after giving birth to her son, Ben, by c-section. The infant welcome packet included extensive information about acclimatizing pets to a new baby, but had failed to adequately alert her to warning signs of complications, despite the heightened risk due to her surgery.

One difficulty is the number of women going into pregnancy already in poor health. A lack of access to health care prior to pregnancy, can lead to unmanaged health conditions that complicate pregnancy for women and babies. Currently, one in five women of reproductive age have no health insurance – that is 13 million women. Women of color account for only one-third of all women, but they represent half of the country’s uninsured women.

Many women lack access to information about family planning and affordable contraceptive services. In reality, about half of all pregnancies in the US are unplanned. This is significant because women with unintended pregnancies are more likely to develop complications, face worse outcomes, start prenatal care late and receive inadequate prenatal care.

Pre-natal care is incredibly important because women without it are three to four times more likely to die. However, Native American women are 3 ½ times more likely and African American and Latina women are 2 ½ times more likely to have no prenatal care as white women. 21 states do not offer “presumptive eligibility,” which allows pregnant women to get temporary access to Medicaid before their paperwork is completed.

There is a very real shortage of health professionals, including maternal health care providers. There are particular shortages among providers who accept Medicaid – this scarcity being even worse among specialists. 65 million people live in medically underserved areas – primarily in inner cities and rural areas. This lack of health care providers can have deadly consequences. Trudy LaGrew was a Native American woman living on the Red Cliff reservation in Wisconsin who died of an undiagnosed heart condition following the birth of her son.  Although her pregnancy was high risk, she was unable to seek care from a specialist who would have been a 2 hour drive each way.

One of the barriers to decreasing rates of maternal death in the US is the lack of national protocols for evidence-based maternal care or to prevent, recognize and treat leading causes of maternal death. Our country’s C-section rate is illustrative of this point. Amnesty International agrees Cesarean deliveries can be a life-saving intervention. However, the US c-section rate is 32%. If that seems high, it is. The World Health Organization recommends a range between 5 and 15%. C-section rates have increased every year since 1996, for all groups of women, for a total of a 53% increase. This is significant because a woman’s risk of death is over three times higher with c-sections, and c-sections carry a greater risk of a number of complications. This complicates the racially disparities because African American women have the highest rates of c-sections.

Just as important is receiving care after birth. Postpartum care in the US is inadequate, generally consisting of a single office visit with a physician around 6 weeks after birth. To help women, there also has to be better access to information about family planning and affordable contraceptive services. Women are 2 ½ times more likely to die if they become pregnant again within 6 months of giving birth.

When you look at all these barriers together, the US lack of an accountability system obviously contributes to the rise of maternal mortality. There is no nationwide requirement to separately report maternal deaths. So in other words, many maternal deaths are never identified as pregnancy related. In fact, 29 states and the District of Columbia have no review process at all

Nearly half of all maternal deaths could be prevented with better access to good quality maternal health care. From a human rights perspective, this is completely unacceptable. To reverse these trends Amnesty International is calling on the government to implement a robust and systematic response to the issue of maternal health in the US using a human rights framework. Domestically, Amnesty International recommends establishing and strengthening Maternal Mortality and Morbidity Review Boards to investigate maternal deaths and improve care and ensuring presumptive eligibility for Medicaid for pregnant women in all states. Nationally, Amnesty International recommends creating a single office within the Department of Health and Human Services to deal with improving maternal health care; allowing pregnant women to get temporary access to Medicaid before their paperwork is completed; and passing the MOMS for the 21st Century Act, which would expand care, improve diversity, and reduce shortages of maternal care providers.

Act now to improve maternal health care and end this human rights crisis!

 

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.

News Abortion

Parental Notification Law Struck Down in Alaska

Michelle D. Anderson

"The reality is that some young women face desperate circumstances and potentially violent consequences if they are forced to bring their parents into their reproductive health decisions," said Janet Crepps, senior counsel at the Center for Reproductive Rights. "This law would have deprived these vulnerable women of their constitutional rights and put them at risk of serious harm."

The Alaska Supreme Court has struck down a state law requiring physicians to give the parents, guardians, or custodians of teenage minors a two-day notice before performing an abortion.

The court ruled that the parental notification law, which applies to teenagers younger than 18, violated the Alaska Constitution’s equal protection guarantee and could not be enforced.

The ruling stems from an Anchorage Superior Court decision that involved the case of Planned Parenthood of the Great Northwest and the Hawaiian Islands and physicians Dr. Jan Whitefield and Dr. Susan Lemagie against the State of Alaska and the notification law’s sponsors.

In the lower court ruling, a judge denied Planned Parenthood’s requested preliminary injunction against the law as a whole and went on to uphold the majority of the notification law.

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Planned Parenthood and the physicians had appealed that superior court ruling and asked for a reversal on both equal protection and privacy grounds.

Meanwhile, the State of Alaska and the notification law’s sponsors appealed the court’s decision to strike some of its provisions and the court’s ruling.

The notification law came about after an initiative approved by voters in August 2010. The law applied to “unemancipated, unmarried minors” younger than 18 seeking to terminate a pregnancy and only makes exceptions in documented cases of abuse and medical emergencies, such as one in which the pregnant person’s life is in danger.

Justice Daniel E. Winfree wrote in the majority opinion that the anti-choice law created “considerable tension between a minor’s fundamental privacy right to reproductive choice and how the State may advance its compelling interests.”

He said the law was discriminatory and that it could unjustifiably burden “the fundamental privacy rights only of minors seeking pregnancy termination, rather than [equally] to all pregnant minors.”

Chief Justice Craig Stowers dissented, arguing that the majority’s opinion “unjustifiably” departed from the Alaska Supreme Court’s prior approval of parental notification.

Stowers said the opinion “misapplies our equal protection case law by comparing two groups that are not similarly situated, and fails to consider how other states have handled similar questions related to parental notification laws.”

Center for Reproductive Rights (CRR) officials praised the court’s ruling, saying that Alaska’s vulnerable teenagers will now be relieved of additional burdensome hurdles in accessing abortion care. Attorneys from the American Civil Liberties Union, CRR, and Planned Parenthood represented plaintiffs in the case.

Janet Crepps, senior counsel at CRR, said in a statement that the “decision provides important protection to the safety and well-being of young women who need to end a pregnancy.”

“The reality is that some young women face desperate circumstances and potentially violent consequences if they are forced to bring their parents into their reproductive health decisions. This law would have deprived these vulnerable women of their constitutional rights and put them at risk of serious harm,” Crepps said.

CRR officials also noted that most young women seeking abortion care involve a parent, but some do not because they live an abusive or unsafe home.

The American Medical Association, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine have said minors’ access to confidential reproductive health services should be protected, according to CRR.