Most American women might presume that the dangers of maternal mortality are a concern and problem only in developing nations. They're wrong. A March 2010 report put out by Amnesty International entitled, Deadly Delivery: The Maternal Health Care Crisis in the USA, highlights eye-opening findings. The data is based on research carried out during 2008 and 2009. The organization has framed their conclusions as a call to action for women's human rights in America. The revelation that "more than two women die everyday in the USA from complications of pregnancy and childbirth," with half of those death being preventable if appropriate maternal health care was accessible, demands accountability. Since there are no federal requirements to report maternal mortality, the actual number of deaths may exceed those counted by double the amount.
What constitutes maternal health? The World Health Organization defines it as the "health of a woman during pregnancy, childbirth, and the post-partum period." How does America, the number one global spender on health care, measure up against other nations? The latest available statistics come from 2006, when there were 13.3 maternal deaths per 100,000 live births. In an example of a one-on-one matchup, when compared with Germany, the United States racks up figures at four times the German numbers.
Within our borders, the news is even more dismal. Broken down by state, Maine had the best showing at 1.2 deaths per 100,000 live births. The District of Columbia had the most disconcerting figures: 34.9 per 100,000 live births. What, as a country, are we doing wrong?
As documented in the 138-page hard copy Amnesty International report, there is no shortage of contributing factors.
First and foremost, America has no nationally implemented guidelines and standards for a comprehensive system of maternal health care. Amnesty has suggested that the "U.S. Congress should direct and fund the Department of Health and Human Services to establish an Office of Maternal Health." Projections show that improving the standard of care could prevent close to 50 percent of deaths.
A starting point is the necessity of prenatal care, which is defined by The Healthy People 2010 Goals as thirteen prenatal visits beginning at the first trimester. Those women who do not receive this medical attention are shown to be three to four times more likely to die of pregnancy-related complications than women who do. The reasons women don't connect with this crucial care emanates from a health system that currently sustains impediments to care, and is rife with bureaucracy, inadequate services, and even discrimination.
In 2009, more than one in six Americans had no health insurance. Thirteen million women from the ages of 15-44 were part of that demographic. Health care costs can be prohibitive. An uncovered ultrasound costs $1,000. Accessibility in both rural areas and inner cities is a major obstacle. In these settings, it can be problematic for women to obtain transportation to clinics, and even then, many of the serving institutions are seriously understaffed. Quandaries arise when a woman has to choose between showing up for her job and keeping a prenatal visit. Inflexible office hours, lack of childcare for other children, and language barriers also present challenges.
Women of color (African-American, Latina, Native American), women in poverty, and immigrant women are hardest hit by these obstacles to prenatal care. It was documented that African-American women were four times more likely to die of pregnancy related complications than white women.
Jennifer Dohrn, DNP, has worked on the frontlines as a midwife since 1987, when she joined forces with the Morris Heights Health Center in the southwest Bronx in New York City. As the first freestanding birth center in the country for urban women, the MHHC served those with no access to health care. Dohrn wrote by e-mail, "Maternal mortality is not an unsolvable problem. We have the technology to provide safe motherhood for women in the United States and globally." When Dohrn started, one-third of the women in the community had received no prenatal care at the time of delivery, and infant mortality ranked amongst the highest in the country. Opening a center that was accessible to women encouraged early entry into prenatal care given by skilled midwives, continuous involvement of the family, and safe delivery with promotion of breastfeeding. There were no long waits, the staff reflected the culture of the clientele, and state financed programs for pregnancy covered the costs. As Dohrn made clear, "This is a model of how it can be done."
Another key factor in the maternal health equation is the Caesarean section. Almost one-third of all American deliveries fall into this category, a number that is twice as high as the World Health Organization recommendation. The odds of death after a C-section are more than three times higher than vaginal births. 75 percent of maternal deaths occur after a Caesarean delivery.
I spoke with Dr. Charles S. Mahan about the alarming extent of procedures taking place nationally. His primary concern was that women were having unnecessary operations. He has seen an escalation in the procedure over the past five to tens years. Dr. Mahan believes that a major reason in the rise of C-sections is that women are not getting enough facts about potential complications to give "true informed consent." He stressed that many patients were under the impression that it was safe to deliver their babies at thirty-seven or thirty-eight weeks. The optimum time frame is between thirty-nine to forty-two weeks. Dr. Mahan suggested that doctors might be choosing this form of delivery based on considerations that were not purely medical. He emphasized the inherent dangers, explaining that "the surgical procedure poses short and long term health risks to mothers and infants." Dr. Mahan pointed out that a "scarred uterus poses risk to future pregnancies and deliveries." In addition, women who have Caesarean deliveries are more likely to experience "deep venous clots that can result in pulmonary embolism or stroke." He referenced the CIMS website and their February 2010 fact sheet for cutting-edge data on Caesarean sections. It should be noted that inadequate post-partum care contributes to more than half of all maternal deaths, which occur between one and forty-two days after delivery.
One of the points that the report highlighted was that "women are not given a say in decisions and do not get enough information about sign of complications and risks of interventions--including induced labor and Caesarean deliveries." Severe complications that almost cause a maternal death during a delivery are euphemistically referred to as "a near miss." Annually, 34,000 American women have that experience.
Angela Burgin Logan falls into this category. When I spoke with her by telephone she related a hair-raising story that combined elements of medical arrogance, missed and ignored symptoms, and a form of physician brow-beating that made her feel dismissed as an "hysterical" mother-to-be. Her mantra now is "Listen to your own voice."
A college educated, upper-income African American woman living in western New York State, she took extreme care in researching and picking her OB-GYN. Yet as she described, "Not too long into the pregnancy, something didn't feel right." She was gaining weight at a troubling rate, and at five months she could not lie flat on her back. She had pains in her left arm. The red flags were up for orthopnea and heart failure.
Only at her urging did her doctor finally agree to send her for a work up. The nurse/technician on duty alerted her to worrisome symptoms. Despite the presence of protein in her urine--a clear indicator of preeclampsia--her doctor "sluffed it off."
Burgin Logan spent her final three months of pregnancy sleeping upright in a chair. When she rushed to the hospital ER at thirty-seven weeks complaining that she "couldn't breathe," her husband was advised that she was having a panic attack. Rather, fluid had flooded her lungs, making it impossible for her to take in air. An ongoing series of medical missteps meant that Burgin Logan had to be induced into a coma in order for her life to be saved. Miraculously, she and her daughter survived the birth process.
Having been given only a 20 percent shot of survival, Burgin Logan told me, "I'm on a mission to make a difference for mothers and babies." She writes about her experience on her site, and blogs about related issues for Lifetime Moms.
In retrospect, Burgin Logan believes that the issue of "gender" and "not being taken seriously" played the largest role in her ordeal. If this is the experience of a privately insured, professional woman-- one can only imagine the tribulations facing those women who lack financial resources and easy availability to health services.
This article originally appeared on the women's health site Empowher.
Image courtesy of ©2010 The Safe Motherhood Quilt Project.
This quilt block is in honor of Tamika Lashaie Williams Winston.
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