While and disturbing history. Until the early 20th century,

While infant mortality rates have dropped
significantly, maternal mortality rates have increased to an alarming rate in
the United States over the past three decades. Each year, 700-900 American
women die from pregnancy or childbirth related causes, the worst record in the
developed world (Martin & Montagne, 2017). This disparity is reflected in
comparison to other countries like Canada, where an American woman is three
times more likely to die from pregnancy and birth complications, and even more
striking, six times more likely to die than a Scandinavian woman (Martin &
Montagne, 2017). The rate of maternal mortality has dropped so significantly in
England that a man is more likely to die than his pregnant partner than she is
(Shannen, Green, & Chappell, 2017). Infant mortality is at the lowest point
in history, yet maternal mortality rates continue to be troubling, especially
in the United States. Some of the problems contributing to this disparity in
the American healthcare model are identifiable and potentially remediated, but the
subtle undertones require a much deeper look at the role of institutionalized sexism
and racism in the United States.

History

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Maternal risk has been a concern for
women since the beginning of time. While modern pregnancy and childbirth is
revered and romanticized, it can also be a dangerous time for women. Childbirth
in the United States has a dark and disturbing history. Until the early 20th
century, most women gave birth at home with a midwife. With the advent of the
medical study of obstetrics and gynecology, birth moved from home with a
midwife, to a hospital with a doctor. Midwives began to be viewed as
competition for obstetric doctors as medical universities, which banned women
from study, continued to grow. Despite data that showed immigrant and African
American midwives provided better health outcomes than physician assisted birth,
the movement gained acceptance and women began to move to hospitals for male obstetrician
assisted childbirth, many of whom had never even witnessed a live birth.

During this time the preferred method for
hospital birth included the use of “twilight sleep,” which involved injecting
women with morphine and scopolamine, and amnesiac drug (O’Mara, 1999). This
practice was later found to contribute greatly to maternal death, and
scopolamine did not remove pain, just the memory of it. Women were frequently
tied, lying on their backs, to beds at the wrists with lamb’s wool to avoid
marks (Epstein, 2008). They were left for hours unattended, often lying in
their own waste, with bonnets covering their eyes. This abusive and inhumane
practice was widely lauded as revolutionary and advanced by obstetricians and
gynecologists. By 1915, maternal mortality in the United States was the highest
in the industrial world, with six deaths per thousand births and infant deaths
from birth injuries rose over fifty percent from the previous decades, due to
improper techniques used by obstetricians during childbirth (O’Mara, 1999). It
is impossible to look at current maternal mortality rates in the United States
without considering this history of obstetrics, and the ways that women’s
bodily autonomy was undermined by “modern medicine”.

             There are several contributing factors to the
current rates of maternal mortality in the United States. Overall, hemorrhage,
cardiovascular and coronary conditions, cardiomyopathy, infection, embolism,
mental health conditions, and preeclampsia and eclampsia are the leading causes
of pregnancy related death in the United States (Maternal Mortality Review,
2017).

More
women are having babies at advanced maternal age (over 35), often with complex
medical histories. High rates of caesarean sections can lead to further
complications, both during the surgery, while recovering in the hospital, and
in the post partum period at home in the subsequent weeks and months. Blood
pressure issues are commonly associated with maternal mortality, yet symptoms
are either ignored or dismissed by providers, even when reported by mothers.

Most doctors and providers are not
properly trained to prepare women for the post partum period, and the
information mothers are given about how to care for themselves and potential
red flags or warning signs are inadequate. The fragmented U.S. healthcare
system further compounds these issues as many women are left without health
coverage shortly after giving birth. Medicaid covers 48% of births in the
United States, and in most states women lose their coverage sixty days after
giving birth (Markus, et al., 2013). Lack of healthcare coverage also limits
the amount of prenatal care a woman may receive. Despite Medicaid “back paying”
in most states, many low-income women lack the resources or systems knowledge
to apply or receive coverage in the early weeks and months of pregnancy.

Additionally, studies have found that black
mothers in the US die at three to four times the rate of white mothers, one of
the widest racial disparities in women’s health (Tucker, Berg, Callaghan &
Hsia, 2007). This disparity is a driving factor in overall maternal mortality
rates in the United States, and similar to Mexico and Uzebekistan’s levels. A
2016 analysis of five years of data found that “black college educated mothers
who gave birth at local hospitals were more likely to suffer severe
complications of pregnancy and childbirth than white women who never graduated
high school” (Martin & Montagne, 2017). Babies born to black mothers are
48% more likely to be born prematurely than white mothers, and black babies are
twice as likely to die before their first birthday (March of Dimes, 2016). This
disparity is so great that education level, class, income and geographic
location do not seem to be a buffer. The institutionalized racism and sexism of
the United States contributes to the chronic stress experienced by women of
color. This type of chronic stress increases the likelihood of a number of
health conditions and complications. Research by Arline Gernonimus of
University of Michigan has shown this “weathering” effect at the molecular
level, where the telomeres (chromosomal markers of aging) appear seven and a
half years older in black women than in whites (Martin & Montagne, 2017).

Interventions

            Great Britain has provided a
comprehensive and promising model for addressing and responding to maternal
deaths. Maternal deaths are looked at as a health systems failure, rather than
a family tragedy, and a national committee investigates every case and collects
all medical records for review. The data is analyzed, and reports are published
to help hospitals address problems and set policy changes. These efforts have
lead to a dramatic decrease in maternal mortality, fewer than one in 100,00
women, with a total of only two women total dying from pre-eclampsia between
the years of 2012-2014 (Shannen, Green, & Chappell, 2017). In the United
States, maternal mortality reviews are generally left to the states, where they
are underfunded, often take years to review, and findings and suggestions are
rarely implemented. Most of these review boards are underfunded, and non
punitive. The Preventing Maternal Deaths Act of 2017, a bipartisan bill in
Congress, would authorize funding for states to either establish or improve
review panels.

California, the most populated state in
the country with the highest number of births, has implemented “hemorrhage
carts” that are readily available in labor and delivery and post partum wards
in hospitals. These carts store medications and supplies that are at the ready
in times of crisis to lessen response time during critical moments.
Additionally, nurses undergo regular drills and have learned to collect and
weigh, rather than previous methods of “eyeballing” and guessing amounts of
blood loss. These actions have helped to lower California’s maternal deaths
down to seven per 100,000 births, a 21% drop (Martin & Montagne, 2017).

Policy Solution and
Proposals

            The Health Resources and Services
Administration (HRSA)’s Maternal and Child Health Bureau (MCBH) launched the
Maternity Health Initiative (MHI) in 2015 as a way to address maternal
mortality by coordinating services across agencies and providers. MCBH administers
Title V block grants to fifty nine states to support public health systems and
programs (Lu, Highsmith, Cruz & Atrash, 2015).

The Maternity Health Initiative has
proposed five priority areas to address maternal mortality rates:

·     
Improving
women’s health before, during, and after pregnancy.

·     
Improving
the safety/quality of maternity care.

·     
Improving
systems of maternity care including both clinical and public health systems.

·     
Improving
public awareness and education.

·     
Improving
surveillance and research.

            One of the ways that the MHI worked
to address their goals is through developing and providing “maternal health
bundles”, which contain “guidelines, protocols, toolkits, triggers and other
tools to help clinicians and hospitals address three of the major causes of
maternal mortality and severe morbidities- hemorrhage, preeclampsia, and
thromboembolism” (Lu, Highsmith, Cruz & Atrash, 2015). A partnership with
the American College of Obstetricians and Gynecologists has aimed to not only
reduce the level of cesarean deliveries in the US, but to implement maternal
safety bundles in every birthing hospital in the U.S. (Lu, Highsmith, Cruz
& Atrash, 2015).

The Affordable Care Act attempted to
mediate the lack of healthcare coverage of low income uninsured women and men.
Unfortunately, states that chose not to extend Medicaid means that many women
are uninsured prior to, and in the early stages of pregnancy. Improving women’s
health prior to conception and increasing access to healthcare are both issues
addressed in the MHI, and aim to support programs on the micro level. The
current Trump administration and Congress have made several attempts to “repeal
and replace” or undermine the ACA, and the current tax legislation proposal
would further weaken it by eliminating the insurance mandate.

Recommendations

Addressing the high rates of maternal
mortality in the United States will require work on several levels. First, addressing
what practical steps can be taken to strengthen and improve medical awareness
and response times to high-risk situations in hospitals like hemorrhage and
eclampsia. Second, exploring what types of innovation could be incorporated
into the current model of medical care to help improve the culture of care for
women and mothers. Third, achieving universal access to healthcare to address
issues of disparity among race, class and gender, and ensuring all women have
access to healthcare during the prenatal and postpartum period.

As seen in California, the use of
“hemorrhage carts” that are stationed throughout a labor and delivery wing has
shown promising results. These types of innovations should be spread throughout
healthcare systems and hospitals throughout the country. “In situ” simulation
trainings have also shown to be effective at improving outcomes related to
health risks during childbirth and the immediate post partum period.  These types of hands on trainings take place
in hospital settings and evaluate protocals, team performance, operational
readiness and system improvements (Lutgendorf et. al., 2017). Hemmorhage and
other emergencies require a rapid assessment, from well functioning teams, with
appropriate action to ensure the best patient outcome (Lutengendorf et. al,
2017). Studies have shown that adults are more likely to learn and retain
information while doing hands on activities, rather than attending lecture
sessions. Implementing these types of “in situ” trainings across healthcare
systems could help to establish uniform methods of response to the leading
causes of maternal death, and in turn help to improve maternal outcomes.

While midwifery has seen an increase over
the past two decades, the vast majority of births in the United States take
place in a hospital with an obstetrician. Feminist frameworks value the
perspective of the female experience, and much of the American medical system
devalues that perspective. Even the language used is gendered: Obstetrician’s
“deliver” a baby, the woman is passive, while midwives “catch” a baby, the
woman does the work of delivering the baby. The specialization of maternal
fetal medicine has shifted the focus onto the infant, and many medical students
often do not spend time learning about care for a mother. Reminiscent of the
past, some may even finish their fellowship without ever being in a labor and
delivery unit (Martin & Montagne, 2017).

When the shift from home birth to
hospital birth took place, the United States was the only country where
midwives did not travel into the hospital with women. Throughout Europe, women
in the post partum period are also visited by a health visitor in the weeks and
months after birth. Incorporating this model of care as a compliment to
American obstetrics could be beneficial in many ways. Midwives tend to spend
more time getting to know their patients and assessing behavioral and
biological risks. They are better at transmitting education and information
about post partum care to their patients, and are available for follow up care
in a much more transparent way. They view pregnancy, birth, and motherhood
through a bio/psycho/social lens, similar to the practice of social work, and
are more adept at meeting their patient’s needs outside of clinical care. The
American Public Health Association (APHA) supports midwifery “as a key strategy
to improving access to care for childbearing families” (American Journal of
Public Health, 2001). This model of care could be help to improve outcomes for
mothers during pregnancy and in the post partum period, it has also shown to be
cost effective throughout Europe.

Finally, the most challenging, yet most
critical factor that could impact rates of maternal mortality would be
achieving universal healthcare or a national healthcare system. Initiatives
like the MHI help provide funding and grants to the states to expand healthcare
access to women and children, yet there are many people who are still unable to
access services. Gridlock in Washington due to lobbying and the corrupt
campaign finance system only serve to further entrench the current problems. The
United States has a fragmented, inefficient, and unjust healthcare system that
manifests itself in so many of the sobering statistics surrounding women’s
health.

Conclusion

Unraveling the layers of maternal
mortality in the United States reveals a number of disturbing trends. Medical
schools have shifted much of the focus of pregnancy and childbirth on to the
fetus or infant, and away from the mother. Public health care policies do
little to address the needs of women prior to conception, and after childbirth.
Institutionalized racism and sexism have a significant impact, especially for
black women, and contribute to the disparity in outcomes compared to the rest
of the developed world. Tackling these problems will require a multi-faceted
approach to address each level of these systems. Europe has provided promising
models for addressing maternal mortality, and implementing their findings may
improve outcomes for women in the United States.