Last week, we featured the five-part completion of Christine Morton and Kathleen Pine's assessment of the current Maternal Quality Care landscape in the United States. What a great way to close out the year by scrutinizing the measures our nation is taking - at both the federal and community levels - to improve the quality of maternity care. This week, as we contemplate the year that lies before us, I would like to add some additional thoughts on the state of our maternity care system, and offer some ideas on policy and programming that might be instituted at various levels to continue that process of improvement.

On December 16, 2011, Diane Sawyer and her 20/20 team ran a special episode entitled, Giving Birth: A Risky Proposition. The forty-minute segment spoke of the risks associated with giving birth in some of the poorest places on earth - and the people and organizations who are working to change that. Unarguably, women in many places outside the U.S. face down a life-and-death proposition with each conception and birth, and when we look at our maternity care system, comparatively, we are able to utter those powerful words: we are so lucky. And yet...

Last semester in my Public Health MCH program, I wrote a series of papers looking at the maternal morbidity and mortality rates here in the U.S. and what type of attention these issues seem to garner at our own federal and local legislation and community levels. Over the next five days, I'd like to share some of these thoughts with you.
[note: references for this five-day series will be made available at the conclusion of the last post]

Maternal Mortality: An Overview of the Increasing Trend in the United States
According to the preliminary, 2009 data from the Centers for Disease Control and Prevention's National Vital Statistics Reports, the leading five causes of death in the United States remain: heart disease, cancer, chronic (lower) respiratory disease, cerebrovascular disease and accidents (Centers for Disease Control, 2011). According to the CDC Vital Statistics report, 10 out of the 15 leading causes of death in the U.S. decreased in total number of people affected between 2008 and 2009. As these causes of death continue to gain - and benefit from - public health attention, their relative risk to the general population is gradually dropping. However, there is another cause of death in the United States which has garnered much less public health attention, despite an increase in recent decades.

According to the report, Trends in Maternal Mortality: 1990-2008 (World Health Organization, 2010) between the years of 1990 - 2008, the estimated maternal mortality ratio for the United States increased from 12 to 24/100,000 - an increase of 3.7% per year. A more conservative estimate places our ratio at 12.7 deaths per 100,000 live births (U.S. Department of Health and Human Services, 2010). Amnesty International's Deadly Delivery Report (2011), cautions that while 147 countries decreased their maternal mortality numbers, 23 countries experienced an increas - the United States being one of them. And according to the report, Maternal Mortality in the United States, 1935-2007 (Singh, 2010) of the roughly 4 million women who give birth in the U.S. each year, black, Native American and low income/impoverished women maintained significantly higher maternal mortality rates than women of other races.

In fact in 2005, the maternal mortality rate for African American women was 36.5 per 100,000 (Kung, Hoyert, Xu, & Murphy, 2005). While 99% of global maternal mortality incidences occur in developing nations (World Health Organization, 2010), there seems to be a disturbing disconnect between the otherwise excellent medical system the United States boasts, and this increasing trend in maternal death. With 2015 looming, the fifth of the Millennium Development Goals - to decrease world-wide maternal mortality by 75%, and our country's maternal mortality ratio to 3.3 deaths per 100,000 live births (Gaskin, 2008) seems to be a long way off for those nations like ours which are still experiencing increases in maternal mortality (http://www.un.org/millenniumgoals/maternal.shtml).

Maternal mortality is defined as follows: the death of a female of childbearing age during or within 42 days of the completion of pregnancy, due to complications associated with the pregnancy, or management of the pregnancy, and excluding non-pregnancy-related accidents or injuries (Ronsmans & Graham, 2006). The primary causes of maternal death world-wide are severe bleeding, hypertensive diseases, and infections. Here in the U.S., hemorrhage is also the leading cause, followed by embolism and hypertensive disorders (Berg, Atrash, Koonin & Tucker, 1996).

Despite the estimated $86 billion per year spent on pregnancy-related hospitalization, women who are pregnant and giving birth in the United States are more likely to die during this time in their lives than they are in 50 other countries around the world (Amnesty International, 2011). In 2007, there were 548 officially documented maternal deaths - slightly higher than the U.S. Department of Health and Human Services' estimation of 12.7 deaths per 100,000 live births (U.S. Department of Health and Human Services, 2010). Perhaps then, the simplistic question to ask is, 'If we are spending so much money each year on maternity care, why is the maternal death rate in our country climbing when expenditures - estimated to be in the hundreds of billions of dollars - on other health conditions, such as cardiovascular disease, are resulting in declining death rates?' (Heindrich, et al., 2011)

From Amnesty International's Deadly Delivery report: 'According to the Centers for Disease Control and Prevention (CDC), approximately half of all maternal deaths in the USA are preventable. Preventable maternal mortality is not just a public health issue, it is a human rights issue.' (Amnesty International, 2011)

Beyond being a public health and human rights issue, maternal mortality in the United States is a systemic tracking issue. Compared to the United Kingdom where a maternal mortality auditing report entitled, Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer is published every triennium, here in the U.S. we have no federally mandated method of tracking pregnancy-related deaths (Confidential Enquiry into Maternal and Child Health [CEMACH], 2007). Disappointingly, 29 of our states have no internal maternal mortality review procedure in place (Amnesty International, 2011). Without a centralized method to track deaths pertaining to pregnancy, estimates of maternal mortality in our country are little more than that crude estimates which may represent gross underreporting.

In tomorrow's post, I will suggest ways of implementing several health behavior models which might be employed to start chipping away at our country's excalating maternal morbidity and mortality rates.

Posted by: Kimmelin Hull, PA, LCCE, FACCE

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