Reducing US Maternal Mortality as a Human Right

Overview of Maternal Health as a Human Rights Issue in the United States

The health of women around the time of pregnancy is an important priority in the United States and worldwide. There are over 4 million births in the United States each year.¹ Childbearing women and newborns account for nearly one quarter of all hospital stays each year, making childbirth by far the most common reason for hospitalization.² As a result, efforts to improve maternal health have a wide impact. Maternal death can be seen as the ultimate and most serious failure of maternal health efforts, and because it is easier to measure than overall maternal health, maternal death (also called maternal mortality) has been widely used as the basis for both national and international comparisons.^3,4 Maternal death is defined as the death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes.⁵ The maternal mortality ratio (also referred to as maternal mortality rate) is the number of maternal deaths per 100,000 live births.⁵ This figure is compared internationally and used as an indicator of development and quality of health care.^3,4

Maternal mortality is also a significant human rights issue.^3,6–8 Preventable maternal mortality is associated with the violation of a variety of human rights, including the mother’s right to life, the right to freedom from discrimination, and the right to health and quality health care.^3,8 As with infant mortality and life expectancy, maternal mortality is considered to be one of the main markers of the health of a nation and a bellwether indicator by which both human rights and public health can be evaluated. Every 90 seconds, around the world, a woman dies from complications of pregnancy or childbirth, yet the vast majority of maternal deaths globally are preventable.^3,9,10 According to Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists, “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”⁷

Global efforts to address maternal mortality started with the Safe Motherhood Initiative in 1987. The problem was further highlighted during the 1994 International Conference on Population and Development and the Women Deliver conferences held in 2007 and 2010.¹¹ Worldwide attention to the problem of maternal mortality has increased dramatically since 2000, when the United Nations included, as one of the 8 Millennium Development Goals (MDG 5), the reduction of global maternal mortality by 75% by 2015.^4,6,9,12,13 In response to these initiatives, many countries have increased efforts to reduce maternal mortality.¹⁴ It is estimated that, between 1990 and 2008, 147 countries experienced a decline in maternal mortality ratio, 90 of which showed a decline of 40% or more. In 2 countries there was no change, and in the remaining 23 countries, including the United States, the maternal mortality ratio actually increased.¹⁰

According to recent World Health Organization (WHO) data, the United States ranks 50th in the world in maternal mortality,¹⁰ despite the fact that the United States spends more on health care than any other country.¹⁵ Both WHO and Centers for Disease Control and Prevention (CDC) vital statistics data show a substantial increase in the maternal mortality ratio over the last 2 decades, some of which may be related to better identification of maternal deaths.^10,16,17 Maternal mortality figures in the United States hit a low of 6.6 deaths per 100,000 live births in 1987.¹⁸ After more than a decade with no further improvement, the ratio began to increase around 2000.¹⁹ Since 2003, CDC data show the maternal mortality ratio hovering between 12 and 15 deaths per 100,000 live births for the last 5 years of data.^17,19,20 This is more than 3 times the Healthy People 2010 goal of 4.3 deaths per 100,000 live births.²¹ While some of the increase is likely due to improvements in data collection, through the adoption of International Classification of Diseases, 10th Revision (ICD-10) coding and the addition of a pregnancy checkbox to the death certificate in most states, the high rates and ongoing lack of improvement are of grave concern.^16,17,20 

Factors Associated With Maternal Death

There are large disparities in the risk of maternal death by race/ethnicity, maternal age, income, and other factors, and an examination of these differences is important to both understanding the causes of disparities and to designing prevention efforts. For example, in 1935, African Americans had a maternal mortality ratio 1.8 times higher than that for Whites. However, since 1950, African Americans have had a maternal mortality ratio which is consistently 3 to 4 times higher than that of Whites, one of the largest health disparities in maternal and child health. Maternal mortality ratios for American Indians are also substantially higher than for White women.¹⁷ Maternal mortality ratios for American Indian and non-Hispanic Black women are 4 and 8 times higher than the Healthy People 2010 goal, respectively.¹⁷ However, as appalling as these disparities are, they cannot entirely explain the poor outcomes for women in the United States. For example, non-Hispanic White women in the United States have a maternal mortality ratio of 10.5 deaths per 100,000 live births, which means that using the most conservative figures, White women in the United States face a higher risk of maternal death than the entire population of women in 31 other countries,^10,14,17 and their ratios are 2.5 times the Healthy People 2010 goal.^8,21

As women get older, they are more likely to develop complications during pregnancy or delivery. From 1998 to 2005, the risk of pregnancy-related death (i.e., death during or within 1 year of pregnancy from direct or indirect obstetric causes) for mothers aged 40 years and older was 6 times that for teenagers.^22,23 Because unmanaged chronic health conditions, including hypertension, obesity, and diabetes, increase health risks for pregnant women and infants, one effective way to improve a mother’s health is to ensure that the pregnancy was planned and intended. Effective strategies to promote maternal health should therefore include expanding access to family planning and reproductive health services.²⁴

Women living in counties with higher concentrations of poverty also face significantly higher risks of maternal death, with women in middle- and high-poverty areas facing a 60% and 100% greater risk of maternal mortality, respectively, than women living in low-poverty areas.¹⁷ Maternal mortality also varied substantially by geographic region of the country, with the highest ratios in the south Atlantic and middle Atlantic states.¹⁷ 

The rate of cesarean births in the United States increased to one third (33%) of all births in 2009,¹ and recent increases in cesarean births may have been a factor in the apparent increase in US maternal mortality.^17,25 A recent study found that states reporting higher-than-average cesarean birth rates had a 21% higher risk of maternal mortality than states with lower-than-average cesarean rates.¹⁷ States with a high immigrant population and high poverty rates also had higher maternal mortality ratios.¹⁷

Community-level factors are also important to maternal mortality prevention, and many communities face substantial gaps in access to comprehensive health care for pregnant women, systemic service delivery problems, and areas in which linkages between community resources are poor. Problems include lack of care coordination and appropriate care for high-risk women, lack of timely and appropriate transfers to higher level care facilities, delay in diagnosis, treatment and response to emergency situations by providers, lack of postpartum follow-up care including home visits and maternal education, and lack of care provisions for incarcerated women.^26,27 Thus, interventions for reducing maternal morbidity and mortality need to address economic, legal, psychosocial, and cultural barriers that women face in obtaining timely and appropriate, quality maternal health care.^26–30 Strategies to increase women’s access to maternal health care are most effective when they result from listening to women themselves and are designed to meet the needs of the local community.³¹

Other risk factors for maternal mortality and morbidity include (1) history of medical problems, (2) nutrition problems, (3) substance use, (4) lack of or delay in prenatal risk assessment, (5) lack of social support, (6) problems with housing, (7) mental health problems, (8) family violence or neglect, (9) environmental or occupational hazards, and (10) family planning or contraceptive method related concerns.^26,27

Causes of Maternal Death and Severe Complications

The leading causes of pregnancy-related deaths (e.g., deaths from direct or indirect obstetric causes during or within 1 year of pregnancy²³) are hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions; each accounts for 10% to 13% of pregnancy-related deaths.²³ 

However, maternal deaths are just the tip of the iceberg: for every woman who dies, about 50 more suffer a severe complication or a near miss. Between 1998 and 2005, severe complications have increased by 27%, to affect approximately 34,000 women in the United States each year.²⁸ About 1.3 million US women each year face some type of complication in pregnancy or childbirth that has an adverse effect on their health.²² Research also indicates that approximately half of all maternal deaths and 30% to 40% of near misses in the United States are preventable.^29,32 Thus, to better understand and develop strategies to prevent maternal mortality, there is a need to increase our knowledge and understanding of maternal morbidity and to address community barriers that contribute to poor, ineffective, or late maternity care.^22,29,32

In summary, the death of a young woman during or after pregnancy is a sentinel event that demands investigation of the factors that led to the tragic outcome.²³ The persistently high maternal mortality ratios in the United States compared with other developed countries, the lack of improvement and possible increases in US maternal mortality over the past 2 decades, and the large and persistent disparities in US maternal mortality by race/ethnicity, socioeconomic status, and other factors all spotlight the need for immediate action to lower maternal mortality ratios in the United States. 

Recommendations

APHA recommends that pregnancy-related mortality and morbidity surveillance be enhanced and strengthened to identify all pregnancy-related deaths in the United States. We need to collect adequate information about maternal deaths to characterize factors contributing to the deaths; to identify health care, economic, legal, social, and cultural barriers that could be reduced; and to develop and implement recommendations, education programs, and policy changes in order to prevent future deaths and complications.^24,26,29 

APHA recommends that in order to reduce maternal deaths, all maternal deaths should be identified and reviewed by maternal mortality review boards and quality collaboratives.^23,29 Key elements of successful pregnancy mortality review boards include independence from undue influence or fear of involvement in malpractice litigation; adequate access to data, records, and information; a multidisciplinary and diverse membership, and the inclusion of community-based participants who can clarify local circumstances surrounding the cases.^26,27,29,33 In addition to reviewing individual cases, review boards should develop recommendations to address problems leading to preventable deaths, and steps must be taken to implement the recommendations in order to reduce preventable maternal deaths in the United States.^23,29

Action Steps

APHA recommends that the US Congress, the Executive Branch, federal agencies, state and local governments, and partners—

1. Increase federal, state, and local funding and support to implement the CDC recommendations to develop and establish multidisciplinary, independent pregnancy-related mortality review boards in every state; 
2. Encourage these review boards to use the multiple sources of data and expanded definition of pregnancy-associated maternal deaths recommended by CDC in their identification of cases, and to use standard guidelines and case abstraction forms in their formation and functioning; 
3. Encourage all states to adopt the US standard birth and death certificates as recommended by CDC, including the 5 recommended checkboxes indicating whether and when the woman had been pregnant at the time of death or at any time during the year preceding death;
4. Encourage all state departments of health to create electronic data linkages between death and birth certificates to better identify pregnancy-associated deaths;
5. Support funding for programs focused on increasing access to timely and appropriate quality health care for all women, free from economic, legal, psychosocial, and cultural barriers;
6. Expand existing efforts to measure, analyze, and report on pregnancy outcomes to include maternal health outcomes, including maternal mortality, near misses, and morbidity; increase research funding that examines a woman’s experience during maternity care; and develop and implement quality indicators to better assess the quality of maternity care; 
7. Encourage maternity care professionals, facilities, and professional associations to revise standards of practice and practice guidelines on the basis of the best available evidence and the recommendations of independent maternal mortality reviews;
8. Increase funding for data collection, research, review, analysis, and education in order to
   1. identify and reduce clinical, economic, legal, psychosocial, and cultural factors, including violence during and after pregnancy, that contribute to maternal mortality and morbidity, poor maternal care practices, and
   2. develop, evaluate, and implement effective interventions; and
9. Support and pass legislation that would reduce maternal mortality and morbidity and improve maternal health both globally and in the United States, including by
   1. increasing the prioritization and coordination of maternity care at the Department of Health and Human Services;
   2. reducing shortages of maternity care providers and facilities;
   3. improving the quality of care provided by improving provider education;
   4. increasing data collection, including the implementation of performance measures; and
   5. ensuring that payment structures include incentives to provide care according to the best evidence (rather than creating perverse incentives). 

References

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2. Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2008. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Available at: http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/pdfs/FF_report_2008.pdf. Accessed May 26, 2011.
3. Hunt P. The Millennium Development Goals and the right to the highest attainable standard of health (part of the International Lecture Series on Population and Reproductive Health). The John D. and Catherine T. MacArthur Foundation, Abuja, Nigeria, August 17, 2007, p 12. Available at: http://www.macfound.org/atf/cf/%7BB0386CE3-8B29-4162-8098-E466FB856794%7D/HUNT_POPULATION.PDF. Accessed May 26, 2011.
4. Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006;368:1130–1132. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69385-9/fulltext#. Accessed May 26, 2011.
5. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Geneva, Switzerland: World Health Organization; 1992. 
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8. Deadly Delivery: The Maternal Health Care Crisis in the USA, One Year Update, Spring 2011. New York, NY: Amnesty International; 2011. Available at: http://www.amnestyusa.org/sites/default/files/deadlydeliveryoneyear.pdf. Accessed May 2, 2011.
9. Countdown to 2015 Decade Report (2000–2010). 2010. Available at: http://www.countdown2015mnch.org/documents/2010report/CountdownReportAndProfiles.pdf. Accessed May 26, 2011. 
10. Trends in Maternal Mortality: 1990 to 2008. Estimates Developed by WHO, UNICEF, UNFPA and The World Bank. Geneva Switzerland: World Health Organization, UNICEF, UNFPA, and The World Bank; 2010. Available at: http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf. Accessed May 26, 2011.
11. International Conference on Population and Development. ICPD ’94: summary of the programme of action. March 1995. Available at: http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm. Accessed May 26, 2011.
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13. United Nations Millennium Project. Available at: http://www.unmillenniumproject.org/goals/index.htm. Accessed May 26, 2011.
14. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–1623. 
15. Organisation for Economic Co-Operation and Development. OECD health data 2010—frequently requested data. Available at: http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.html. Accessed May 26, 2011.
16. Hoyert DL. Maternal mortality and related concepts. Vital Health Stat 3. 2007;(33):1–13. Available at: www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf. Accessed May 26, 2011.
17. Singh GK. Maternal mortality in the United States, 1935–2007: substantial racial/ethnic, socioeconomic, and geographic disparities persist. US Dept of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Available at: http://www.hrsa.gov/ourstories/mchb75th/mchb75maternalmortality.pdf. Accessed May 26, 2011.
18. Health Resources and Services Administration. Child Health USA 2008–2009: maternal mortality. Available at: http://mchb.hrsa.gov/chusa08/hstat/hsi/pages/204mm.html. Accessed May 26, 2011.
19. Centers for Disease Control and Prevention. CDC Wonder, compressed mortality data base. Updated annually. Available at: http://wonder.cdc.gov. Accessed May 26, 2011. 
20. Xu J, Kochanek KD, Murphy SL, et al. Deaths: final data for 2007. Natl Vital Stat Rep. 2010;58(19). Available at: http://www.cdc.gov/NCHS/data/nvsr/nvsr58/nvsr58_19.pdf. Acessed May 26, 2011.
21. US Dept of Health and Human Services. Healthy People 2010 objectives. Available at: http://www.healthypeople.gov/2010/data/midcourse/comments/faobjective.asp?id=16. Accessed May 26, 2011.
22. Berg CJ, MacKay AP, Qin C, Callaghan WM. Overview of maternal morbidity during hospitalization for labor and delivery in the United States, 1993–1997 and 2001–2005. Obstet Gynecol. 2009;113:1075–1081. Available at: http://journals.lww.com/greenjournal/fulltext/2009/05000/overview_of_maternal_morbidity_during.17.aspx. Accessed May 26, 2011.
23. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005, Obstet Gynecol. 2010;116:1302–1309.
24. Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Fam Plann. 2008;39:18–38. 
25. Solheim KN, Esakoff TF, Little SE, et al. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24(11):1341–1346. 
26. Florida Dept of Health. Pregnancy associated mortality review (PAMR). Available at: http://www.doh.state.fl.us/Family/mch/pamr/pamr_info.html. Accessed May 26, 2011.
27. Deadly Delivery: The Maternal Health Care Crisis in the USA. New York, NY: Amnesty International; 2010. Available at: http://www.amnestyusa.org/our-work/campaigns/demand-dignity/maternal-health-is-a-human-right/maternal-health-in-the-us. Accessed May 25, 2011.
28. Kuklina E, Meikle S, Jamieson D, et al. Severe obstetric morbidity in the US, 1998–2005. Obstet Gynecol. 2009;113:293–299. 
29. Bacak SJ, Berg CJ, Desmarais J, et al. State Maternal Mortality Review: Accomplishments of Nine States. Atlanta, GA: Centers for Disease Control and Prevention; 2003. Available at: http://www.cdph.ca.gov/data/statistics/Documents/MO-CDC-ReportAccomplishments9States.pdf. Accessed May 26, 2011. 
30. Safe Motherhood Initiative. Priorities for safe motherhood. Available at: http://www.safemotherhood.org/priorities/index.html. Accessed December 7, 2010.
31. Declercq ER, Sakala C, Corry MP, et al. Listening to Mothers: Report of the First National US Survey of Women’s Childbearing Experiences. New York, NY: Maternity Center Association; 2002. Available at: http://www.childbirthconnection.org/pdfs/LtMreport.pdf. Accessed May 26, 2011.
32. Geller SE. Reliability of a preventability model in maternal death and morbidity. Am J Obstet Gynecol. 2007;196:57.e1–57.e6.
33. Wright RF, Smith JC. State level expert review committees—are they protected? Public Health Rep. 1990;105:13–23. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579974. Accessed May 26, 2011.

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