The Public Health Crisis of the Maternal Mortality Rate

What is it and how to address it

Posted Feb 25, 2019

Pregnancy and childbirth: Often one of the most beautiful times in a woman’s life. However, this is unfortunately not the case for all women. In fact, many women do not survive this period. According to the Centers for Disease Control (CDC), each year in the United States about 700 women die from pregnancy-related causes and the rate has continued to increase despite medical advances[1]. Pregnancy-related deaths entail the death of a woman during pregnancy or within one year of the end of the pregnancy due to any condition, complications, or chain of events caused by the pregnancy[2].

The best way to measure how often these deaths occur is the pregnancy-related mortality ratio, an estimate of the number of pregnancy-related deaths for every 100,000 live births. In the U.S., the 2013 ratio was 17.3 deaths per 100,000 live births[3]. While the risk for a pregnancy-related death seems small, some women are at a higher risk for this outcome. Specifically, significant racial health disparities exist. On average, African American women are 3 to 4 times more likely to die from pregnancy-related complications than White women. According to the CDC, from 2011-2013, White women had 12.7 deaths per 100,000 births, but African American women had 43.5 deaths per 100,00 births. The maternal mortality rate by itself is an issue, but it becomes an ever larger one when particular groups of women are at a higher risk of dying as a result of pregnancy. Thus, racial disparities in the maternal mortality rate are indeed a social justice and public health issue.

It is estimated that over 60% of the observed pregnancy-related deaths were preventable[4]. In order to move toward prevention, the underlying factors and causes must be clearly recognized and understood. Some well-known causes of pregnancy-related deaths include several chronic conditions that can increase the risk for pregnancy complications, including high blood pressure, diabetes, heart disease, and obesity. However, these causes don’t explain the existing racial disparities. A closer look is needed at the social determinants underlying this health disparity. A better understanding of the causes yields increased opportunities to strategize and implement policies aimed at addressing and preventing maternal mortality.

A Case Example:
Washington, D.C. had the highest maternal mortality rate in the U.S. from 2005 to 2014. D.C. averaged 39 deaths per 100,000 live births[5], which is more than double the previously mentioned national average. The pattern of disparate racial/ethnic rates in maternal mortality also exist in D.C., as 75% of maternal deaths in D.C. between 2014 and 2016 were African American women[6]. The million dollar question is why. The circumstances leading to D.C.’s status as a “maternity desert” with the highest rate of maternal mortality in the nation was precipitated by a multitude of decisions and policies that mainly affected women from low socioeconomic backgrounds and African Americans. These decisions affected access to care, which is arguably one of the biggest contributing factors. For example, in 2017, a hospital in NE D.C. closed its obstetrics unit, including all prenatal care, and another closure occurred several months later in SE D.C. in a neighborhood that is 93% African American. As a result, the East side of the District is now a maternity desert due to the complete lack of labor and delivery services available. Women who already had barriers to adequate prenatal care now have the added weight of having to travel across the city to receive services. This can be problematic for women who cannot afford the travel, cannot take time off work, or have limited health insurance plans.

Moving Forward:
Currently, 35 states have a maternal mortality review committee that conducts comprehensive analyses of deaths that occur during pregnancy and up to one year after. Within the past year, Washington D.C. passed legislation that establishes the Maternal Mortality Review Committee within the Office of the Chief Medical Examiner to determine the causes associated with maternal deaths in D.C. and find solutions to lower the maternal death rate and improve maternal health. The legislation also requires the Board to submit an annual report of findings, recommendations, and steps taken to evaluate the implementation of recommendations, to the public, the Mayor, and the Council of the District of Columbia. Ideally, this new committee will help decrease the inequities in maternal health care in the District and allow low-income and African American women to access preventative and prenatal care. In order to continue this momentum in D.C., or initiate it elsewhere, it is essential to continue to raise awareness of this social issue. Psychologists can play a role in this advocacy and inform policies aimed at addressing the problem through education, data collection and analyses, and community involvement.

Taylor Darden is a third-year student in the Community Psychology Ph.D. program at the University of Maryland, Baltimore County and SPSSI member. Her research and professional interests center on how social determinants (e.g., racial discrimination, racism, and SES) impact health inequities in marginalized communities, such as African-Americans and those from low socioeconomic backgrounds. She aims to advocate for health equity and make a positive change by using psychological, evidence-based research in this area to inform decisions and evaluation of policies and programs

References

[1] Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2017). At a Glance 2016 Maternal Health: Advancing the Health of Mothers in the 21st Century.

[2] Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2018). Pregnancy Related Deaths. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm

[3] Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2018). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

[4] Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from the Nine Maternal Mortality Review Committees. Retrieved from http://reviewtoaction.org/sites/default/files/national-portal-material/Report%20from%20Nine%20MMRCs%20final%20edit.pdf

[5] Jacob, A. (2018, February 9).  DC Has Highest Maternal Mortality Rate in US; Council Wants to Learn Why. First Read DMV. Retrieved from https://www.nbcwashington.com/news/local/DC-Maternal-Mortality-Review-Committee-Amid-Highest-Death-Rates-in-US-473449653.html

[6] Editorial Board. (2018, April 21). D.C.’s maternal mortality rate is at crisis proportions. The Washington Post. Retrieved from https://www.washingtonpost.com/opinions/dcs-maternal-mortality-rate-is-at-crisis-proportions/2018/04/21/cc268af2-4411-11e8-8569-26fda6b404c7_story.html?noredirect=on&utm_term=.49dd8ffdc57a