Why Do So Many Mothers Still Die in Childbirth?
On maternal mortality and morbidity in the United States
Posted Jan 14, 2019
When anticipating the coming of a new baby, one thing that most mothers-to-be don’t consider is that there’s a chance they might die during childbirth. Well, maybe not most mothers, but this one sure didn’t. The birth of my first son went as smoothly as it could possibly go: My water broke at the stroke of midnight on New Years Eve, contractions started half an hour later, and my son was born after 8 hours of labor as the sun rose over Central Park, with no complications or stress. I had no reason to believe that the birth of my second son would be any different. And in fact, it wasn’t at first. I was induced on a Saturday afternoon a couple of days before my due date. After a few hours of little progress, my doctor broke my water to get the ball rolling, and my body soon took over. My son was born a few hours later after no more than 6 pushes. He was beautiful and healthy, like my first son was. A few minutes after my new baby boy was measured and cleaned, my doctor bid me farewell and left the hospital to have dinner with her family. Everything was fine, and there was no reason for her to think she needed to stick around.
My husband and I ordered dinner as well, greeted my sister and brother-in-law who came to visit us in the hospital, and I FaceTimed with my parents who were at home with my older son, exchanging smiles as we all admired the new arrival. At some point during the festivities, nearly two hours after I had given birth, my husband looked down and noticed that there was a lot of blood now staining both the bed and my hospital gown. We didn’t think much of it (some bleeding after giving birth is completely normal), but we called for the nurse and the attending doctor to come in and take a look. They didn’t seem alarmed at first, and said that there were three interventions they would try that almost always stopped the bleeding instantly. After trying all three in quick succession, they started to exchange whispers and worried looks. Just as I noticed the mood change in the room, I felt sick and light headed, and the next thing I knew, I was being wheeled quickly out of the room. I saw ceiling lights, a gas mask, and then total black.
When I woke up, my husband and doctor were calling my name. I asked them what was happening; my doctor said that my cervix had ruptured, I was losing blood faster than they could pump it into me, and that they needed to do surgery immediately to stop the bleeding. First, they were going to try to stitch everything they could, and then I would undergo a catheter embolization, where a radiologist would snake a catheter through my veins to the arteries that pump blood to my uterus. Once the catheter reached the arteries, the doctors would temporarily glue each one of them shut, essentially “turning off the faucet” to stop the blood from flowing to my cervix. The embolization would save my uterus; if it didn’t work, the last resort was going to be an emergency hysterectomy. I didn’t really have much choice in the matter: I needed one of these surgeries to save my life.
Lucky for me, the embolization stopped the bleeding, and at 5:30am, nearly twelve hours after my son was born and after three surgeries and seven blood transfusions, I was rolled into intensive care. I had lost nearly 40% of the blood in my body that night. I would be watched carefully for two days to make sure the bleeding was under control, especially when they removed the packing from the site of the rupture. For those two days, I would be pumped full of antibiotics, have my blood drawn constantly to check for white blood cells, and nurses would monitor the status of my bleeding on an hourly basis. Every single time they came in to check the bleeding, I nervously searched their faces for signs of concern. I was finally cleared to leave the hospital a few days later, with my baby, and thankfully, with my life. The experience left me bruised, weak, and dazed, and not to mention afraid. And I was lucky.
My doctors said that what happened to me was rare, but it turns out that it isn’t as rare as it should be. More women die of pregnancy-related complications in the United States than in any other developed country. According to the Centers for Disease Control and Prevention, 700 women die in childbirth every year, and over 50,000 more nearly die, experiencing “severe maternal morbidity,” most often due to complications from severe bleeding.
These surprising numbers have caught the attention of several news organizations in the past year. In fact, ProPublica, National Public Radio, (Martin, & Montagne, 2017; Montagne, 2018) and U.S.A. Today (Young, 2018) did in-depth investigations of maternal mortality in the U.S., each concluding that the United States is the most dangerous country in the developed world to have a baby. In fact, the rate of maternal mortality in the U.S. has been increasing, making it worse now than it was 20 years ago. The trend goes in the opposite direction internationally, with maternal death rates steadily declining in every other developed country (MacDorman, Declercq, Cabral, & Morton, 2016).
The question is, why is this happening? Why are our mothers dying?
The reports found that one major reason is that many hospitals do not have effective protocols in place to protect mothers from complications related to childbirth. NPR reported that many of our medical practitioners work under the assumption that women rarely die in childbirth, and are trained to respond to complications involving the newborn instead of the mother. Other potential causes might have to do with the rise in C-sections, which can lead to complications like hemorrhages and blood clots, and scheduled inductions, which are also associated with higher rates of postpartum hemorrhage, even in low risk patients (Khireddine et al., 2013). Having babies later in life and the increased incidence of obesity could also lead to complications with high blood pressure or preeclampsia.
Importantly, the risk of maternal death and morbidity isn’t the same for everyone. According to the CDC, African American women are 3-4 times more likely to die of complications during pregnancy or birth than White or Hispanic women. A similar trend exists for infant mortality. Researchers have argued that this isn’t necessarily because of income disparity, as it exists even for middle to high-income African American women (Schoendorf, Hogue, Kleinman, & Rowley, 1992). As a result, some have suggested that chronic stress (often associated with a lifetime of experiencing institutionalized racism) could cause high anxiety and blood pressure, which could in turn be linked to complications with pregnancy and birth (Martin, N., & Montagne, R. 2017). Indeed, preeclampsia—which is again characterized by high blood pressure—is 60 percent more common in African American woman than in other women (Fingar, Mabry-Hernandez, Ngo-Metzger, Wolff, Steiner, & Elixhauser, 2006).
Another factor that could make maternal death and morbidity more of a risk is limited access to health care. On top of that, even if a woman does have access to health care, but does not have enough health insurance to cover that care, the cost of her treatment could be debilitating. A month after my surgeries, I received the bill for my treatment, containing a total amount of over $100,000. This cost is quite typical for women who have an emergency surgery like a hysterectomy, and any further complications can raise the total cost to much, much more. Without health insurance to cover it, the cost of saving my life would have financially crippled our family, as it would many families lucky enough to receive the proper treatment in the first place.
Among the most unfortunate conclusions of recent investigations into maternal death in the U.S. is that many of these deaths could have been prevented. However, the upside of this conclusion is that proper training and intervention can help. The California Maternal Quality Care collaborative recently began implementing a new quality improvement program to prevent maternal mortality and morbidity, and a recent study reporting on the outcomes of the program showed that it resulted in a significant reduction in life-threatening complications for mothers (Main et al., 2017). Further, last year, New York City launched the Maternal Mortality and Morbidity Review Committee to review cases of both maternal death and life-threatening complications (which often don’t get investigated) with the goal of making recommendations and providing data for how to reduce these complications, particularly for women of color. And just three days after my own life-threatening complications with childbirth, the state of New Jersey named January 23rd "Maternal Health Awareness" day to draw attention to the number of women who die or nearly die every year giving birth. We can hope that by raising awareness and supporting new training and intervention programs aimed at responding to and reducing the incidence of maternal mortality and morbidity, we can make the experience of childbirth what it should be for women—a new and exciting beginning.
Fingar, K. R., Mabry-Hernandez, I., Ngo-Metzger, Q., Wolff, T., Steiner, C. A., & Elixhauser, A. (2006). Delivery Hospitalizations Involving Preeclampsia and Eclampsia, 2005–2014: Statistical Brief# 222.
Khireddine, I., Le Ray, C., Dupont, C., Rudigoz, R. C., Bouvier-Colle, M. H., & Deneux-Tharaux, C. (2013). Induction of labor and risk of postpartum hemorrhage in low risk parturients. PloS one, 8(1), e54858.
MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues Short title: US Maternal Mortality Trends. Obstetrics and gynecology, 128(3), 447.
Main, E. K., Cape, V., Abreo, A., Vasher, J., Woods, A., Carpenter, A., & Gould, J. B. (2017). Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. American journal of obstetrics and gynecology, 216(3), 298-e1.
Martin, N., & Montagne, R. (2017). Nothing protects black women from dying in pregnancy and childbirth. Propublica, December 7, 2017.
Montagne, R. (2018). For every woman who dies in childbirth in the U.S., 70 more come close. National Public Radio, May 10, 2018. https://www.npr.org/2018/05/10/607782992/for-every-woman-who-dies-in-childbirth-in-the-u-s-70-more-come-close
Schoendorf, K. C., Hogue, C. J., Kleinman, J. C., & Rowley, D. (1992). Mortality among infants of black as compared with white college-educated parents. New England Journal of Medicine, 326(23), 1522-1526.
Villarosa, L. (2018). Why America’s black mothers and babies are in a life-or-death crisis. The New York Times, April 11, 2018.
Young, A., (2018). Hospitals know how to protect mothers. They just aren’t doing it. U.S.A. Today, July 27, 2018. https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/