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Why Are Women Still Dying of Pregnancy and Childbirth?

Sofer, Dalia

AJN The American Journal of Nursing: September 2018 - Volume 118 - Issue 9 - p 12
doi: 10.1097/01.NAJ.0000544959.90367.24
In the News

Inequity is a key contributor.

Dalia Sofer

Figure.

Figure.

About 830 women worldwide die each day from pregnancy and childbirth-related causes, according to the World Health Organization (WHO). In 2015, this amounted to 303,000 mostly preventable deaths among pregnant and postpartum women, 99% in developing countries. And, though the rate of maternal mortality has dropped significantly worldwide, the United States experienced an increase in recent years with a disproportionate share of deaths among black women.

These are among the findings presented in June at the Maternal Mortality Summit hosted by the Health Resources and Services Administration (HRSA) at its headquarters in Rockville, Maryland. Participants included health care experts from the WHO and from seven countries: Brazil, Canada, Finland, India, Rwanda, the United Kingdom, and the United States.

The good news is that maternal deaths worldwide dropped between 1990 and 2015 by about 44%. Maternal mortality rates range widely from an average of 239 per 100,000 live births in developing countries to 12 per 100,000 live births in developed countries. Progress also varies: some countries during the 25-year period reduced their rates by more than half.

In the United States, however, maternal mortality rose, due to what one study calculated as an increase of 26.6% in maternal deaths between 2000 and 2014 in 48 states and Washington DC. (California had a declining trend, while Texas experienced a sharp increase in 2011–12.) The overall U.S. maternal mortality rate has been difficult to track in recent years because of a 2003 federally mandated change in the definition of maternal mortality that states implemented unevenly on their death certificates. The U.S. definition also differs from that of the WHO.

Adjusting for disparities in data reported by individual states, one group of researchers estimated that the U.S. maternal mortality rate, excluding California and Texas, increased from 18.8 per 100,000 live births in 2000 to 23.8 per 100,000 live births in 2014. The Centers for Disease Control and Prevention (CDC) estimates that about 700 U.S. women die annually as a result of pregnancy or delivery complications.

Several themes emerged from the HRSA summit. Key among them was the problem of inequity in access to health care services. Worldwide, according to the WHO, high maternal mortality rates correlate with inadequate medical resources, particularly for women living in poor and rural areas. The picture is more complicated in the United States, where black women are three to four times more likely to die of pregnancy-related causes than white women, according to the CDC. “Let's not be afraid of the word ‘racism,’” said Joia Adele Crear-Perry, founder and president of the National Birth Equity Collaborative, at the summit. She noted that health is influenced by multiple factors, including psychosocial and environmental factors. “We must focus on decreasing stressors on black women,” she said.

Also discussed was the rise in conditions in pregnant women that contribute to maternal morbidity and mortality such as cardiovascular disease, obesity, diabetes, opioid abuse, and mental illness. The importance of standardizing approaches to these and other risk factors through safety bundles was noted. Safety bundles that lay out step-by-step procedures to prevent specific complications of pregnancy and childbirth—venous thromboembolism, hypertension, or obstetric hemorrhage, for example—have been developed by the Alliance for Innovation on Maternal Health, a national maternal safety and quality improvement initiative. Bundles are available at https://safehealthcareforeverywoman.org/patient-safety-bundles.

The vulnerability of women in conflict areas and in regions undergoing climate change was underscored. Several speakers agreed that in times of crisis, pregnant women are the first to suffer harm.—Dalia Sofer

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