Women in the United States are dying during pregnancy, or within 42 days after delivery due to pregnancy-related causes, at a higher rate than most other high-income countries. According to a Perspective article published in the NEJM, the rate of maternal death has risen over the past two decades and reflects racial, ethnic and socioeconomic inequities, as well as the changing demographics of reproductive-age women, who are getting pregnant later in life and are more likely to have health issues.
The authors point out that “issues surrounding maternal mortality have been notably absent from most health care policy debates” and that the “continuing upward trend” highlights gaps in our care for reproductive-age women.”
Although improvements in data collection may have led to overreporting, the US rate remains higher than other high-income countries even when only considering the deaths that are least subject to overreporting.
The authors attribute changing demographics, including women getting pregnant at an older age and the increasing prevalence of obesity, hypertension and diabetes in young women, as an important cause of these findings, noting that “cardiovascular disease is now a leading cause of maternal death.” The authors also list cesarean deliveries with cumulative surgical risks, and variation in hospital based intrapartum care quality as contributing factors.
Additionally, “low-income women and women in rural areas are more likely to die during pregnancy and a non-Hispanic black woman is more than three times as likely to die during or shortly after childbirth, as a white woman,” according to the authors.
Molina and Pace express concern about policy proposals that could reduce access to health insurance and reproductive health care. They issue a call to action for renewed focus on maternal health that includes:
1. More research to explore reasons for poor maternal outcomes in the U.S.
2. Recognize the role of prenatal care in detection and surveillance of pregnancy complications and chronic disease.
3. Research to investigate the effect of insurance coverage before, during and after pregnancy. 4. Ensure access for pregnant women to maternity care by expanding opportunities to obtain health insurance and mandating coverage of essential health benefits.
5. Promote cost sharing subsidies.
6. Continued access to Medicaid coverage for prenatal care, care during childbirth and postpartum care.
7. Promote policies that minimize women’s transitions on and off insurance around pregnancy and childbirth.
8. Recognize the critical need for coordinated primary, obstetrical and specialty care.
9. Access to effective contraception (to reduce risk of unintended pregnancy which is associated with adverse outcomes and improve women’s ability to manage health-related conditions before conception).
10. Comprehensive approaches to poverty and discrimination.
Reference: Renewed Focus on Maternal Health in the United States; The New England Journal of Medicine, November (2017).
Authors: Rose Molina, MD, MPH, Obstetrician-Gynecologist at The Dimock Center and Beth Israel Deaconess Medical Center, Associate Scientist in the Division of Women's Health at Brigham and Women's Hospital, Lydia E.W. Pace, MD, MPH faculty director of the Women’s Health Policy and Advocacy Program in the Connor’s Center for Women’s Health, BWH.