What is it?
The dismal state of maternal mortality and morbidity in the U.S.
The U.S. is the only industrialized nation where the maternal mortality rate is increasing. From 2000 to 2017, the global maternal mortality ratio decreased by 38%, while the U.S. ratio increased by 58%. The majority of these pregnancy related deaths were preventable.
Maternal mortality ratio across industrialized nations
Maternal deaths per 100,000 live births in 2017 among women ages 15-49
The major clinical causes of pregnancy-related deaths in the U.S. include:
• Heart disease
• Obstetric emergencies
• Severe bleeding
• High blood pressure
Severe maternal morbidities are even more prevalent than pregnancy-related mortalities. These “near misses,” such as hemorrhages or organ failure, can result in long-term clinical and psychological complications. Estimates from the CDC and the Alliance for Innovation on Maternal Health indicate that 60,000 to 80,000 patients experience severe morbidities every year. Morbidity incidence is increasing faster than mortality at a rate of 190% vs. 62% between 1993 and 2014.
Social determinants of health exacerbate clinical challenges
Clinical causes of pregnancy-related mortality and morbidity are just one part of the story. A host of non-clinical factors, such as restricted access to care, also impact outcomes. Many low-income patients cannot afford private insurance but do not qualify for Medicaid, particularly in non-expansion states. Patients who do have coverage are often under-insured and unable to afford costly copays, limiting access to quality care.
Additionally, reductions in government funding of social services and benefits, including recent federal restrictions to the Supplemental Nutrition Assistance Program (SNAP) and fair housing protections, layer added financial strain on patients who struggle to afford health care. These restrictions to key social programs compound the impact of community-wide social determinants of health that are common in low-income neighborhoods.
Black and Native American patients face greatest risk of death
Maternal mortality and morbidity is a nationwide crisis that impacts every community regardless of its demographic makeup. However, some groups fare significantly worse than others. Black and Native American patients have much higher pregnancy-related mortality rates than their white counterparts. The mortality rate for black patients is 3.3x the rate for white patients. For Native American patients, it’s 2.5x the rate. Any maternal health intervention must center on the needs of black and Native American patients and communities (and others, including transgender and gender non-conforming patients) who are most at-risk of adverse outcomes.
Pregnancy-related mortality ratios per 100,000 live births
Centers for Disease Control and Prevention, 2011-2015
Recent studies indicate that black women experience worse outcomes compared to white women, regardless of educational attainment and socioeconomic status. In fact, black women with a college degree are more likely to experience severe morbidities than white women without a high school education.
Less research has been conducted on the experiences of Native American patients, who are often overlooked in national media attention on the maternal health crisis. But for both groups, the root cause of these disparities is structural racism.