Sec. 2. Findings
2,313 words·~11 min read·
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Congress finds the following: Every year, across the United States, nearly 4,000,000 women give birth, about 700 women suffer fatal complications during pregnancy, while giving birth or during the postpartum period, and about 70,000 women suffer near-fatal, partum-related complications. The maternal mortality rate is often used as a proxy to measure the overall health of a population. While the infant mortality rate in the United States has reached its lowest point, the risk of death for women in the United States during pregnancy, childbirth, or the postpartum period is higher than such risk in many other high-income countries.
The estimated maternal mortality rate (deaths per 100,000 live births) for the 48 contiguous States and Washington, DC, increased from 14.5 percent in 2000 to 17.3 in 2017. The United States is the only industrialized nation with a rising maternal mortality rate. The National Vital Statistics System of the Centers for Disease Control and Prevention has found that in 2018, there were 17.4 maternal deaths for every 100,000 live births in the United States. This ratio is more than double that of most other high-income countries.
It is estimated that more than 60 percent of maternal deaths in the United States are preventable. According to the Centers for Disease Control and Prevention, the maternal mortality rate varies drastically for women by race and ethnicity. There are about 13 deaths per 100,000 live births for White women, 40.8 deaths per 100,000 live births for non-Hispanic Black women, and 29.7 deaths per 100,000 live births for American Indian/Alaskan Native women. While maternal mortality disparately impacts Black women, this urgent public health crisis traverses race, ethnicity, socioeconomic status, educational background, and geography.
In the United States, non-Hispanic Black women are about 3 times more likely to die from causes related to pregnancy and childbirth compared to non-Hispanic White women, which is one of the most disconcerting racial disparities in public health. This disparity widens in certain cities and States across the country. According to the National Center for Health Statistics of the Centers for Disease Control and Prevention, the maternal mortality rate heightens with age, as women 40 and older die at a rate of 81.9 per 100,000 births compared to 10.6 per 100,000 for women under 25.
This translates to women over 40 being 7.7 times more likely to die compared to their counterparts under 25 years of age. The COVID–19 pandemic risks exacerbating the maternal health crisis. A recent study of the Centers for Disease Control and Prevention suggests that pregnant women are at a significantly higher risk for severe outcomes, including death, from COVID–19 as compared to non-pregnant women. The COVID–19 pandemic has also decreased access to prenatal and postpartum care.
The findings described in paragraphs
(1)through
(8)are of major concern to researchers, academics, members of the business community, and providers across the obstetric continuum represented by organizations such as— the American College of Nurse-Midwives; the American College of Obstetricians and Gynecologists; the American Medical Association; the Association of Women’s Health, Obstetric and Neonatal Nurses; the Black Mamas Matter Alliance; the Black Women’s Health Imperative; the California Maternal Quality Care Collaborative; EverThrive Illinois; the Illinois Perinatal Quality Collaborative; the March of Dimes; the National Association of Certified Professional Midwives; the National Birth Equity Collaborative; the National Partnership for Women & Families; the National Polycystic Ovary Syndrome Association; the Preeclampsia Foundation; the Society for Maternal-Fetal Medicine; and the What To Expect Project. Hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, infection or sepsis, embolism, mental health conditions (including substance use disorder), hypertensive disorders, stroke and cerebrovascular accidents, and anesthesia complications are the predominant medical causes of maternal-related deaths and complications. Most of these conditions are largely preventable or manageable. Even when these conditions are not preventable, mortality and morbidity may be prevented when conditions are diagnosed and treated in a timely manner. According to a study published by the Journal of Perinatal Education, doula-assisted mothers are 4 times less likely to have a low-birthweight baby, 2 times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding. Doula care has also been shown to produce cost savings resulting in part from reduced rates of cesarean and pre-term births. Intimate partner violence is one of the leading causes of maternal death, and women are more likely to experience intimate partner violence during pregnancy than at any other time in their lives. It is also more dangerous than pregnancy. Intimate partner violence during pregnancy and postpartum crosses every demographic and has been exacerbated by the COVID–19 pandemic. Oral health is an important part of perinatal health. Reducing bacteria in a woman’s mouth during pregnancy can significantly reduce her risk of developing oral diseases and spreading decay-causing bacteria to her baby. Moreover, some evidence suggests that women with periodontal disease during pregnancy could be at greater risk for poor birth outcomes, such as preeclampsia, pre-term birth, and low-birth weight. Furthermore, a woman’s oral health during pregnancy is a good predictor of her newborn’s oral health, and since mothers can unintentionally spread oral bacteria to their babies, putting their children at higher risk for tooth decay, prevention efforts should happen even before children are born, as a matter of pre-pregnancy health and prenatal care during pregnancy. In the United States, death reporting and analysis is a State function rather than a Federal process. States report all deaths—including maternal deaths—on a semi-voluntary basis, without standardization across States. While the Centers for Disease Control and Prevention has the capacity and system for collecting death-related data based on death certificates, these data are not sufficiently reported by States in an organized and standard format across States such that the Centers for Disease Control and Prevention is able to identify causes of maternal death and best practices for the prevention of such death. Vital statistics systems often underestimate maternal mortality and are insufficient data sources from which to derive a full scope of medical and social determinant factors contributing to maternal deaths, such as intimate partner violence. While the addition of pregnancy checkboxes on death certificates since 2003 have likely improved States’ abilities to identify pregnancy-related deaths, they are not generally completed by obstetric providers or persons trained to recognize pregnancy-related mortality. Thus, these vital forms may be missing information or may capture inconsistent data. Due to varying maternal mortality-related analyses, lack of reliability, and granularity in data, current maternal mortality informatics do not fully encapsulate the myriad medical and socially determinant factors that contribute to such high maternal mortality rates within the United States compared to other developed nations. Lack of standardization of data and data sharing across States and between Federal entities, health networks, and research institutions keep the Nation in the dark about ways to prevent maternal deaths. Having reliable and valid State data aggregated at the Federal level are critical to the Nation’s ability to quell surges in maternal death and imperative for researchers to identify long-lasting interventions. Leaders in maternal wellness highly recommend that maternal deaths and cases of maternal morbidity, including complications that result in chronic illness and future increased risk of death, be investigated at the State level first, and that standardized, streamlined, de-identified data regarding maternal deaths be sent annually to the Centers for Disease Control and Prevention. Such data standardization and collection would be similar in operation and effect to the National Program of Cancer Registries of the Centers for Disease Control and Prevention and akin to the Confidential Enquiry in Maternal Deaths Programme in the United Kingdom. Such a maternal mortalities and morbidities registry and surveillance system would help providers, academicians, lawmakers, and the public to address questions concerning the types of, causes of, and best practices to thwart, maternal mortality and morbidity. The United Nations’ Millennium Development Goal 5a aimed to reduce by 75 percent, between 1990 and 2015, the maternal mortality rate, yet this metric has not been achieved. In fact, the maternal mortality rate in the United States has been estimated to have more than doubled between 2000 and 2014. Many States have struggled to establish or maintain Maternal Mortality Review Committees (referred to in this section as MMRC ). On the State level, MMRCs have lagged because States have not had the resources to mount local reviews. State-level reviews are necessary as only the State departments of health have the authority to request medical records, autopsy reports, and police reports critical to the function of the MMRC. The United States has no comparable, coordinated Federal process by which to review cases of maternal mortality, systems failures, or best practices. Many States have active MMRCs and leverage their work to impact maternal wellness. For example, the State of California has worked extensively with their State health departments, health and hospital systems, and research collaborative organizations, including the California Maternal Quality Care Collaborative and the Alliance for Innovation on Maternal Health, to establish MMRCs, wherein such State has determined the most prevalent causes of maternal mortality and recorded and shared data with providers and researchers, who have developed and implemented safety bundles and care protocols related to preeclampsia, maternal hemorrhage, peripartum cardiomyopathy, and the like. In this way, the State of California has been able to leverage its maternal mortality review board system, generate data, and apply those data to effect changes in maternal care-related protocol. To date, the State of California has reduced its maternal mortality rate, which is now comparable to the low rates of the United Kingdom. Hospitals and health systems across the United States lack standardization of emergency obstetric protocols before, during, and after delivery. Consequently, many providers are delayed in recognizing critical signs indicating maternal distress that quickly escalate into fatal or near-fatal incidences. Moreover, any attempt to address an obstetric emergency that does not consider both clinical and public health approaches falls woefully under the mark of excellent care delivery. State-based perinatal quality collaboratives, or entities participating in the Alliance for Innovation on Maternal Health (AIM), have formed obstetric protocols, tool kits, and other resources to improve system care and response as they relate to maternal complications and warning signs for such conditions as maternal hemorrhage, hypertension, and preeclampsia. These perinatal quality collaboratives serve an important role in providing infrastructure that supports quality improvement efforts addressing obstetric care and outcomes. State-based perinatal quality collaboratives partner with hospitals, physicians, nurses, patients, public health, and other stakeholders to provide opportunities for collaborative learning, rapid response data, and quality improvement science support to achieve systems-level change. The Centers for Disease Control and Prevention reports that nearly half of all maternal deaths occur in the immediate postpartum period—the 42 days following a pregnancy—whereas more than one-third of maternal deaths occur while a person is still pregnant. Further, 21 percent of maternal deaths occur between 1 and 6 weeks postpartum, and 12 percent of maternal deaths occur during the remaining portion of the postpartum year. Yet, for women eligible for the Medicaid program on the basis of pregnancy, such Medicaid coverage lapses at the end of the month on which the 60th postpartum day lands. The experience of serious traumatic events, such as being exposed to domestic violence, substance use disorder, or pervasive and systematic racism, can over-activate the body’s stress-response system. Known as toxic stress, the repetition of high-doses of cortisol to the brain, can harm healthy neurological development and other body systems, which can have cascading physical and mental health consequences, as documented in the Adverse Childhood Experiences study of the Centers for Disease Control and Prevention. A growing body of evidence-based research has shown the correlation between the stress associated with systematic racism and one’s birthing outcomes. The undue stress of sex and race discrimination paired with institutional racism has been demonstrated to contribute to a higher risk of maternal mortality, irrespective of one’s gestational age, maternal age, socioeconomic status, educational level, or individual-level health risk factors, including poverty, limited access to prenatal care, and poor physical and mental health (although these are not nominal factors). Black women remain the most at risk for pregnancy-associated or pregnancy-related causes of death. When it comes to preeclampsia, for example, for which obesity is a risk factor, Black women of normal weight remain at a higher at risk of dying during the perinatal period compared to non-Black obese women. The rising maternal mortality rate in the United States is driven predominantly by the disproportionately high rates of Black maternal mortality. Compared to women from other racial and ethnic demographics, Black women across the socioeconomic spectrum experience prolonged, unrelenting stress related to systematic racial and gender discrimination, contributing to higher rates of maternal mortality, giving birth to low-weight babies, and experiencing pre-term birth. Racism is a risk-factor for these aforementioned experiences. This cumulative stress, called weathering, often extends across the life course and is situated in everyday spaces where Black women establish livelihood. Systematic racism, structural barriers, lack of access to care, lack of access to nutritious food, and social determinants of health exacerbate Black women’s likelihood to experience poor or fatal birthing outcomes, but do not fully account for the great disparity. Black women are twice as likely to experience postpartum depression, and disproportionately higher rates of preeclampsia compared to White women. Racism is deeply ingrained in United States systems, including in health care delivery systems between patients and providers, often resulting in disparate treatment for pain, irreverence for cultural norms with respect to health, and dismissiveness. However, the provider pool is not primed with many people of color, nor are providers (whether maternity care clinicians or maternity care support personnel) consistently required to undergo implicit bias, cultural competency, respectful care practices, or empathy training on a consistent, on-going basis. Not all people who have been pregnant or given birth identify as being a woman . The terms birthing people or birthing persons are also used to describe pregnant and postpartum people.