Amnesty International is probably best recognized in the U.S. for its work worldwide that reports on issues such as human rights violations, discrimination, or health disparities. But for its latest report, the group turns its focus on the U.S.
While this country may have one of the most advanced healthcare systems in the world, AI said, it also has major problems with maternal mortality and pregnancy-related complications when compared with other industrialized nations.
In the U.S., women have a greater lifetime risk of dying from pregnancy related complications than women in 40 other countries, according to the report, Deadly Delivery: The Maternal Health Care Crisis in America, which was released last week.
From a comparative standpoint, the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain.
The Centers for Disease Control and Prevention (CDC) statistics back this up: They show that 13.3 maternal deaths now occur for every 100,000 live births—well over the target of 3.3 maternal deaths per 100,000 live births, a goal of the US Healthy People 2010 initiative.
"This country's extraordinary record of medical advancement makes its haphazard approach to maternal care all the more scandalous and disgraceful," said Larry Cox, executive director of Amnesty International USA.
"Good maternal care should not be considered a luxury available only to those who can access the best hospitals and the best doctors. Women should not die in the richest country on earth from preventable complications and emergencies," Cox added.
Maternal mortality actually doubled from a low of 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While the increase may partially reflect improved data collection, an increase to double digits is a cause for concern, according to the report.
Similar maternal mortality rates have been recently found in California as well, where maternal mortality rates nearly tripled from 1996 2006—and are 4.5 times higher than the Healthy People 2010 benchmark, according to the California Maternal Quality Care Collaborative. No specific reason is identified for this troubling increase.
In the 1990s, California's rates ranged from 5.6 to 10.7 deaths per 100,000 live births, which is consistent with the overall U.S. rate. Beginning in 2000 the rate climbed to 10.9, then to 14.6 and in the last reported year it is nearly 17. Also concerning is a similar rise in the entire U.S. rate.
The five main causes of maternal death the U.S. are:
- Embolism or blood clots, 20%.
- Hemorrhage or severe blood loss, 17%.
- Pre eclampsia or eclampsia, 16%.
- Infection, 13%
- Cardiomyopathy or heart muscle disease, 17%.
Complications associated with pregnancy are a major issue as well. In 2004 and 2005, more than 68,000 women almost died in childbirth in the US. These complications, known as "near misses," increased by 25% between 1998 and 2005.
In addition, more than a third of the women who give birth in this country—1.7 million women annually- experience at least one complication that will have adverse effect on the mother's health.
Native American and other minority women, women living in poverty, are immigrants, speak little or no English, or are living in rural or isolated areas are particularly impacted, the report noted. But, even for white women, the maternal mortality ratios are higher than for women in 24 other industrialized countries.
These disparities have not improved in more than 20 years.
Overall, the number of maternal deaths is significantly understated, Cox said, because of a lack of effective data collection nationwide.
"Reform is primarily focused on healthcare coverage and reducing healthcare costs," said Rachel Ward, one of the Deadly Delivery report authors. "It does not address discrimination, systemic failures and the lack of government accountability."
The report makes 10 suggestions for reducing maternal mortality, including the creation of an Office of Maternal Health, which would be charged with improving maternal health care and outcomes and eliminating disparities.
In addition, state governments should ensure that low-income pregnant women have temporary access to Medicaid while their permanent application for coverage is pending (presumptive eligibility) and that Medicaid provides timely access to prenatal care. In cases where a woman receives prenatal care before eligibility is confirmed, states should ensure that Medicaid reimburses retroactively for services provided.
The Joint Commission has weighed in earlier this year with a Sentinel Event Alert that suggests hospitals take a series of steps to prevent maternal death or injury, such as:
- Educating physicians and other caregivers about underlying conditions such as high blood pressure, diabetes or morbid obesity that may put women at risk if they become pregnant.
- Using specific protocols to treat pregnant women who have, for example, experienced a change in vital signs, hemorrhage or pre eclampsia.
- Training emergency room staff to consider whether female patients may be pregnant or recently pregnant.
- Referring high-risk women to experienced prenatal care providers who can direct specialized services for women.
But another answer may be that health systems should simply provide more and better prenatal care. Ron Anderson, MD, CEO of Dallas-based Parkland Hospital and Health System, which delivers over 16,000 babies per year, told the Medicare Payment Advisory Commission (MedPAC) in Washington this month that as the system increased the amount of prenatal care, it decreased the number of babies born prematurity.
"Prematurity, as you know, in the United States is going up. We actually have seen a reduction over the last 20 years," he said. Through outreach programs sponsored by the hospital, the hospital now delivers prenatal care to 98% of the women—some of whom may be undocumented women—who actually come to Parkland prior to their delivery.
"The results are a reduction by almost two thirds in stillbirth, neonatal deaths, intracranial bleeds and days in the neonatal ICU—so it saves us a lot of money," Anderson said. "When we're asked why we provide prenatal care to undocumented women, the economic argument [comes to the top], but the humane argument should [as well]."
"Deadly Delivery" is a "clarion call to action to transform our healthcare system and ensure that every woman has access to high quality maternal and newborn care within a coordinated, integrated and equitable system designed to best meet the needs of mothers and their fetuses/newborns," says Maureen Corry, executive director of the New York-based Childbirth Connection, which has closely studied how to improve and transform the maternity care system.
"Rapid gains are within our reach if we apply what we know from best evidence is optimal care for mothers and babies," she adds.
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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.