Abstract on maternity care than any other country (Gaskin,


Every minute a woman dies during
labor or delivery; most causes of death relating to maternal mortality are
preventable. Maternal mortality has become an increased public health concern
in the United States and is highest among women living in rural areas and
low-income communities. Over the past 25 years, the maternal mortality rate in
the United States has doubled and in some areas are higher than rates of
developing countries. There has been a significant gap in literature since 2003
because of inconsistent record keeping. Leading causes of death among women in
the United States are hemorrhage, hypertension and infection. In order to
reduce maternal mortality in the United States, communication and services need
to be strengthened amongst providers and families.

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Introduction. Maternal mortality is a preventable public health
concern that effects mothers and families around the world. Every
two minutes, a woman dies from complications related to pregnancy and
childbirth (Merck for Mothers, 2017). When examining the concern on a
global spectrum, an estimated 830 women die each day from causes related to
pregnancy and childbirth (World Health Organization, 2016). These causes are
preventable. The maternal mortality rate is generally higher amongst women living
in rural areas and among poorer communities (WHO, 2016). The United States of
America is one of the wealthiest countries in the world and spends more money
per capita on maternity care than any other country (Gaskin, 2008). However,
even the country that spends the most money on maternity care has had a
significant increase in the incidence of pregnancy related deaths.

There has been a significant amount of research published to
explain the increasing maternal mortality rate in the United States, but why
this issue remains is still unclear. This review will focus on three major issues
mentioned repeatedly throughout the literature reviewed. These issues are: data
collection and record keeping, racial disparities and the rise of cesarean
births. This review will also discuss action that is being taken to address
this crisis. Although the literature presents the mentioned issues in a variety
of contexts, this review will focus primarily on pregnancy related deaths as a
public health concern and ways public practitioners can address the issue.

Background. Approximately four million women give birth in
the United States each year; about 700 of those women die annually as a result of pregnancy or delivery complications (Centers for Disease
Control and Prevention, 2017). Maternal
mortality is the death of a woman during pregnancy,
childbirth, or in the 42 days after delivery (World Health Organization, 2016). While maternal mortality rates
are dropping in developing countries, the rates are increasing in the United
States. More than 99% of women who die from pregnancy related complications are
from low and middle-income countries (Neggers, 2016). When one looks at that
statistic, it may appear that maternal mortality is not an issue that needs to
be addressed in the United States, however the issue is bigger than most people
believe. The United Nations Millennium Development set a 25
year goal to improve maternal health and reduce maternal mortality by 75%
worldwide between 1990 and 2015 (MacDorman, 2015). During that 25 year period,
the maternal mortality rate in the United States has nearly doubled (Neggers,
2016). In 2010, the United Nations released
statistics that placed the United States 46th in the world for
maternal mortality with a maternal mortality ratio (MMR) higher than European,
Asian and Middle Eastern countries (Creanga, Berg, Ko, Farr, Tong, Bruce,
Callaghan, 2014). The significant rise of maternal deaths in the
United States has been worrisome due to its preventable nature and reasons for
the rise are still unclear.

Public Health Significance. Pregnancy related deaths are a major
public health concern not only in the United States but worldwide. When a
mother passes away, this not only affects one individual, but the family and
community as well. Addressing this issue in the United States is important
because why deaths are occurring in a country that pays the most for medical
care is still unclear.

History. Between 1987 and 2013, the
maternal mortality rate had increased from 7.2 to 17.3 deaths per 100,000
births (CDC, 2017). In 1987, the Safe Motherhood Initiative was created as a
way to strengthen policy intervention for maternal mortality (Starrs, 2006).
The focus on maternal health became a global concern in 1990 when maternal
health and the reduction of maternal mortality became one of eight Millennium
Development Goals for the United Nations (MacDorman, 2015). In 2011, former
President Barack Obama and UK Prime Minister announced a partnership to address
the issue of global health with an emphasis on care for women and girls around
the world (The White House, 2012). According to the CDC, the National Vital
Statistics System’s plan is to reduce the maternal mortality rate to 11.4
deaths per 100,000 women by the year 2020 (CDC, 2017).

Contributing Factors. There are many factors contributing to the increasing incidence of
maternal mortality. Priya Agrawal, the Executive Director of Merck for Mothers explained
three clear factors that have contributed to the increasing rates of maternal
mortality in the United States. These factors are: inconsistent obstetric
practice, increasing number of women who present chronic conditions and the
general lack of good data (Agrawal, 2015). Many hospitals in the United States lack
a standard approach to managing obstetric emergencies and identify pregnancy
and childbirth complications too late. The general attitude and assumption by
doctors and nurses that mothers “will be okay” has been observed in many
maternal mortality cases in the United States.

In regular
maternity wards, babies are monitored more closely than mothers during and
after birth (NPR, 2017). When newborn babies are in any danger they are
relocated immediately to the neonatal intensive care unit (NICU), which is
equipped with a staff of highly trained specialists (NPR, 2017). While mothers
are monitored by nurses and doctors who expect things to be fine and are often
unprepared when they aren’t (NPR, 2017). This assumption occurs both during the
hospital stay and leads up to discharge. Women are routinely prepped prior to
discharge on how to breastfeed, who to contact if the newborn is sick, but no
information on how to tell if they, the mother needs medical attention. Many
hospitals in the United States forget about the “M” in maternal child health
(MCH), and focus to a great degree on the child or infant.


Risk Factors. There are many risk factors
that play a role in maternal deaths in the United States. An increasing number
of pregnant women in the U.S. are diagnosed with chronic conditions such as high
blood pressure, diabetes, or heart disease that may put them at risk of
pregnancy complications or death (CDC, 2017). Chronic conditions such as
obesity during pregnancy is an important indicator of the current and future
health of the mother and baby (CDC, 2017). According to the CDC, nearly half of
women are overweight or obese before they become pregnant, which puts them at
risk for pregnancy complications (CDC, 2017).

Smoking during and after
pregnancy is also a risk factor for maternal mortality. Smoking during
pregnancy increases the risk of complications for mothers; complications can
include problems with the placenta and water breaking too early (CDC, 2017). According to the Pregnancy Risk Assessment Monitoring
System, about 1 in 5 women smoked in the three months prior to pregnancy and
about 1 in 10 smoked during their last three months of pregnancy (CDC, 2017).


Record Keeping Problems. Lack of comprehensive data collection has played a
significant role in the rise of maternal mortality rates in the United States. Much
has been done to address inconsistent reporting of maternal deaths. In 2003, a
pregnancy question with checkboxes was added to the United States standard
death certificate revision to make causes of death amongst pregnant or
previously pregnant women consistent across all states (MacDorman, et., 2016). The
addition of the pregnancy check boxes was to improve data. The question
incorporated checkboxes to determine pregnancy status within the last year,
pregnancy at time of death, not pregnant but pregnant within 42 days of death,
not pregnant but pregnant 43 days to 1 year before death, or unknown if
pregnant within the last year (MacDorman, et., 2016). While this was a
breakthrough in consistency for identifying maternal deaths, there was a delay
in states adoption of this new pregnancy question. This created a dilemma where
data was not consistent amongst every state because some states had implemented
the question, while others had not. States
that did not use the check box addition have underestimate maternal mortality
rates (MacDorman, et., 2016). Robert Anderson of the Centers for Disease Control
and Prevention stated that the CDC stopped reporting national maternal
mortality rates because of the state differences they were finding when
reporting and decided that the rates were not accurate and not comparable year
to year (Lewis, 2014). It’s crucial for states to adopt standardized death
certificates so that the CDC and other public health experts can collect and
analyze information from each state and look for trends and patterns in
maternal risk factors. While examining this literature, it was apparent that
record keeping played a significant role in the gap of literature and data on
maternal mortality.


Racial Disparities. Nearly one third of
women in the United States self-identify as members of a racial or ethnic minority
group (Racial and Ethnic Disparities in Women’s Health,
2005). African American or women who identify as black in the
United States are 3 to 4 times more likely to die in pregnancy and childbirth than
Caucasian women (Berg, 2010). In parts of the United States with high
concentrations of women of color who live in poverty, such as Mississippi,
maternal death rate has surpassed rates of sub-Saharan Africa (Lewis, 2017).
Women of color typically have poorer health outcomes than white women which
make them more likely to have high-risk pregnancies. Chronic conditions
disproportionately affect poor and minority populations and more women are
entering pregnancy with these conditions (CDC, 2017).

Access to
contraception and prenatal care play a major role in the increasing maternal
mortality rate among minority women. Minority women face significant barriers
to contraception, which contribute to higher rates of unintended and higher risk
pregnancies (Lewis, 2017).

According researcher Crystal Lewis, low-income women, women of color and immigrant women
in the United States are also more likely to be uninsured (Lewis, 2017). Many
low-income women of color receive Medicaid benefits in the United States. The Medicaid
finances approximately half of all births in the United States, however
accessing quality prenatal care on Medacaid is difficult (Markus, Andres, West,
Garro, Pelligrini, 2013).  

Among all
literature presented, no authors were able to explain the reasons for racial
disparities in maternal mortality. However, there was a significant difference
in the quality of prenatal delivery and postpartum care among minority women. According
to the Robert Wood Johnson Foundation, “race and ethnicity influence a patient’s
chances of receiving many specific health care interventions and treatments” (Egede,

Rise in Cesarean Births. According to the World
Health Organization, 32.7% of births in the United States are via cesarean; the
recommended percentage is between 10-15% (WHO, 2016). The rate of C-sections
has recently increased to 33% in the United; these recent increases may have
played a role in the increase of the United States maternal mortality rates
(Singh, 2011). While cesareans save the lives of
many mothers and babies, there are still complications that can increase
maternal mortality (CDC, 2017). A cesarean is an intensive surgery and is
associated with both higher health and safety risks for mothers and babies (CDC,

Public Health Implications and
Evidence-Based Solutions. There are many no-profit
organizations in the United States that have done extensive research and
dedicated resources to decreasing maternal mortality. The Merck for Mothers program is a 10 year, $500 million public health initiative,
that addresses maternal mortality worldwide and assists in funding maternal
health programs (Merck for Mothers, 2017). 
In the United States, Merck for
Mothers has nine partnerships which are located in low-income and rural
areas such as Philadelphia, PA, Camden, NJ, Manhattan, NYC and Los Angeles, CA.
Merck for Mothers assisted in funding
Building U.S. Capacity to Review and Prevent Maternal Deaths, an initiative
dedicated to promoting the maternal mortality review process; the program uses the
process to understand why there is a significant increase in maternal mortality
cases in the United States while also identifying interventions that can assist
the issue.

Recommendations. In order to decrease the rates of maternal mortality in the
United States, surveillance should be strengthened and should identify all
pregnancy related deaths in the United States on an annual basis. When
examining the cases of maternal mortality, information should be collected to
identify health care, social and cultural barriers that could be addressed;
this would also assist in implementing education programs and changes in policy
to prevent an increase in future rates.

In addition to surveillance, all
maternal deaths should be reviewed by maternal mortality review boards. Review
boards should have access to all data and records and members of the board
should be of diverse background (public health practitioners, medical professionals,
social service organizations and community members).

Medical providers can
facilitate change by providing women with as much information as possible to
assure that they have a healthy pregnancy, delivery, and postpartum period.
Communication and thorough explanation of medical procedures, and common
pregnancy complications such as preeclampsia and gestational diabetes should be
discussed with not only high-risk mothers but all expecting mothers. Prior to
discharge from the hospital, all mothers are provided with breastfeeding
education and are told what to do if their infant is sick, however mothers are
not told about the changes that will be occurring in their body and when to
seek medical attention.

Women can take charge of their
health by incorporating healthy diet, exercise, avoiding smoking, managing
stress, attending doctors’ appointments regularly and acting on possible
complications as soon as possible. Taking those steps will decrease a woman’s
chance of developing chronic health conditions before and during pregnancy and
ultimately protecting both herself and the infant from dangerous health

Connecting mothers with birth
and postpartum doulas and programs may assist in mothers feeling more confident
about their health during and following pregnancy and make them more aware of
medical procedures the process of birth. Doulas can be a benefit to women and
the community. Creating more community doula programs could be a solution to
bridging the gap between mothers and medical providers in low income
communities. Doulas provide continuous support to families prior to, during and
after childbirth. There are many community organizations that receive grants to
fund doula programs in low-income communities. In Philadelphia, Maternity Care
Coalition created a community doula program that services not only Philadelphia
but it’s surrounding counties. Any woman in the area that would like a doula to
support her during pregnancy and childbirth can be assigned one, free of charge.
More programs like the community doula program at Maternity Care Coalition, can
assist in decreasing the maternal mortality rate in the United States.

pregnancies represent a significant amount of pregnancy complication cases,
making contraception available to low-income and rural communities may assist
in avoiding this crisis. Creating and maintaining access to contraception and
family planning services has the potential to strengthen communities and
decrease the incidence of maternal mortality cases in the United States. Examining
where services are in these targeted communities could assist researchers in
identifying this issue and strengthen policies regarding maternal health in
different states.

between all stakeholders involved with maternal health is needed to address
this issue. Consistency among all state documents will assist with researchers
and the CDC identifying causes of death and analyze data. Continuing research
on maternal mortality is key to keeping the issue at the forefront of public
health issues.

Summary. Overall, maternal mortality is
becoming an increasing public health issue in the United States. In order to
address this issue, there needs to be thorough communication amongst providers
and between families and providers addressing concerns for specific populations
and ways that this problem can be resolved. are a major public health concern not only in the United
States but worldwide. When a mother passes away, this not only affects one
individual, but the family and community as well. Addressing this issue in the
United States is important because why deaths are occurring in a country that
pays the most for medical care is still unclear.


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