Improving Maternal Healthcare in the United States

Many consider maternal mortality and morbidity a problem that mostly affects the developing world. However, these issues remain a challenge in the United States, and our country is lagging in progress compared to others across the globe. Maternal health outcomes for women and infants in the United States are getting worse but there are steps that can be taken to improve outcomes.

The state of maternal health in the US

To quantify maternal health, the World Health Organization (WHO) makes use of the Maternal Mortality Ratio (MMR), which represents the number of women who die for every 100,000 children born. In those terms, a lower MMR is indicative of progress. The good news is that in the rest of the world, the MMR is going down. The bad news—in comparison—is that the US isn’t improving maternal health fast enough, despite our advanced healthcare systems.

Around the globe, factors that influence the MMR vary, but in this country, the leading causes of death are fairly evenly matched:

• Cardiovascular diseases: 15%
• Non-cardiovascular diseases (eg diabetes): 14%
• Infection or sepsis: 14%

In addition, according to a WHO publication, 3 factors have been cited as likely contributors to the upward trend in maternal morbidity and mortality in the US:

1. Inconsistent obstetric practice Hospitals across the country lack a standard approach for managing obstetric emergencies and identification of complications is often delayed.
2. An increase in chronic health conditions As noted previously, such conditions lead to complications in pregnancy, as well as maternal death.
3. Lack of credible data There are no federal reporting requirements for maternal deaths, maternal mortality review boards only exist in a limited number of states, and there is no national forum in which to collaborate on such issues.

Improving maternal health

With the confluence of physical and social determinants that impact maternal health in the US and create great disparity among populations, improving maternal health is no simple matter. However, there are several strategies that health systems might employ that would support progress. One relates to the method of newborn delivery. In 2012, the rate of Cesarean sections was 32.8%, which is significantly higher than the WHO’s recommended range of 5% to 15%. Since risk of maternal death is higher with planned Cesarean delivery than planned vaginal delivery, an effort to decrease this method may have a significant impact.

Additionally, an increased use of midwives may improve maternal health. Since 1990, the countries that have shown the most improvement in MMR have largely done so through the deployment of midwives. Studies in the US and around the world have proven that the midwifery model of care is effective—with improved outcomes reflected in increased rates of survival; better health and well-being of both women and infants; and more efficient use of resources.

On an individual basis, the CDC makes a number of recommendations for pregnant women to better care for themselves and their unborn children, including:

• Maintaining a healthy lifestyle
• Addressing pre-existing health issues prior to getting pregnant
• Working closely with a healthcare provider to prepare for pregnancy, ensure prenatal proper care, and monitor for complications

Better spending for better outcomes

In the US, we spend $98 billion annually on hospitalizations for pregnancy and childbirth—higher than any other country in the world. Yet, maternal death rates related to pregnancy and childbirth continue to rise. Such a dynamic requires further assessment of how healthcare dollars can be put to better use. Changes in national policies, such as the Affordable Care Act, may help, since insurance plans are now required to cover antenatal and maternal care.

However, those without insurance remain at increased risk. Data indicates that in the US, women without health insurance are 3-4 times more likely to die of pregnancy-related complications. This dynamic highlights the need for an increased focus on spending for case management and community-based care that can help to surpass such barriers.

In reference to lack of federal requirements for reporting maternal deaths, use of funds to support such a mechanism may help. This would enable a better assessment of the state of maternal health, exploration of contributing factors, implementation of needed interventions, and evaluation of future progress.

With a goal in the US to improve maternal health by decreasing the current MMR of 28 to 11.4 by 2020, a vision is in place for improvement. In order to achieve it, the efforts of all stakeholders involved will be required to push the negative trends of maternal health in our country in a positive direction.