America Already Knows How to Make Childbirth Safer

Years ago, researchers discovered that American women were dying in childbirth at an alarming rate, far higher than in many other Western countries. Black women, they found, were dying at even more elevated rates. Data in hand, they called for change.

“It is earnestly believed that whenever the public realizes the facts it will awake to action,” said a report for the Department of Labor. “The hazards to health and life connected with childbirth have been either ignored or accepted as unavoidable accidents,” it read. “No facts brought out in this study are as striking as the difference in rates from childbirth of the white and colored population of the death-registration area.”

The year was 1917.

Over the next century, deaths in childbirth declined in the United States, largely thanks to advances in care in the 1940s, especially the use of sulfa drugs and antibiotics, as well as blood transfusions and high blood pressure screenings.

Yet more than 100 years after that landmark report, written by Dr. Grace Meigs, Americans are still dying of pregnancy and childbirth-related causes at rates far above many parts of the world. Even as maternal mortality declined globally by a third from 2000 to 2015, deaths rose in the United States. The racial disparity persists as well. Even when Black women have higher incomes, they are more likely to die from pregnancy and childbirth than white women are.

The Supreme Court decision overturning abortion rights may lead to still more maternal deaths, by further limiting access to reproductive care in the United States. The concern is particularly acute in states like Mississippi, which have among the highest rates of maternal deaths in the country and have enacted near total bans on abortion.

Research is underway to better understand why the deadly racial disparity persists, and how to close it. But plenty is already known about how to reduce deaths from childbirth and pregnancy in general. Yet the United States seems to have accepted these deaths, failing to widely carry out measures that have been shown to stop them.

Researchers, medical professionals and advocates say the United States should adopt best practices similar to those deployed in states like California, which according to federal data has the lowest rate of maternal deaths in the country; focus on improving the health care received by American women — but especially Black and Native women — during pregnancy and delivery, and up to a year after; and enhancing the social services offered to pregnant women, from transportation to housing.

The California Model

One way forward is to take a close look at how California made progress.

California’s maternal mortality rate surged during the pandemic, a trend seen across the country. But in the years before Covid hit, the state had significant success in reducing its maternal mortality, lowering it to 12.8 deaths per 100,000 births. That is still higher than in many developed countries, but significantly under the national rate of 20.1 deaths for every 100,000 births in 2019. Though the racial disparities persist in California, as in the rest of the country, it had, before Covid, narrowed that gap.

The state has been working on this issue for more than a decade. In 2006, its Department of Health began investigating maternal deaths, which were on the rise in the state. The same year, it began a public-private partnership with Stanford University, known as the California Maternal Quality Care Collaborative, aimed at reducing the deaths. Nearly every hospital in the state belongs to the group. Membership includes benefits, like financial bonuses for reducing C-section rates, and responsibilities, like sharing data with other members.

That allowed the state to identify trends and share what worked, leading to changes like adding “hemorrhage carts” to delivery suites, reducing the incidence of a leading cause of maternal death. California, like 35 other states, the District of Columbia and the U.S. Virgin Islands, has also expanded Medicaid coverage to include postpartum care for women for a full year after birth.

Legislators in other states can expand this coverage, so all women can seek the health care they need for up to a year after giving birth. Along with the federal government, states can also push every hospital to look at California’s model, or other proven ways to make childbirth safer.

California’s maternal mortality review committee also investigates each pregnancy-related death and whether racial bias may have played a role. Dr. Amanda Williams, the collaborative’s clinical innovation adviser, said racial bias can sometimes be indicated in cases where nursing notes describe patients who later died as “disruptive,” or in which medical professionals were slow to respond to lab results.

“I experienced it firsthand in labor,” Dr. Ndidiamaka Amutah-Onukagha, a professor of Black maternal health at Tufts University School of Medicine, told me. “It’s a little out of body to be an expert in maternal health and then to experience microaggressions while in labor.”

Those determinations of racial bias are made public, but they are used to help shape training and policies across the state.

Dr. Tiffany Green, a professor at the school of medicine and public health at the University of Wisconsin, Madison, said she believes the effort to reduce maternal mortality should focus not only on care received in hospitals, but on the social and economic conditions faced in general by Black women. The United States should consider using federal civil rights law in cases where racial bias severely hurt the care a patient received. “If you think bias is a fundamental driver of these iniquities then you have to hold providers accountable,” Dr. Green said.

Healthier pregnancies and safer deliveries

Following better protocols inside hospitals, where most American women give birth, is a key part of any strategy to reduce maternal deaths. Hemorrhage, or excessive postpartum bleeding, is a leading cause of deaths from childbirth. Hemorrhage carts can be added to delivery rooms, bringing the equipment needed to stop the bleeding much closer to the patient.

Giving a standing order to allow nursing staff to give medication that prevents strokes, another leading cause of maternal deaths, is another smart measure, researchers and practitioners say. Making hospitals welcoming to nurse-midwives and doulas can also help. So can approving blood transfusions with verbal orders instead of waiting for paperwork. But across the United States and even within cities, the adoption of these practices varies widely.

Experts say the solutions go beyond care in hospitals. Pregnant Americans are seeking care in a country with a severe shortage not only of obstetricians-gynecologists, but also midwives, who are associated with good health outcomes in low-risk births.

Closing the racial disparity may be a more complex challenge; more research is needed on the most effective ways to close the gap. One immediate need is clear: The United States needs many more providers, especially Black providers. Many maternal health researchers I spoke with, citing a 2020 study that found Black newborns were more likely to survive when cared for by Black physicians, said they believed that adding Black providers isn’t only a matter of increasing trust for Black patients but may also lead to better care. Initiatives aimed at increasing the number of providers, such as debt forgiveness and investment to add residency seats, could make a difference.

Offering Americans easy-to-access information about birthing outcomes by race could also help, by empowering women to make informed choices about where they deliver, and encouraging hospitals to improve care. “Data on maternal mortality and morbidity by race and income per hospital is not publicly available. That seems quite important,” said Dr. Maya Rossin-Slater, a professor of public health at Stanford, who has closely studied racism in maternal and infant health.

More social services and better postpartum care

Nearly one in four maternal deaths in the United States take place one to six weeks after delivery. Yet new mothers and their families have far less access to social services in the United States than women in many developed countries, from health care to housing. That can make it harder to seek care after delivery. The stress of poverty can also add strain to the bodies of women before they deliver, especially Black and Native American women who are at increased risk of hypertension during pregnancy, another leading cause of maternal mortality.

At least one effort afoot in Washington, the “Momnibus” legislation sponsored by Representative Lauren Underwood of Illinois, is promising and can begin to offer some relief. The package includes 13 bills. One would expand eligibility for WIC, the federal food assistance program for women and children. Another would fund community organizations that help provide housing, transportation and other essential services to pregnant women and new mothers. Yet another bill would fund a critical study on maternal health among Native American women.

A breakthrough would be to finally mandate paid leave for new parents, a benefit offered in at least 40 other developed countries, but not the United States, even though paid leave has been associated with better maternal health and better outcomes for babies, too. One study found infant mortality in California fell 12 percent in the years after the state instituted partial paid family leave in 2004.

The United States can do much more. It needs a sustained national effort to prevent these deaths, including a dedicated campaign to prevent them among Black and Native women.

In the wake of the Supreme Court ruling last year that stripped Americans of their constitutional right to abortion, the sense of urgency around women’s health should be acute. Instead, as with gun violence, the steady trickle of deaths related to pregnancy and childbirth has largely become an accepted feature of life in the United States.

So too have the higher rates of the deaths among Black and Native women. Stories like that of the tennis star Serena Williams, who nearly died giving birth to her first child in 2017, are echoed in the experiences of Black women across the United States.

In 2017, Shalon Irving, a prominent Black epidemiologist at the Centers for Disease Control and Prevention who had devoted her career to addressing health disparities, died weeks after giving birth to her daughter. Representative Underwood, the sponsor of the Momnibus legislation, counted Dr. Irving as a close friend. Dr. Anne Schuchat, a former acting C.D.C. director who attended the funeral, said the C.D.C. community was stunned. “This shouldn’t happen,” Dr. Schuchat told me by phone.

“You know the work we’re doing is very important,” she said. “You wish it was going faster.”

Source photographs by JGI/Tom Grill and ljubaphoto/Getty Images

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