“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.
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 one-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.
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
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.
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, aimed at reducing the deaths. Nearly every hospital in the state belongs to the group. Membership includes benefits, such as 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. 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.
California’s maternal mortality review committee also investigates each pregnancy-related death and whether racial bias may have played a role.
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. “If you think bias is a fundamental driver of these iniquities then you have to hold providers accountable,” Green said.
Healthier pregnancies and 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.
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 cited a 2020 study that found Black newborns were more likely to survive when cared for by Black physicians. Initiatives aimed at increasing the number of providers, such as debt forgiveness and investment to add residency seats, could make a difference.
Better services and care
Nearly 1 in 4 maternal deaths in the United States takes 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. 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.
A breakthrough would be to 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.
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.
Mara Gay writes for The New York Times Editorial Board.