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HEALTHLINE NEWS

Why is the United States’ Maternal Death Rate so High?

A mother in the U.S. is three times more likely to die during pregnancy or after childbirth than a woman in Canada. How do we remedy that?

maternal deaths

Mallory Brasseale’s pregnancy was a textbook first pregnancy.

“The worst I ever felt was uncomfortable, exhausted, and a little bit nauseous at the smell of certain foods, but I never got sick,” said Brasseale, a 27-year-old web editor who lives in Alabama with her husband, Sam, a web developer.

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Even her doctor’s appointments were perfect.

“My blood pressure remained its normal-low range. I passed every test with flying colors, and most importantly, my baby was healthy and growing right on target,” Brasseale told Healthline.

Like many first-time moms, Brasseale saw her due date come and go.

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Eight days after she expected to deliver, her doctors decided she should be induced. On May 8, 2014, she arrived at a local hospital to begin the process.

“After several hours of labor and a few hours of hard pushing without making much progress, my doctor recommended a C-section,” Brasseale said.

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Twelve hours after she was induced, a daughter, Genevieve, was born “weighing a perfect, healthy 8 pounds, 3 ounces.”

For Brasseale, a 5-foot-5-inch woman with a petite frame, delivering Genevieve naturally, the doctors explained, might have been too difficult anyway.

Recovery from a cesarean delivery is often difficult, and Brasseale expected that.

“Right off the bat, my C-section recovery was rough. I was dazed from the [beginning] and in a lot of pain, but nothing appeared out of the ordinary,” she recalled. “We were discharged three days after she was born, on Mother's Day.”

Brasseale would be back to the hospital five days later, hemorrhaging and in need of emergency medical attention.

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“One week after Genevieve was born, Sam and I were sitting on our bed around 9 p.m. while I was nursing. My uterus had been contracting while nursing, which I'd remembered hearing from the nurse was normal, but all of a sudden I had a painful contraction, felt a whoosh, and was sitting in a pool of blood,” Brasseale recalled.

She set Genevieve down on the bed and walked the few steps to the bathroom.

“I’d experienced what I thought was normal postpartum bleeding before, but this did not feel right,” Brasseale said.

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She reached for the phone and called 911.

As Sam was talking to emergency dispatchers, Brasseale called her doctor’s emergency OB-GYN hotline. The nurse asked her routine questions but assured her what she was experiencing was probably normal. But she added, “… if it made me feel better, I could come into the ER. I stayed for a few hours in the emergency room, and they discharged me early in the morning and told me to call my doctor first thing in the morning to get checked out. I felt silly, like I was overreacting.”

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That wouldn’t be Brasseale’s last visit to the hospital.

Read more: What happens during the trimesters of pregnancy »

America’s maternal health crisis

Each year, 700 to 900 women in the United States die as a result of pregnancy or childbirth-related issues.

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Another 65,000 nearly die.

An American woman is three times more likely to die during the maternal period, a span that includes pregnancy and up to a year post-pregnancy or termination, than a woman in Canada.

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She’s six times more likely to die than a woman living in Scandinavia.

This number is on the rise, too. From 2000 to 2015, global maternal death rates fell by half. In the United States, they increased by nearly 27 percent.

In the United Kingdom, the maternal death rate has fallen so low, a woman’s partner is more likely to die while she is pregnant than she is.

So how is it that the United States, with one of the most expansive and wealthiest healthcare systems on the planet, is falling so far behind other countries?

U.S. maternal death rate
  • 3 times higher than Canada
  • 6 times higher than Scandinavia

That’s a complicated issue.

For one, American mothers are older than before. The average age for a first-time mother increased from 24.9 years in 2000 to 26.3 years in 2014. This brings with it a longer medical history and the possibility for more complex issues.

Additionally, almost half of pregnancies are unplanned. That means mothers-to-be haven’t been able to address health issues or lifestyle changes that will be most beneficial for them and their infants.

Nearly one-third of all deliveries in the United States are by cesarean delivery. While the procedure and the recovery period have been improved over decades of practice, the surgery still increases a woman’s risk for post-delivery complications.

In addition, the collective focus has been on the infant, not the mother, for quite some time.

Many hospitals and medical organizations have shifted the mother-baby dynamic to focus on the baby’s outcome. The United States is at a historic low point for infant mortality rate — 23,000 babies per year — though the number still greatly exceeds the maternal death rate.

Lastly, there’s the human element. Many hard-to-recognize symptoms may be passed over as part of natural birth recovery.

Standardized treatment protocols leave little room for “instinct” interactions between patient and doctor.

What may seem unusual to a new mom might be mundane to a nurse or doctor who sees hundreds of women each week.

Finding the rare, serious health complication is difficult, even for medical professionals with decades of experience.

Read more: More women in their 30s having babies than women in their 20s »

Being taken seriously

The day after Brasseale’s visit to the ER, feeling like an overly anxious new mom, she had an appointment with her regular OB-GYN.

Her doctor prescribed a medication that was supposed to increase uterine contractions and help reduce postpartum blood loss. Her doctor assured her the bleeding was normal and this new medicine would stop it.

Brasseale headed home, but the bleeding didn’t stop.

“I call the emergency hotline again over the weekend, and the nurse on call assures me what I’m experiencing is normal,” Brasseale recalled.

Three days after her post-ER checkup with her doctor, she returned for another postoperative appointment with her doctor.

“They performed the regular blood test, and I remember sitting in the examination room waiting to see my doctor when I overhear her saying outside the closed door, speaking presumably to the nurse, something along the lines of ‘How did she get this low?’” Brasseale said. “When she comes into my room shortly after she tells me that I've become anemic and if my blood levels go any lower, I’m going to need a blood transfusion. She schedules a D&C to be sure I don't have any retained placenta.”

The D&C procedure went well and Brasseale returned home that night.

Four days later, the bleeding was worse than ever. Emergency responders arrived and Brasseale’s normally low blood pressure was significantly lower than normal.

“I remember almost passing out in our bathroom. At the ER, I received blood transfusions, but I continued to hemorrhage,” she said.

Brasseale was admitted to the ICU on May 26.

“After about five days in with no talk of going home, I realized they must be taking me seriously,” she said.

Several doctors were consulted, and many different treatments and procedures were performed, all trying to save the young mom’s uterus. Five days after she was admitted to the ICU, the doctors performed a hysterectomy.

Her uterus was sent to a lab for testing. Brasseale was diagnosed with placenta increta, a condition in which the placenta attaches deeply into the muscle walls of the uterus.

Placenta increta is a rare maternal health complication and a form of placenta accreta. As many as 7 percent of women with placenta accreta die before or soon after delivery.

Most maternal deaths in the United States are from hemorrhaging and preeclampsia, a condition that causes high blood pressure.

Read more: ‘Positive Birth Movement’ empowers women »

Where to from here?

The highest maternal death rates are among women who have unplanned pregnancies, African-American women, and women living in poverty.

The odds that their risk for death would be higher falls into line with what is known about the individual risk factors these groups have for maternal complications.

“It may be true that the maternal death rate is higher than many other countries, but it’s important to highlight that it’s still a very rare and small occurrence,” Dr. Sherry Ross, OB-GYN, and women’s health expert at Providence Saint John’s Health Center in California, told Healthline.

Ross, and doctors like her, point out that they and the hospitals where they work are aware of these numbers and are working to improve a mother’s care.

“It has been on a national and international level to improve the standard of practice with hospitals and all medical personnel involved with patient care,” Ross said. “Standardizing protocols, creating quality improvement committees and standards of practice will help reduce the maternal death rate and other obstetrical complications.”

Dr. Ashley Roman, director of the Division of Maternal Fetal Medicine in the Department of Obstetrics and Gynecology at NYU Langone Medical Center, echoes that call for consistent standards.

She told Healthline her hospital is working to ensure those standards are met for each woman.

“Standardization of care improves outcomes in critical situations,” Roman said. “To this end, all obstetrical providers must undergo mandatory education as part of their hospital credentialing process every two years. This process includes simulation training on obstetrical hemorrhage.”

NYU Langone already has a protocol other similarly-sized hospitals are working to adapt for the sake of a mother’s health.

“We have response teams for the most common life-threatening scenarios that can arise during labor, such as hemorrhage, in order to assemble crucial team members quickly and activate other areas of support from the blood bank to the central lab to the elevators,” Roman said. “One phone call brings everyone to the patient’s bedside within seconds to evaluate the patient and determine best next steps.”

Other health organizations, like the California Maternal Quality Care Collective (CMQCC) are adopting “toolkits.”

“CMQCC develops toolkits for use by clinicians to help standardize practices and improve systems for obstetric hemorrhage, early elective deliveries, preeclampsia and cardiovascular disease in pregnancy and postpartum,” CMQCC states on its website.

Essentially, each major area of maternal health complication has a specially-designed set of practices and standards that can immediately help doctors and nurses assess, respond, and treat a patient.

The toolkits were launched in 2014 and hospitals that began using them saw a 21 percent decrease in near deaths from maternal bleeding. Hospitals that did not use the collaborative care tool only saw a 1.2 percent decrease. Only half of California’s hospitals currently use the kits.

Other policies are also needed.

For example, Medicaid, which pays for almost half of all births in the United States, only pays for 60 days of post-delivery care for mothers. Babies are covered for one year.

Medicaid is only available to individuals with low incomes, and women living in poverty are at an increased risk for maternal death. Their short window of insurance-covered care could put them at an even greater risk.

Standards, Ross said, are no substitute for being honest about how you’re feeling.

“Women and caregivers have to pay attention to their body and understand what is normal and what is not after giving birth,” she said. “If something is just not feeling right after giving birth, contacting your healthcare provider should happen immediately to avoid potential complications that can turn deadly.”

That’s exactly what Brasseale did in the days and weeks following her baby’s delivery, but she said the response she got from her doctors and nurses wasn’t as helpful as she, a nervous new mother, needed.

“I’ve always had the feeling that they missed something with me and I still don't completely understand how my condition got so far undetected,” she said. “On the other hand, I didn’t have any signs or symptoms, besides the severe postpartum bleeding, of placenta increta, and my baby girl was, and still is, perfectly healthy and for that I’m very thankful. Though, when the hemorrhaging first began, I felt like I was being dismissed as being overly dramatic. It’s not a good feeling when you’re scared.”

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