The final entry of this blog series has arrived. This week will focus on the financial side of improving maternal health in the United States (U.S.). Due to the current situation, this discussion is going to look a little different. We are in unprecedented times when funds are being allocated toward the Coronavirus Disease 2019 (COVID-19) and unable to be put toward other bills. The country is understandably at a standstill.

I had the opportunity to interview Arizona State Senator Heather Carter this week, courtesy of the quarantine popular Zoom. We discussed maternal health and two bills that she has sponsored, S.B. 1290 and S.B. 1392, both of which promote the health of mothers in Arizona. S.B. 1290 would establish a Maternal Mental Health Advisory Committee in order to recommend improvements for screening and treating maternal mood and anxiety disorders. S.B. 1392 extends Medicaid health coverage for women up to one year postpartum (Arizona State Legislature, 2020). Both of these bills would have made a significant impact on mothers within the state. When discussing the future of these bills, Sen. Carter stated, “we had huge support, everybody said they wanted in, and then it didn’t get included in the skinny budget. Now it looks like we have a billion-dollar deficit, so there’s no way that is going to get done.” Due to the current state of Arizona, the country, and the world, priorities have changed.

Sen. Carter discussed how she is “super passionate about maternal health and maternal mental health” and has been “working on these issues over the years.” It was clear that she is disappointed she will not be able to follow through with the positive momentum she has created this year in impacting maternal health. Speaking in reference to maternal mortality and morbidity, “it’s shocking that we have these numbers, not only across the country in a first world country, but in Arizona specifically. Disproportionately. There is so much more we need to be doing.”

 “This year I said I am going to shine a bright light on the lack of access to care in Arizona for our moms, every single solitary corner… let’s look at it and figure it out.” There were new ideas and solutions on the horizon.

“We went through everything from workforce development issues to not having enough providers. We have one whole county on the east side of Arizona that has no OBGYN nurse practitioners, doctors, nothing. They have to drive six hours into [the city] to be seen. It’s so bad.” She continued on to explain that they examined the workforce, training, and current available services to discover every issue this state currently had.

“We’ve been talking about this stuff for years. It’s been one little bill here and one little bill there.” Instead they decided to put in all together in one “mom and baby package.” We had this great tsunami of support and then COVID-19. So now I have no idea what is happening, I don’t know what we will be able to do this year. Nothing.”

So, where do we go from here?

She made it clear, “the need and the interest are still there. We just don’t have any money.”

The last few months I have focused on the U.S. as a whole, and while this interview primarily focused on Arizona, this problem currently exists across the nation. This discussion made me wonder for how long into the future will this pandemic affect the U.S.? Will the financial ramifications carry on into the next legislation? Will it continue to stall all of the needed bills? Will funding continue to be allocated? How will the health of the nation suffer indirectly from COVID-19?

We must continue to fight for investment in maternal health. Investing in women’s health has been shown to contribute to more productive and better-educated societies. In fact, the development and economic performance of nations relies on how each country protects and promotes the health of women, before, during, and after childbirth (Onarheim, Iversen, & Bloom, 2016).

I have brought up the statistics multiple times, but I must draw your attention to them one more time. The U.S. has the highest maternal death rate among developed nations in the world with approximately 700 women dying every year due to pregnancy related complications. Up to 60% of these maternal deaths are PREVENTABLE. For each of these women who die, up to 70 suffer from avoidable complications that result in near death. The annual cost of these near deaths to the mothers, their families, taxpayers and the healthcare system runs into the billions of dollars (Anderson & Roberts, 2019)

The U.S. spends more on health care than any other country in the world but has poorer population health outcomes (Feldscher, 2018). This is evidenced by the statistics I just mentioned. Sustainability relies on us changing our focus. Prevention is key. Implementing the solutions that I have addressed in this series to prevent maternal mortality, such as technological advancements, including bringing telehealth services to rural and underserved areas and utilizing tracking systems to identify areas that need improvement, creating programs for healthcare professionals to identify and address biases in care, training providers to work in rural areas, and increasing access to care through increased Medicaid coverage through pregnancy and for up to one year postpartum. Rather than paying billions of dollars for the result of maternal morbidity and mortality, we can invest those dollars into prevention and health maintenance for all moms.

References

Anderson, B. A., & Roberts, L. R. (2019). The maternal health crisis in America: Nursing implications for advocacy and practice. New York, NY: Springer Publishing Company.

Arizona State Legislature. (2020). Bill status inquiry. Retrieved from https://apps.azleg.gov/BillStatus/BillOverview

Feldsher, K. (2018). What’s behind high U.S. health care costs. The Harvard Gazette. Retrieved from https://news.harvard.edu/gazette/story/2018/03/u-s-pays-more-for-health-care-with-worse-population-health-outcomes/

Onarheim, K. H., Iversen, J. H. & Bloom, D. E. (2016). Economic benefits of investing in women’s health: A systematic review. PloS One, 11(3). doi: 10.1371/journal.pone.0150120

The Centers for Disease Control and Prevention (CDC) (2020) initiated a national surveillance of pregnancy-related deaths in 1986 to understand the causes of maternal mortality in the United States (U.S.). Every year the CDC requests all 52 states and Washington D.C. send copies of death certificates for all women who died during pregnancy or during up to one year postpartum, associated live birth or fetal death certificates, and additional data when available. Medically trained epidemiologists determine the cause and time of death related to pregnancy and it is then coded in the system. The data is analyzed by the CDC and the information is released periodically through peer-reviewed literature, the CDC’s Morbidity and Mortality Weekly Reports, and the CDC website. This information is used to better understand the causes of pregnancy-related mortality and what actions need to be taken to prevent them. Advancements in technology and computerized data linkages by state has improved the identification of pregnancy-related deaths. Though errors in reported pregnancy status on death certificates have been identified, potentially leading to overestimation of maternal mortality numbers (CDC, 2020).

To better understand maternal complications, discover errors in the reporting system, and identify solutions, new legislation was established. In my first blog post I introduced you to H.R. 1318: Preventing Maternal Deaths Act that was signed into law in December 2018. This legislation “directs the Department of Health and Human Services (HHS) to establish a program under which HHS may make grants to states for the purpose of: (1) reviewing pregnancy-related and pregnancy-associated deaths (maternal deaths); (2) establishing and sustaining a maternal mortality review committee to review relevant information; (3) ensuring that the state department of health develops a plan for ongoing health care provider education in order to improve the quality of maternal care, disseminate findings, and implement recommendations; (4) disseminating a case abstraction form to aid information collection for HHS review and preserve its uniformity; and (5) providing for the public disclosure of information included in state reports” (GovTrack, 2018). It serves to help solve the shortage of reliable data about what leads to maternal mortality in the U.S. by improving how states track and investigate the deaths of expectant and new mothers up to one year postpartum. Reviewing data is essential to develop prevention efforts and quality improvement and quality control programs. The committees help to guarantee the data is organized and categorized correctly into the system, so the data is reported accurately across the nation.

Protection of Data

The mortality surveillance data are protected under the Assurance of Confidentiality. This is a formal confidentiality protection authorized under Section 308(d) of the Public Health Service Act. The protection allows CDC programs to assure individuals and institutions protect the confidentiality during data collection and maintenance of sensitive identifiable or potentially identifiable information. All data and documents in the Pregnancy Mortality Surveillance System are considered confidential materials and are safeguarded to the highest degree possible. This protection also extended to all pregnancy mortality surveillance data obtained from individual states and reporting areas (CDC, 2020).

References

Centers for Disease Control and Prevention. (2020). Pregnancy Mortality Surveillance System. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

GovTrack. (2018). H.R. 1318 (115th): Preventing Maternal Deaths Act of 2018. Retrieved from https://www.govtrack.us/congress/bills/115/hr1318

Just as the public sector serves an important role in the healthcare system, the private sector is just as needed. The private sector fills in gaps that the government is unable to provide due to the growing need of services. Non-profit organizations and non-governmental organizations (NGOs) help strengthen health systems and greatly contribute to ending preventable maternal deaths. There is an emerging understanding that building a strong health delivery system requires multi-sectoral collaboration between non-profits and NGOs and government agencies. This innovative approach values how organizations and their donors can engage key stakeholders, involve the community, monitor and use data to inform decisions, create programs, and partner with policymakers (Story et al., 2017). Some influential and important organizations that are working to decrease maternal morbidity and mortality will be discussed below.

March of Dimes:

https://www.marchofdimes.org/

March of Dimes leads the fight for the health of all moms and babies. They are working to create health equity and remove disparities, no matter the age, socio-economic background, or demographics of the mother. They advocate for policies to support mothers and their families and pioneer research to find solutions for the greatest health threats. They utilize their access to tools, technology, and knowledge to educate health professionals, support lifesaving research, and guide mothers through every stage of pregnancy.

March for Moms:

https://marchformoms.org/

March for Moms is an advocacy group who raises awareness to improve the health and well-being of mothers. They work year around with healthcare providers, policymakers, and families to advocate for improvements in healthcare practices and better access to healthcare. One time a year they gather at the U.S. Capitol in Washington D.C. to bring together diverse individuals across the country who support the health of mothers and their families.

https://www.youtube.com/watch?v=TdxG1_t66Xg

National Birth Equity Collaborative:

https://birthequity.org/

The National Birth Equity Collaborative (NBEC) works in partnership with the National Collaborative for Health Equity to create solutions to improve Black maternal and infant health through training, policy advocacy, research, and community-centered collaboration. Recognizing the need for providers and systems to know the experiences of patients, they developed a community-informed theoretical model to create and test a participatory patient-reported experience metric (PREM) of mistreatment and discrimination in childbirth. The PREM will be utilized in systems accountability, quality improvement, patient advocacy, and interprofessional education. NBEC works with organizations, communities, and stakeholders to develop and implement strategies to achieve health equity.

American College of Obstetricians and Gynecologists

The American College of Obstetricians and Gynecologists (ACOG) is the premier membership organization for obstetrician–gynecologists and providers of women’s health care. They facilitate programs and initiatives aimed at improving women’s health and advocate on the behalf of members and patients. ACOG is the lead partner in The Alliance for Innovation on Maternal Health (AIM) Program. AIM is the national alliance program working to reduce maternal mortality and severe maternal morbidity that was discussed in the last blog post.

References

American College of Obstetricians and Gynecologists. (2020). About. Retrieved from https://www.acog.org/about

March for Moms. (2019). Who we are. Retrieved from https://marchformoms.org/who-we-are/

March of Dimes. (2020). Who we are. Retrieved from https://www.marchofdimes.org/mission/who-we-are.aspx

National Birth Equity Collaborative. (2020). What we do. Retrieved from https://birthequity.org/what-we-do/mothers-voices-driving-birth-equity/

Story, W. T., LeBan, K., Altobelli, L. C., Gebrian, B., Hossain, J., Lewis, J., …Weiss, J. (2017). Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era. Global Health, 13(37), 1-13. doi: 10.1186/s12992-017-0259-z

The public sector is made up of organizations that are owned and operated by the government and provide services for the citizens in the U.S. Public sector programs can have a meaningful and significant influence on both individual and community health. Public sector programs and health policies are often put in place by the government to provide healthcare and services to individuals who are unable to afford it on their own (Longest, 2016).

Over the last 100 years the U.S. government has put in place policies and programs to promote maternal and infant health.

In 1921, Congress passed the Maternity and Infancy Act which allowed states to be funded with grants to develop health services for mothers and children (Longest, 2016). This was the first federally funded social welfare program and was intended to reduce the alarming rates of maternal and infant mortality. Using their newly won voting rights, women urged Congress to pass the 5-year program and renew it in 1926. However, with the Supreme Court question of its constitutionality and opposition from the American Medical Association, the act was terminated in 1929 (U.S. Capitol, n.d.).

In 1963, the Social Security Act of 1935 was amended with the Maternal and Child Health and Mental Retardation Planning Amendments with the goal of expanding and refining maternal and child health programs that would improve care for individuals with conditions associated with childbearing that may lead to mental retardation (Longest, 2016).

In 1965, Medicaid was enacted as a new title to the Social Security Act as a federal and state program to pay for medical assistance for individuals and families with low income and resources. Medicaid ensures medical assistance for certain basic services, allowing women to seek pregnancy related services, including prenatal care and 60 days postpartum pregnancy-related services, from physicians, nurse practitioners, and nurse-midwives (Longest, 2016).

In 1970, The Family Planning Services and Population Research Act, also known as the Title X Family Planning program, was passed with bipartisan approval. This was a significant advancement in women’s health in the public sector, because this act provided women resources to aid in family planning no matter their economic conditions. The Act provided funding to both public and nonprofit private organizations to develop comprehensive family planning programs and aimed to improve the administration of family planning services and population research programs. Most importantly, it made comprehensive family planning services, available to low income and uninsured families. It is the only federal grant program dedicated solely to providing comprehensive family planning and related preventive health services (Longest, 2016; Office of Population Affairs, 2019).

In 1972, the Child Nutrition Act was amended to establish the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (Longest, 2016). This program provides federal grants to states for supplemental food, health care referrals, and information on healthy eating for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Studies have proven WIC to be one of the nation’s most successful and cost-effective nutrition intervention programs. It has led to a greater likelihood of receiving prenatal care, longer pregnancies, higher maternal hemoglobin levels and lower risk of maternal obesity in subsequent pregnancies, fewer premature births, low incidence of low birth weight babies, fewer incidents of infant death, and a health care cost savings of $1.77 to $3.13 on every dollar spent on the program (U.S. Department of Agriculture, n.d.).

In 1977, the Rural Health Clinic Services Amendments was put in place to allow reimbursement of services provided by nurse practitioners and physician assistants to Medicaid beneficiaries seeking care in clinics in rural settings (Longest, 2016). This act is extremely important to maternal health since women who live in rural areas are at higher risk for maternal morbidity and mortality.

In 1986, Congress enacted the Emergency Medical Treatment and Active Labor (EMTALA) to ensure hospitals treat and stabilize patients regardless of their ability to pay, including women in labor (Longest, 2016).

In 2010, the Patient Protection and Affordable Care Act was passed into law. This major health reform law increased access to affordable health insurance for the millions of Americans without coverage, made health insurance more affordable for those who already had it, and expanded Medicaid eligibility (Longest, 2016), increasing access to healthcare for millions of women.

Current Public Sector Programs and Initiatives Focused on Maternal and Women’s Health

Alliance for Innovation on Maternal Health (AIM) Maternal Health and Safety Initiative: AIM assists with the implementation of maternal safety bundles to improve the quality and safety of maternity care to reduce maternal morbidity and mortality. These safety bundles are straightforward sets of evidence-based practices that have been shown to improve patient outcomes. The AIM safety bundles include:

• Obstetric Hemorrhage
• Severe Hypertension in Pregnancy
• Maternal Venous Thromboembolism Prevention
• Safe Reduction of Primary Cesarean Birth
• Supporting Intended Vaginal Births
• Reduction of Peripartum Racial/Ethnic Disparities
• Postpartum Care Basics for Maternal Safety from Birth to the Comprehensive Postpartum Visit
• Postpartum Care Basics for Maternal Safety Transition from Maternity to Well-Woman Care
• Obstetric Care for Women with Opioid Use Disorder

Women’s Preventive Service Initiative: 5-year effort that aims to improve women’s health across the lifespan and access to high-quality health care through preventive services, including screening for gestational diabetes, breastfeeding support, supplies, and counseling, screening for diabetes after pregnancy, and contraceptive methods and counseling.

Healthy Start: Eliminating Racial/Ethnic Disparities: This program has a goal to reduce the rate of infant mortality, improve perinatal health, and reduce racial and ethnic disparities in high-risk communities through community-based approaches to service delivery and increase access to comprehensive health and social services for women and their families.

The Maternal, Infant, and Early Childhood Home Visiting Program: This program provides home visitation by trained professionals to at-risk expectant parents or families with young children. They provide services to build strong, healthy families through teaching positive parenting skills and parent-child interactions, promoting early learning and communication, guidance on breastfeeding, safe sleep, injury prevention, and nutrition, screening of postpartum depression, substance abuse, and domestic violence, and providing adequate family resources.

(Health Resources and Services Administration, Maternal and Child Health, 2020).

Public sector programs and policies are vital to improving the well-being of mothers and their families. Ensuring the well-being of women determines the health of the following generations and can help prevent future public health challenges for families, communities, and the healthcare system as a whole.

References

Health Resources and Services Administration, Maternal and Child Health. (2020). Programs and initiatives. Retrieved from https://mchb.hrsa.gov/maternal-child-health-initiatives/mchb-programs

Longest, B. B., Jr. (2016). Health policymaking in the United States. Chicago, IL: Health Administration Press.

U.S. Capitol Visitor Center. (n.d.). Protecting mothers and infants. Retrieved from https://www.visitthecapitol.gov/exhibitions/april-2010-september-2011/protecting-mothers-and-infants

U.S. Department of Agriculture, Food and Nutrition Services. (n.d.). Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Retrieved from https://www.fns.usda.gov/wic

U.S. Department of Health and Human Services, Office of Population Affairs. (2019). Title X Family Planning. Retrieved from https://www.hhs.gov/opa/title-x-family-planning/index.html

In order to understand current legislation addressing maternal mortality, we first need to understand the process of bills becoming laws. Anyone can come up with an idea for a bill, such as constituents (the voting public), a member of Congress, the president or the Executive Branch (Longest, 2016). However, only a member of either the House of Representatives or the Senate can introduce a bill. Based on the subject matter of a bill it will be assigned to a committee to review, amend, and vote on a bill. If a bill passes through a committee, it then moves to the floor for consideration, possible amending, and a vote. Both the House of Representatives and the Senate must pass a bill before it is sent to the president to sign the bill into law (The United States House of Representatives, n.d.). The process of a bill becoming a law is cumbersome, but this prevents the passing of senseless or dangerous laws. Understanding the complex judicial system and the law-making process can be tedious; the graphic below illustrates the progression.

The Institutions and Actors

Individuals, organizations, and interest groups all contribute to the development of legislation. Interest groups are particularly influential due to their resources. Legislators are often motivated to amend or repeal existing laws or introduce new laws based upon the problems that directly affect their constituents or society as a whole. The members of Congress serve the important role of sponsoring or endorsing bills to move them into committee review. The legislative committees and subcommittees within both House of Representatives and Senate operate as essential institutions for moving proposed ideas through the legislative process. The president arguably has the most control with the ability to veto a bill (Longest, 2016).

Statutory and Regulatory Mechanisms

So now that we understand the process of bills, we can evaluate what has been done and what is currently in process in terms of maternal mortality. Legislation regarding maternal mortality and its contributing factors is relatively new.

2016: H.R.34- 21st Century Cures Act. Bringing Postpartum Depression Out of the Shadows Act

A part of this Act addressed the use of federal grant money to develop and/or maintain maternal mental health programs to educate, screen, and treat postpartum depression (March for Moms, 2019).

2018: H.R.315/S.783- Improving Access to Maternity Care Act

This Act addresses the maternity health care provider shortage and helps identify the areas of greatest need (March for Moms, 2019).

2018: H.R.1318/S.1112- Preventing Maternal Deaths Act

This was the Act discussed in my first blog post. This bipartisan bill establishes a program under the Department of Health and Human Services which provides grants for states to establish and support committees to review every maternal death and based on those findings develop recommendations on how to prevent future deaths (March for Moms, 2019).

Active Legislation

H.R.4995 The Maternal Health Quality Improvement Act

This bill establishes grants for rural obstetric networks to improve access to care, telehealth resources for maternal care providers, training for providers practicing in rural areas, training for providers in implicit and explicit bias, and integrated services for pregnant and postpartum women (March for Moms, 2019).

H.R.4996 The Helping Medicaid Offer Maternity Care Services (MOMS) Act

This bill gives states the option to extend Medicaid and Children’s Health Insurance Program (CHIP) coverage from 60 days to one year postpartum for women who have pregnancy-related Medicaid or CHIP coverage. It will increase the state’s federal matching rate of 5% for one year. It also addresses Medicaid policies for the reimbursement of doula services (March for Moms, 2019).

What can you do?

Contact your legislator and voice your support of these active bills that directly benefit mothers in the United States. People that schedule meetings and directly speak to their legislator generally have their voices heard and increase their influence. Mobilizing support, writing letters, sending delegations, and motivating allies to join efforts can get the attention of government officials (Kingdon, 2011). As discussed above, the legislative process has many steps. The more support a bill garners, the easier the progression of it will be.

References

Kingdon, J.W. (2010). Agendas, Alternatives, and Public Policies, Updated Second Edition. London: Longman Publishing Group

Longest, B. B., Jr. (2016). Health policymaking in the United States. Chicago, IL: Health Administration Press.

March for Moms. (2019). Federal legislation. Retrieved from https://marchformoms.org/advocacy/federal-legislation/

The United States House of Representatives. (n.d). The legislative process. Retrieved from https://www.house.gov/the-house-explained/the-legislative-process

Health policy involves the authoritative decisions, plans, and activities taken by the government that directly influences the health of individuals. These policies are established by the government at the local, state, or federal level. While health policy has positively impacted the health in the United States, there are also significant challenges that slow efforts to continue improvement. It is important to note that policies are made by humans, who are often driven by political beliefs and a mix of altruism and egoism (Longest, 2016).

Ethics help create and amend policies by influencing how individuals define problems and develop solutions. Further, they influence the political circumstances that may lead to new or modified policies. The four philosophical principles that should guide these ethical considerations include: respect for persons, justice, beneficence, and nonmaleficence (Longest, 2016).

Maternal Mortality and Respect for Persons

The ethical principle of respect for persons is recognizing individuals have the right to make decisions and choices based upon what they believe and value (Longest, 2016). An important aspect of health care is shared decision making, in which patients are presented the best available evidence to consider their options and make informed decisions, alongside their provider, about their plan of care. In order to ensure that patients can appropriately participate in their care decisions, the health system must ensure that the patient’s self-identified race, ethnicity, and primary language is documented. English language proficiency should be evaluated to assess for the need of an interpreter. Discharge materials and education should meet patients’ health literacy, language, and cultural needs. Staff should be educated regarding maternal racial and ethnic disparities and their root causes. Implementing each of these interventions has been shown to reduce disparities and promote active patient involvement in care (American College of Obstetricians and Gynecologists (ACOG), 2016).

Maternal Mortality and Justice

The principle of justice ensures that there is an element of fairness in the policymaking process, as well as within the policies themselves. Both benefits and burdens should be fairly distributed (Longest, 2016). An important component of preventing maternal mortality is adopting a culture of safety, which involves creating an environment that has the foundation of equity and respectful care. Healthcare systems and providers have a responsibility to promote and participate in this inclusive, just environment (Anderson & Foster, 2019). A mechanism should be established that allows patients, families, and staff to report inequitable care and occurrences of miscommunication or disrespect. When an incident of inequity or disrespect is reported, there must also be a system in place that ensures a timely and tailored response (ACOG, 2016).

Maternal Mortality and Beneficence

The main idea of the principle of beneficence is to do good. Practicing beneficence also includes the concept of balancing benefits and burdens. Provider should take into consideration each patient’s individual needs; what may benefit one patient, may not benefit another (Longest, 2016). ACOG (2016) recommends a disparities dashboard to be developed that is able to monitor processes and outcomes with respect to race and ethnicity. This data should be regularly disseminated to staff and leadership. Quality improvement projects should be implemented that targets disparities in healthcare access, treatment, and outcomes. When conducting reviews of maternal mortality and morbidity, the role of race, ethnicity, language, poverty, literacy, and other social determinants of health, including racism, at the interpersonal and system levels.

Maternal Mortality and Nonmaleficence

The principle of nonmaleficence is an obligation not to harm or cause injury (Longest, 2016). As discussed in my last blog post, African American mothers have a disproportionately high maternal mortality rate. Cesarean delivery, versus a vaginal birth, carries with it a higher morbidity and mortality rate and African American women have higher cesarean rates compared with Caucasian women (Anderson & Foster, 2019). This raises the issue of whether race and ethnicity contribute to whether providers choose to perform a cesarean. It may also suggest that the focus of African American pregnant women being more often considered high risk could lead providers toward performing a cesarean delivery. A high-risk woman may lose confidence in her ability to participate in shared decision making about the delivery, and providers may communicate this message indirectly or overtly (Anderson & Foster, 2019).

Practicing these ethical principles and ensuring they are considered when creating and amending policies helps to build a culture of health equity, leading to a reduction in racial and ethnic disparities (Anderson & Foster, 2019).

References

American College of Obstetricians and Gynecologists. (2016). Reduction of peripartum racial/ethnic disparities (+AIM). Retrieved from https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Reduction-of-Peripartum-Disparities-Bundle.pdf

Anderson, B. A., & Foster, J. (2019). Equity in clinical care. In B. A. Anderson & L. R. Roberts (Eds.), Maternal health crisis in America: Nursing implications for advocacy and practice (pp. 101-128). New York, NY: Spring Publishing Company.

Longest, B. B., Jr. (2016). Health policymaking in the United States. Chicago, IL: Health Administration Press.

No mother should die bringing life into the world.

The Background

The United States alarmingly has the highest maternal death rate among developed nations in the world with nearly 700 women dying every year due to pregnancy related complications (Anderson & Roberts, 2019; Centers for Disease Control and Prevention (CDC), 2019). Three out of five of these deaths are preventable (CDC, 2019). The CDC (2019) defines pregnancy-related death as the death of a women while pregnant or for up to one year following the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, excluding accidental or incidental causes. The outcome, duration, or site of the pregnancy is not significant.

With the advancement in medicine, one would think that maternal care was improving, however that is not the case. In 1990, 17 maternal deaths per every 100,000 pregnant women in the U.S. was recorded. By 2015, this number had risen to more than 26 deaths per 100,000 pregnant women. As this number continues to rise, American women are 50% more likely to die related to childbirth than their own mothers (Shah, 2018).

Pregnancy-related death can occur during pregnancy, delivery, or postpartum

• 31% occur during pregnancy
• 33% occur during delivery or up to one week after
• 36% occur between 1 week to 1 year postpartum (CDC, 2019)

So, what do these statistics mean? Perceptions of the reality of maternal death is likely misunderstood. It is not just occurring during or immediately following delivery, when many believe a woman is at highest risk. Over one-third of these deaths are happening after a woman is sent home with her baby. They are happening in our communities.

Who is it happening to?

The United States has failed to ensure a safety net that includes all mothers.

Barbara A. Anderson & Lisa R. Roberts

The maternal health crisis in the U.S. is largely influenced by economic, geographical, cultural, and racial factors, also referred to as social determinants of health (Anderson & Roberts, 2019).  The stress experienced among women living in poverty impacts pregnancy, as well as long-term health (Lu, 2018). They may experience inadequate housing and transportation, lack of access to nutritious foods leading to obesity and gestational diabetes, lack of education, shortened maternity leave from work, inability to obtain childcare, lack of insurance, or decreased access to healthcare. Geography significantly affects maternal health. Often women living in rural communities have limited or no prenatal care, greatly increasing the risk for severe maternal morbidities. As many as 40% of counties within the U.S. lack even one qualified maternity healthcare provider. Decreased access to a tertiary maternity hospital among these communities further increases their risk of pregnancy-related death. The U.S. is a multicultural national that presents a variety of scenarios that could impact the care a woman receives, including language, immigration status, cultural norms, sexual orientation, gender identity, and age (Anderson & Roberts, 2019). The racial disparities in this country are perhaps the most alarming. Regardless of education, income, or other socioeconomic factors, African American women are three to four times more likely to die of pregnancy related causes than non-Hispanic white women (Anderson & Roberts, 2019). In fact, the pregnancy related mortality rate for African American women with at least a college degree was 5 times as high as white women with a similar education (CDC, 2019). The disparity is also apparent among other women of color. Below you will see the U.S. maternity mortality rate reported by the CDC in 2018.

• 47.2 deaths per 100,000 live births for black non-Hispanic women.
• 38.8 deaths per 100,000 live births for American Indian/Alaskan Native non-Hispanic women.
• 18.1 deaths per 100,000 live births for white non-Hispanic women.
• 12.2 deaths per 100,000 live births for Hispanic women.
• 11.6 deaths per 100,000 live births for Asian/Pacific Islander non-Hispanic women (Anderson & Roberts, 2019)

What are the causes?

The number of pregnant women experiencing chronic health conditions, such as hypertension, diabetes, and chronic heart disease, is increasing in the U.S. These conditions put a pregnant woman at higher risk for complications. Although hemorrhage during and after delivery, hypertensive disorders of pregnancy, and anesthesia related complications causing maternal death has decreased, the contribution of cardiovascular, cerebrovascular accidents, and other medical conditions have increased. Collectively, cardiovascular conditions account for greater than a third of pregnancy-related deaths (CDC, 2019).

What are we doing about it?

H.R. 1318: Preventing Maternal Deaths Act of 2018

To support States in their work to save and sustain the health of mothers during pregnancy, childbirth, and in the postpartum period, to eliminate disparities in maternal health outcomes for pregnancy-related and pregnancy-associated deaths, to identify solutions to improve health care quality and health outcomes for mothers, and for other purposes.

Despite these shocking trends, the U.S. has only recently joined the rest of the developed world putting in place infrastructure to systematically assess maternal deaths. On December 21, 2018 the president signed the bipartisan bill. The bill directs the Department of Health and Human Services (HHS) to establish a program that allows grants to be directed toward states to review maternal deaths, establish a committee to review the gathered information, ensure the state department of health develops a plan for health care provider education to improve quality of maternal care, disseminate findings, and implement recommendations, and provide the public with the information included in state reports. States will develop procedures for mandatory reporting of maternal deaths by health care facilities and providers and voluntary reporting by family members. States will then investigate each case and prepare a case summary for review by the committee (GovTrack, 2018).

The story behind the bill.

I highly recommend you watch this video below. The man speaking is Charles Johnson IV who lost his wife Kira Johnson hours after she delivered their son via a scheduled Cesarean section. Refusing to allow this to happen to another family, he went to Capitol Hill to share his wife’s story with members of Congress, working alongside Representative Jaime Herrera Beutler, who experienced her own personal difficulties with pregnancy.

References

4KIRA4MOMS. (2018, June 4). Charles Johnson shares the tragic story of his wife Kira’s death hours after giving birth. [Video file]. Retrieved from https://www.youtube.com/watch?time_continue=1&v=05uBCBfrY4g&feature=emb_logo

Anderson, B. A., & Roberts, L. R. (2019). The maternal health crisis in America: Nursing implications for advocacy and practice. New York, NY: Springer Publishing Company.

Centers for Disease Control and Prevention. (2019). Maternal Mortality. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html

GovTrack. (2018). H.R. 1318 (115th): Preventing Maternal Deaths Act of 2018. Retrieved from https://www.govtrack.us/congress/bills/115/hr1318

Lu, M. (2018). Reducing maternal mortality in the United States. JAMA, 320(12), 1237-1238. doi:10.1001/jama.2018.11652

Shah, N. (2018). A soaring maternal mortality rate: What does it mean for you? Harvard Health Publishing. Retrieved from https://www.health.harvard.edu/blog/a-soaring-maternal-mortality-rate-what-does-it-mean-for-you-2018101614914