JoAnne Fischer is executive director, and Bette Begleiter deputy executive director, of the Maternity Care Coalition, a Philadelphia nonprofit that works to improve maternal and child health and wellbeing through the collaborative efforts of individuals, families, providers and communities.
By JoAnne Fischer and Bette Begleiter
Each year, Americans spend an average of more than $7,500 per person on healthcare and over $10,000 per birth. This is more than in any other country in the world. Does this expense lead to improved health outcomes? In terms of maternal mortality it is totally counterintuitive. The United States has some of the best economic development, nutrition, technology, and medical institutions in the world. We'd expect that mothers would no longer die in childbirth. We have made steady improvements over the past 80 years. Nonetheless, we are losing ground. And if we don't make important changes in our health and our health-care system, the trajectory is grim.
The U.S. ranks a dismal 50th in maternal mortality – dead last in the developed world and behind numerous other countries, from Turkey and Saudi Arabia. About 1,000 women across the country die each year from pregnancy-related complications, a rate of 14.5 deaths per 100,000 live births in 2007, the most recent data available from the Centers for Disease Control and Prevention. Another 34,000 women experience "near misses" that often result in chronic illness such as diabetes and hypertension. And the trend in recent decades often has been toward more deaths, not fewer. In Pennsylvania, for example, the maternal mortality rate rose from 9.7 per 100,000 live births in 2005 to 14.5 in 2010. These women do not have to die. Many of the complications are preventable with better access not only to prenatal care but to healthcare in general for women of child bearing age.
The harsh fact is that young women today are arriving to pregnancy in poorer health than their mothers. The obesity epidemic has impacted teens and young women, with over 50 percent of women giving birth in Philadelphia overweight or obese according to the Philadelphia Department of Public Health. Obese women are 50 percent more likely to have a surgical (Cesarean) birth and to experience more complications such as preeclampsia (1.5-3 times the risk) and gestational hypertension (2-3 times the risk). These complications dramatically increase their chance of dying.
Women are also experiencing higher rates of diabetes, asthma, hypertension, depression and abuse, all of which contribute to more complicated pregnancies and births, and poorer outcomes for mother and baby. Furthermore, the racial and ethnic disparities we've seen in other health outcomes are exacerbated by these chronic health problems. As a result, African American women are three times as likely as white women to die as a result of pregnancy and childbirth.
Changes in the health-care environment also may have unintentionally fuelled increases in maternal deaths. The rise in elective C-sections, especially for so-called "late preemies" has increasingly come under attack. The closure of OB units in the Philadelphia region may have made prenatal care less accessible and hospitals more crowded.
What has not gotten adequate attention is the need to address the chronic health conditions that have led to the increasingly poor health of young women. In 2010, the city health department took the lead in introducing a comprehensive approach to improving health outcomes in Philadelphia by hosting a conference, "Strong Routes, Healthy Fruit: Transforming Generations through the Life Course Perspective." The Life Course perspective, outlined in a conference presentation that described how it was used in New York, is a conceptual framework that helps to explain health and disease (especially disparities) and points to the need to address social, economic and environmental factors that often have a bigger impact on health than do doctors or hospitals. Critical to Life Course theory is the commitment to work as a community to identify and increase "protective factors" that lead to healthier outcomes.
Care before pregnancy (a.k.a. preconception) and in between pregnancies (interconception) is vital -- not just for folic acid but to address nutrition, exercise, and to teach healthy ways of coping with life's stresses. The Affordable Care Act's provisions for preventive health care, maternity care and home health visits need to be expanded. Women with chronic conditions should be fast-tracked into home-visit and other pregnancy support programs such as Early Head Start, Nurse-Family Partnership, Healthy Families America, and our own organization's MOMobile. These programs work with at-risk women and their children, from pregnancy through their baby's early years, helping them access health care and critical resources, while providing vital information and support for their family's health and well-being. Home visiting programs need to also strengthen outcomes for women as well as their babies.
Obesity reduction efforts need to pay special attention to postpartum weight reduction and breastfeeding as critical opportunities to influence future health … and future births. The Maternity Care Coalition, where we work, is partnering with Charmaine Smith-Wright at the University of Pennsylvania School of Medicine, for example, to develop effective interventions for reducing weight retention after birth (a key contributor to lifelong obesity). In North Philadelphia, MCC is piloting a community-based doula (labor and birth support) program designed to increase breastfeeding rates – another way to reduce obesity and enhance health!
The United States can do better than dead last on maternal mortality in the developed world. We can show the way. Philadelphia has world-class health-care institutions, and public and nonprofit providers with expertise in maternal health – now let's get them all the resources they need to ensure there are healthy mothers for the 20,000+ babies we welcome to this city every year.