The United States healthcare system is one of paradoxes. The biggest paradox is that while the US spends more on its healthcare than any other nation and boasts access to the latest and most advanced medical technologies in the world, it also has one of the highest mortality rates in the world amongst developed nations. Given the knowledge, skills, and technologies that exist in the US, the maternal death rate should be significantly lower than it is.
And yet women and babies are at considerably more risk of dying during childbirth than women in similarly advanced nations. The figures on the maternal death rate in the USA are sad enough in isolation. However, these figures don’t count the women and children who suffer permanent injury or disability because of complications during childbirth. Pregnancy complications occur at the same rate across different nations, the only difference is how medical staff respond to those complications. The question of why women in the US are so much more likely to suffer serious consequences because of these complications is one that desperately needs addressing.
The Maternal Mortality Rate in the USA
There has been a global downward trend in maternal and infant mortality rates – the number of instances where the mother died within a year of falling pregnant for every 100,000 births. However, the USA has bucked this trend and has been experiencing a climbing rate for more than two decades. In fact, the mortality rate has been rising for 25 years straight. This problem was identified a long time ago, but there seems to have been relatively little done to identify the root causes and address the problem. The USA has been an outlier for some time, and yet we still haven’t seen the kind of large-scale public health campaigns that we would expect for such an easily identifiable issue.
In the period from 2000-2014, there was a 26.6% increase in the rate of maternal deaths. During this same period, every other OECD nation saw its maternal death rates continue to fall. The Center for Disease Control conducted a federal study in 2016 that concluded that there was a need to “redouble efforts to prevent maternal deaths”. This study came after the US had seen its rate rising for more than 20 years without fail.
Why Is the Rate Higher?
There seems to be little doubt that this trend is at least in part due to the wider gender-imbalances in American society. The provision and distribution of healthcare in the United States are very uneven; Americans access to healthcare directly correlates with their level of wealth. The poorest and most vulnerable Americans are also the ones who have the most difficulty accessing the healthcare services that they need.
However, economic factors are not the only divider that separates the haves from the have-nots when it comes to healthcare. For example, people of color are much less likely to be given strong painkillers, the same strong painkillers that are being dished out to Caucasians by the bucketful. Similarly, women are less likely to be prescribed pain relief when they need it and are generally less likely to have their symptoms taken seriously. Interestingly, research has found that the gender of the doctor has no bearing on this – both male and female doctors are less likely to take women’s complaints seriously.
One of the results of this is that women are more likely to die from heart attacks because doctors are less likely to consider it as a diagnosis. Again, this is observed whether the treating physician is male or female – in both cases, they are less likely to consider a heart attack for a woman, even when she is complaining of the same symptoms that would lead them to that conclusion in a male patient.
Different groups of women are also treated differently by the healthcare system. For example, Hispanic women are around 20% more likely to suffer from a serious illness during the course of their pregnancy. This is likely reflective of broader trends across the United States; patients from ethnic minority backgrounds have worse general access to healthcare and so are not as able to benefit from the preventative measures that white Americans benefit from.
Another factor that puts some women at greater risk than other women is physical access to healthcare facilities. In the rural parts of the United States, there are some healthcare facilities that are providing services to a small number of people but are the only facility for many miles. This means that if they aren’t equipped to deal with a complication during childbirth, women face a significant delay before they can be transferred elsewhere.
There are a number of issues related to rural healthcare provisions that make it more challenging than providing adequate care in an urban setting. The United States is a large country with numerous states the size of countries in their own right. For some rural-dwelling Americans, there is only a single healthcare facility that they could access during an emergency. For most women who are in labor, their only option is to go to the facility that is nearest to them.
Rural MOMS Act
A bill introduced last month, the Rural MOMS Act, aims to improve the provision of maternity care for women in the rural United States. The act’s name stands for the Rural Maternal and Obstetric Modernization of Services, and its aim is to amend the US Public Health Service Act in order to add incentives that will encourage healthcare providers to provide equipment and facilities to rural areas.
The purpose of this increased investment would be to provide better access to obstetrics facilities and to aid in the gathering of data that will be useful in formulating and refining maternal healthcare policies going forward. The bill will target the full range of service providers that play a role in providing maternity care to women, including doctors, nurses, and midwives. Among the incentives on offer will be grants to fund research and build networks to enable collaboration amongst urban and rural healthcare providers.
Another key provision of the bill for improving rural-dwelling pregnant women’s access to doctors and consultations involves expanding the telemedicine options available to them. A growing number of hospitals and other healthcare facilities across the United States have been embracing the concept of remote consultations conducted online. Now that HD cameras are standard on smartphones and laptops, doctors can diagnose many of the most common ailments remotely with relative ease.
The bill has bipartisan support, so it has a good chance of passing both the house and the senate, where the bill has been introduced.
One of the challenges facing the American midwifery sector is an ongoing staff shortage. Across the country, healthcare facilities have been struggling to attract enough applicants to fill all the available positions. This is a trend that we are seeing repeated across roles and departments within healthcare facilities – it is a universal problem.
The US is spending enormous amounts of money on its healthcare system in general, and its midwifery services specifically. However, it is becoming clear that just throwing money at selected ob-gyn departments is having little effect, the challenges facing rural areas will require more than just better funding to overcome.
These staffing shortages impact rural areas more than urban areas. Within a city, it is possible that a hospital that is short on staff can call in some reinforcements from nearby. Alternatively, they can ask staff to work overtime. For rural facilities, both of these options are more difficult to arrange. With the nearest facilities being many miles away, it is very difficult to get locum doctors to come in and provide support. Similarly, with small staff rosters, it isn’t practical to continually ask staff to work overtime.
Across the United States, the rate of cesarean sections is also much higher than it is in comparable nations. The World Health Organization states that the ideal rate of cesarean sections should be around 10%. Cesareans should only be used when necessary, there are advantages to both mother and child of a vaginal delivery.
For example, when a mother delivers her child vaginally, the child passes through the vagina, picking up vaginal fluid on the way out. This vaginal fluid is awash with antibacterial compounds and doctors now believe that this initial coating of vaginal fluid gives the baby’s immune system an initial boost. Babies delivered via cesarean section aren’t given this initial boost and some doctors are now advocating that babies delivered via c-section are smeared with a small amount of vaginal fluid. Research suggests that this provides a meaningful boost to their immune system.
However, for a variety of cultural and societal reasons, expectant mothers are starting to think of the c-section as an option they can choose if they don’t want to deliver vaginally. The US’s private healthcare system and consumer attitudes means that many doctors see their patients as being like customers and believe that if women are willing to pay for a c-section, they should be given one.
Encouraging more women to give birth vaginally would help to reduce the rates of complications and maternal mortality. Many women are under the impression that vaginal delivery is going to be significantly more traumatic than a cesarean. However, just ask any midwife – cesarean sections are not gentle or painless processes. Equally, while many women are apprehensive about the impact of the physical trauma of childbirth, it is much better for doctors and midwives to work compassionately with expectant mothers to alleviate their concerns than it is to perform unnecessary c-sections.
How Can We Encourage More Midwives?
Understanding the roots of America’s Midwifery sector helps to demonstrate its importance. America’s midwifery sector has its roots in the late 19th century. It was around this time that knowledge of germ theory and anesthesia both revolutionized the way that we approach maternity care. These discoveries enabled us to provide a much safer and cleaner environment for women to give birth in and significantly reduce the danger to them and their newborns.
During the 20th century, mostly male obstetricians usurped the role of mostly female midwives and became the primary maternal caregivers within hospitals. By the 1960’s, midwifery had all but disappeared from the United States and women would routinely give birth surrounded by all-male staff. It was also around this time that doctors began encouraging American women to embrace ‘twilight sleep’.
Twilight sleep is representative of what happens when midwives, and women more generally, are removed from the equation and it is left to the mostly male medical staff to decide what’s best. Women who were put into a twilight sleep were given a combination of morphine and scopolamine. The effect of this combination was strong pain relief and anesthesia. Women in this state would remember nothing of the birthing process. Women who underwent the procedure report going into labor, meeting their doctor, and then waking up with a newborn in their arms.
Twilight sleep removed the mother from the birthing process entirely. It feeds into the idea that the labor and birthing processes are negative and to be avoided. However, it soon became clear that women who underwent this procedure would not experience the initial flood of oxytocin that is vital for bonding between mother and child. While these mothers would go on to develop the usual affection for their children, there was a remarkable qualitative difference in their bonding experience.
Since then, midwives have played a central role in ensuring that the process of childbirth is as painless as possible so that women can focus on embracing the significance of bringing their own child into the world. It is a uniquely rewarding career, especially for women. There are online certified nurse midwife programs for those who want to transition from nursing to midwifery. Similarly, those who don’t have any prior training can begin their studies through online courses. If you would like to get involved in improving maternal care in the United States, training to be a midwife will put you on the front lines.
The sustained high maternal death rate in the USA is unacceptable and action needs to be taken. This new bill will go some way to addressing the issue, but it is clear that more needs to be done.