Maternal deaths and the elephant in the room

Below is a judicious article from a medical journal that addresses a problem that should not be happening.  Why is giving birth in the USA so often fatal?  The article runs through the range of possible causes and notes that it is mainly a black problem, but not entirely so. And the various potential causes do make sense.  So, as with many social phenomena, it is reasonable to conclude that a range of factors contribute to the final outcome.  There are many things you can die from.

But there is an elephant in the room that is only obliquely mentioned. One that could very well contribute to the deaths: Obamacare. Many people cannot afford the much higher premiums now demanded and there are even more people who are only nominally insured. They have insurance but their deductibles can easily reach $10,000 or more -- which in effect means that they are not insured at all. A lot of routine medical costs are way below $10,000 so no help with such costs is available. And even costs below $10,000 can be hard to meet for a big family or for people with many calls on their funds -- such as working single mothers who have to pay for childcare. And some people are just not good at saving so the effective absence of insurance to help with medical costs simply means that medical care is simply not sought by them on many occasions.

So there can be little doubt that many precautionary visits to the doctor are not made and many possibly revealing scans are not carried out. So problems are missed until it is too late.  Early diagnosis is universally advantageous but is not practically available.  So Obamacare should be called DeniedCare.  Someone should tell the "rebel" GOP senators who are blocking reform that they are killing mothers

In 2005, 23 US mothers per 100 000 live births died from complications related to pregnancy or childbirth. In 2015, that number rose to 25. In the United Kingdom, the number was less than 9. In Canada, it was less than 7.

Very few wealthy countries saw increases over those years. Many poorer countries, including Iran and Romania, saw declines. But here in the United States, things got worse.

These numbers have been confirmed by independent research. Last year, a study published in Obstetrics and Gynecology found that the maternal mortality rate in the United States had increased by more than 25% from 2000 to 2014. This trend differed by state, however. Although California had shown some declines, Texas had seen significant increases.

Texas in particular has been the focus of much of the news on maternal mortality in the last few years. From 2011 to 2014, the rate doubled. Although we lack good data to tell us why, many have postulated that changes to family planning in the state coincided with this increase. In 2013, for example about half of the state’s clinics that provided abortion in addition to other reproductive health services were closed because of regulations passed against them. In 2011, the family-planning budget was slashed in an attempt to defund Planned Parenthood. Many clinics closed and more were forced to reduce their services.

Family planning matters. About 50% of pregnancies in the United States are unplanned and might lack preventive care that properly planned-for pregnancies might.

There’s more to this story than changes in regulations and family planning. Some of the increase is likely due to the growing prevalence of other chronic conditions. Obesity, diabetes, and heart disease likely contribute to maternal mortality, and trends for many conditions have been increasing over the last decade. Women are having children later in life than they used to, and some have more complex conditions. More women have caesarian deliveries, which can lead to complications. The opioid epidemic may contribute to maternal mortality, as well.

Disparities exist in maternal mortality as they do in other areas of health care. The increases we’ve seen are most noticeable in non-Hispanic black women. The number of deaths per 100 000 live births among black women is more than 3 times that among white women. In fact, for any state, the higher the percentage of black women in the delivery population, the higher its rates of maternal mortality. But racial disparities can only account for so much of the problem. Even if you look only at white women in the United States, the rates of mothers who die is greater than those in other developed countries.

The fragmented nature of the US health care system doesn’t help either. Too many people in the United States go without necessary care, because they lack access to care or avoid it because of cost. This is just as true of pregnant women as it is of everyone else. As many politicians argue that maternity care shouldn’t be considered essential benefits, some worry that coverage might get worse with reform.

It is possible that some of the increase in maternal mortality is due to better record keeping. States have been working to improve how they keep track of maternal deaths, as well as other causes of death, and better reporting would be reflected as increases in prevalence. It’s hard to imagine, however, that this increase in better records has been solely in the United States, and could account for all of the increases. There’s no reason to believe that all other countries would be keeping themselves in the dark. Moreover, the more universal and socialized health systems are less likely to have women, and their deaths, fall through the cracks and be missed.

Pregnancy and childbirth are risky. We don’t like to talk about it, but maternal mortality is the sixth most common cause of death among US women age 25 years to 34 years old. Proper maternal care helps to prevent morbidity and mortality, but that care is difficult when clinics close and insurance lapses. Medicaid can help to close the gap and often does with pregnant women, but even then, both physician services and mother’s finances are strained.

As with many things in health care, a rising tide would lift all boats. Efforts to improve the health of women in general would improve our rates of maternal mortality. Reducing levels of obesity, diabetes, and heart disease would achieve results. So would getting a handle on the opioid epidemic. But we’ve spent the last few years—if not more—focused on efforts to reduce infant mortality. Mothers may need a similar commitment.


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