Archive for the ‘Pregnancy & Childbirth’ Category

August 23, 2011

Oregon Hospitals Act on Recommendations To Prevent Elective Births Before 39 Weeks

In recent years, attention has been focused on the issue of early elective inductions and cesareans – births that are scheduled, for no medical reason, before 39 weeks.  Because even moderately early births can result in worse health outcomes for newborns, organizations including the American College of Obstetricians and Gynecologists and the March of Dimes have recommended against them. However, such procedures continue to be performed far too often.

Now, seventeen hospitals in Portland, OR have decided to put a stop to elective inductions and cesareans prior to 39 weeks unless there is a medical need to do so.

This is an important step, and hospital policies can clearly reduce the numbers of early births.  But education for both prospective parents and providers is also important. Too often the media address the issue with the assumption that women are asking for these procedures. In “Rigging the Election: When it comes to elective induction, are women asking for it?, Amy Romano, midwife and member of the editorial team for the 2011 edition of Our Bodies, Ourselves examines this assumption and concludes that:

… this woman-blaming paradigm is simplistic and flawed. New research shows that, not only have maternity care providers failed to convey the risks of early delivery to women, they may be offering or recommending elective deliveries despite the risks, and telling women they have a medical reason for induction but documenting the inductions as “elective”.

It didn’t take long to find an example of just this treatment of the Oregon news: MSNBC’s coverage takes exactly that approach, framing the issue from the outset as one of women asking for something they shouldn’t have and being denied by the providers who know what’s best for them. It begins: “Beginning next month, many pregnant women in Oregon will no longer be able to have the early delivery they’ve been dreaming of.”

“Dreaming of?” No doubt, many women are uncomfortable toward the end of a pregnancy. I’d be interested, though, in how many women are presented with the option of early induction/cesarean but aren’t clearly told the possible risks of doing so. Perhaps it should be no surprise, but this point really struck me: that in a process controlled by medical providers – women don’t have access to their own induction drugs or operating rooms, after all – women are the ones being blamed for demanding medically unnecessary procedures that could potentially harm their babies.

I’d be interested in your own stories in the comments – did you have an elective induction or cesarean before 39 weeks? How was it presented to you?

Related post: we covered it in January when the Leapfrog Group released data on the practice.

Also, from the March of Dimes: Why at least 39 weeks is best for your baby (a guide for women), and blog posts from the Oregon chapter on the recent change.

August 1, 2011

Yes! HHS Approves IOM Recommendations for Preventive Care for Women

Today, the U.S. Department of Health and Human Services announced that it is adopting the Institute of Medicine’s recommendations for preventive care services for women. This will ensure that women have access to the following services under health insurance plans without having to pay a co-payment, co-insurance or deductible:

  • well-woman visits
  • screening for gestational diabetes
  • HPV testing
  • STI counseling
  • HIV screening and counseling
  • contraception methods and counseling
  • breastfeeding support, supplies, and counseling
  • screening and counseling for domestic and interpersonal violence

Coverage for these services is expected to begin Aug. 1, 2012.

There is one caveat for some women regarding access to contraception without a co-pay — a provision that “Group health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services.”

An announcement at the site indicates that public comment is welcome on this provision. Although I haven’t yet been able to locate it on, instructions for comment and more detail about the exemption is provided in this document.

July 7, 2011

Quick Hits: UN Report on Justice for Women, a New Maternity Blog, and More

From dorms at USF to justice for women around the world, here are a few items of interest:

The United Nations’s UN Women group released a report, “Progress of the World’s Women: In Pursuit of Justice,” which looks at the legal rights of women around the world, barriers to accessing and navigating the justice system, and the impact of war/conflict on women, among other issues. It also includes ten recommendations for making justice systems work for women.

The University of South Florida has begun offering students gender-neutral housing options in response to a transgender student who reported hostility and harassment in campus housing. The school is going to offer several housing options and allow students to indicate male, female, or transitioning on their campus housing applications.

NPR’s All Things Considered ran a piece yesterday on mother-to-child transmission of HIV in Mozambique; there is a related piece on breastfeeding and HIV in developing nations.

Childbirth Connection has launched the Transforming Maternity Care blog with Amy Romano, formerly of Science & Sensibility and part of the editorial team for the forthcoming edition of “Our Bodies, Ourselves.” It looks like the blog will focus on quality improvement, patient advocacy, and shared decision-making in maternity care.

June 2, 2011

DES: A Story of Doctors Not Knowing Best

by Susan  Bell

Forty years ago, the New England Journal of Medicine published an article about the synthetic estrogen DES that is now recognized as a watershed in the annals of medicine.

The authors of the study, physicians at Massachusetts General Hospital, reported an association between DES – a prescription “wonder drug” intended to prevent miscarriages – and vaginal cancer in women who were just 15 to 22 years old. From the 1940s to the 1970s, between 5 and 10 million pregnant women and their sons and daughters were exposed to DES during pregnancy. When the daughters became teenagers and some of them developed reproductive tract cancer, the MGH physicians identified DES as the first transplacental carcinogen, and the daughters took on the new identity of “DES daughters.”

When DES daughters had trouble becoming pregnant and giving birth to healthy babies, DES was connected with miscarriage and other problems during pregnancy. These characteristics – crossing the placenta, disrupting the developing fetus, and affecting the bodies of DES daughters in multiple ways that often do not appear for many years – are those that identify DES as the first endocrine disruptor.

Much has been written in the past few weeks about DES. There have been reports of current research about damaging effects of DES: of its possible effects on the children of DES daughters, of its significance for understanding how human reproductive organs develop, and of the dangers of too much haste and too little prudence in adopting medical technologies.

Physicians writing in the New England Journal of Medicine use the words “humble” and “trauma” and “unanswered questions” in looking back and looking ahead to the future of DES. All of this is wise and good. Yet there is more that must be said in this time of remembering.

The DES story is about more than a tragedy that occurred to a population in the mid-20th century and more than a humbling experience for medicine. It is also about a women’s health movement that questioned whether doctors always know best. These women were among the first to judge science based on their intimate, firsthand knowledge of their own bodies, and joined together in collective action for social change.

Thank goodness for one “DES mother” whose daughter developed vaginal cancer during the 1960s and for her doctor who worried too. This mother asked her daughter’s physician—who was also puzzled about the cause of her daughter’s very rare cancer and was searching for answers—whether it could have been caused by the DES she took during the pregnancy.

Her physician was Dr. Howard Ulfelder, who listened to her, took her question seriously and researched the possibilities. We should celebrate this mother for voicing her hunch and this physician for listening to her. Ulfelder became one of the authors of the NEJM article; the mother remains anonymous.

DES mothers and DES daughters began the grassroots organizations DES Action (in 1975) and the DES Cancer Network (in 1982). Among other things, we should be grateful to these organizations for their efforts in bringing about an interdisciplinary, international “workshop” about DES in 1992 – a watershed in DES research, legislation and funding. Lines of research and practice initiated at that 1992 workshop have transformed the doing of science by incorporating activists in the conceptualization and conduct of DES science.

Thirty years ago, I began a research project to understand DES daughters’ experiences. I interviewed DES daughters, read their letters to the editor of these grassroots organizations, and traced their participation in the DES workshop. The results, published in my book, trace story by story their individual and collective efforts that galvanized the watershed DES research, legislation and funding.

One DES daughter who had vaginal cancer in her early 20s was devastated when her surgeon told her she would need a complete hysterectomy. Years later, after she had returned to see him many times for examinations she told me, “I was one of the wonders of medical science,” a woman whose surgeon had saved her life and rebuilt her body. For her surgeon – one of the pioneers in surgery for DES cancer – her body was “the most wonderful thing in the world.”

By the time she told me her story, “it was nothing abnormal to have five or six guys standing around” watching and learning as her surgeon examined her during follow-ups. They learned both from him and from her. As she put it, during those exams, “I used to tease him a lot you know, ‘Oh yeah, I know what to do now.’” The repeated examinations and displays of her body had educated her as well as doctors. She too, became a bearer of knowledge about the clinical contours of DES.

In taking care of themselves these patients and their mothers created new pathways, transformed relations of power and knowledge, and contributed to making new spaces and bringing world wide attention to DES. So on this 40th anniversary of that publication, let us celebrate the courage and the unique contribution of women’s health activism to the DES story.

Susan E. Bell is Professor of Sociology and A. Myrick Freeman Professor of Social Sciences at Bowdoin College in Brunswick, Maine. She is the author of “DES Daughters: Embodied Knowledge and the Transformation of Women’s Health Politics” (Temple University Press, 2009).

May 27, 2011

Vermont Passes Law Providing for Insurance Coverage of Home Births and Midwives, Birth Certificate Changes for Transgender Individuals

Last week, Vermont Governor Peter Shumlin signed into law a bill requiring that any health insurance and health benefit plans that provide maternity benefits (including Medicaid and public health care assistance plans) must provide coverage for midwifery services in hospitals, other health care facilities, and at home.

As I read the legislation, it includes coverage for both certified professional midwives and certified nurse-midwives.

The Governor remarked, “Access to midwifery care and home birth should not be limited only to those who can afford those services out of pocket. This law will ensure that all expectant mothers get the coverage and care they want and deserve.”

The legislation establishes a maternal mortality review board made up of an obstetrician, maternal-fetal medicine specialist, neonatologist, CNM, CPM, and other relevant specialists, along with a member of the public. This board will review maternal deaths in Vermont for factors associated with the deaths, and will make recommendations for systemic changes and legislation to address those factors.

Although it seems to have received less media attention, the law also includes a provision to allow transgender individuals to acquire new birth certificates reflecting their gender rather than the one assigned at birth. This will require a doctor’s note submitted to a court “stating that the individual has undergone surgical, hormonal, or other treatment appropriate for that individual for the purpose of gender transition.”

This reportedly makes Vermont the only state with a law that explicitly specifies that surgery is not required in order to obtain a new birth certificate. The law also provides that the original birth certificates will not be available for public inspection in order to protect individual privacy.

May 9, 2011

What Medicines Are Pregnant Women Taking?

An increasing number of women are prescribed medications while they are pregnant, and unfortunately, far too often, too little is known about the safety of the medicines during pregnancy. A new article in the American Journal of Obstetrics and Gynecology looks at what medicines pregnant women are taking, and how that has changed over time, with a goal of showing the need for further research on the risks of medication use during pregnancy.

Researchers used data on women and their children from the Slone Epidemiology Center Birth Defects Study and the CDC’s National Birth Defects Prevention Study. For these studies, mothers of children with and without birth defects reported what prescription and over-the-counter medicines they remembered taking while pregnant. They excluded vitamins, blood, oxygen, and topical and IV medicines.

Among the findings:

  • In 2008, 93.9% of pregnant women took at least one medicine; 82.3% used at least one medicine during their first trimester.
  • The average number of medicines used at any time during pregnancy increased from 2.5 medicines in 1976-1978 to 4.2 in 2006-2008.
  • The percentage of women taking 4 or more medicines during pregnancy increased from 23.3% in the early years to 50.1% in the most recent years.
  • Antidepressant use increased the most, with less than 1% women taking any antidepressant during pregnancy through 1988-1990, climbing to 7.5% of women in the most recent years.
  • The top 20 mostly commonly used medicines (in the first trimester) were identified, an include examples of antibiotics, the flu vaccine, allergy and asthma drugs, thyroid drugs, antidepressants, hormones, and a diabetes drug.

The researchers note that of course women’s recall of medication use may be imperfect. However, they conclude that the most commonly used medicines should have their risks and safety in pregnancy evaluated, and ongoing monitoring should be done to better inform women and their providers of potential risks of the medicines they use.

May 4, 2011

Civil Rights Win in Case of Woman Shackled During Labor

In 2008, we wrote about the treatment of Juana Viilegas, who was shackled to a hospital bed during labor and after delivery, and denied access to her newborn or a breast pump in the days immediately after the birth.

Villegas was nine months pregnant and leaving a prenatal clinic with her three children when she was stopped by police. She did not have a driver’s license or auto insurance; Tennessee has recently made it much more difficult for immigrants to obtain driver’s licenses. Because of her immigration status, although authorities had the option to simply issue a citation, Villegas was held in jail. When she went into labor, she was taken to the hospital, kept under guard with no privacy or ability to make a phone call, and shackled to the hospital bed during labor. Even requests by nursing staff that she be unshackled for personal care were denied by the guards assigned to her.

This week, a federal judge has now ruled in favor of Villegas in a civil rights case against the Metropolitan Government of Davidson County/Nashville, Davidson County Sheriff’s Office, and police officers involved in the case.

According to the local newspaper, The Tennessean:

In his decision Wednesday, Haynes wrote that Villegas was “neither a risk of flight nor a danger to anyone,” citing medical testimony. The judge concluded that shackling Villegas during the final stages of her labor and her post-partum recovery violated her civil rights.

One reference in the judge’s decision is an ACOG statement that “The practice of shackling an incarcerated woman in labor may not only compromise her health care but is demeaning and unnecessary.” Some states have banned the practice of shackling during labor, and following the Villegas incident the Sheriff of Davidson County announced that inmates at any stage of pregnancy, labor or delivery would no longer will be restrained except in rare circumstances when there is a credible threat of escape.

For much more background information and detail from the time of the 2008 incident, see our previous post. Colorlines has also covered the updated story.

The full decision is a fascinating and complex read, but is not freely available online; if you have access to a resource like Lexis-Nexis, see Juana Villegas, Plaintiff, v. Metropolitan Government of Davidson County/Nashville Davidson County Sheriff’s Office, et al., Defendants. If we have any law student or lawyer readers, I’d love to hear your take on the full decision in the comments.

May 3, 2011

Put on Your Walking Shoes: Walk for Maternal Health on May 5

The International Confederation of Midwives is asking member associations, midwives and their supporters to take to the streets on May 5 — International Day of the Midwife — to raise the profile of maternal mortality and access to midwifery care before, during and after childbirth.

From the ICM: “Over 340,000 women die each year, with millions more suffering infection and disability as a result of preventable maternal causes. The ICM, alongside UN agencies, WHO and a range of other international partners, is committed to addressing maternal mortality and morbidity through greater access to essential midwifery care worldwide, particularly in developing countries where 90% of maternal deaths occur.”

The walk is the first stage of the Road to Durban, where midwives from around the world will gather at the ICM Triennial Congress in South Africa (June 19-23). A new publication, “The State of the World Midwifery Report,” will be released during the gathering. It will provide new information and data gathered from 60 countries in all regions of the world, to:

• examine the number and distribution of health professionals involved in the delivery of midwifery services;
• explore emerging issues related to education, regulation, professional associations, policies and external aid;
• analyse global issues regarding health personnel with midwifery skills, most of whom are women, and the constraints and challenges that they face in their lives and work;
• call for accelerating investments for scaling up midwifery services, as well as “skilling up” the respective providers.

Close to OBOS headquarters, the Massachusetts affiliate of the American College of Nurse-Midwives is sponsoring a 5K walk in Cambridge (pdf). The walk will begin between 6 and 6:30 p.m. at the Cambridge Boat Club at 2 Gerrys Landing Road. The event is free, but onsite registration is required.

Other walks from West Virginia to Montana are listed here. If you’re involved in a walk in your community, feel free to leave a comment with the details.

For information on maternal health in the United States, see Amnesty International’s 2010 report “Deadly Delivery: The Maternal Health Care Crisis in the USA.” A one-year update was released earlier this spring (both are pdf’s). Amnesty has more information available online.

April 21, 2011

U.S. Trends in Midwife-Attended Births

A new article in the March/April 2011 issue of The Journal of Midwifery and Women’s Health (from the American College of Nurse-Midwives) describes trends in the percentage of U.S. births attended by midwives from 1989 to 2007.

Author Eugene Declercq looked at birth certificate records through the CDC’s VitalStats tool. Of course, it is possible (as the author notes) that there may be some misclassification, missing data, or other errors associated with birth certificate data. With that in mind, the findings were as follows:

  • The percentage of live births attended by certified nurse-midwives (CNMs) increased from 3.3% in 1989 to 7.7% in 2002, and decreased slightly to 7.5% by 2007.
  • The percentage of vaginal births attended by CNMs increased from 4.8% to a high of 10.8% in 2006, decreasing slightly to 10.6% in 2007.
  • The states with the highest proportion of CNM-attended births in 2007 were New Mexico (28.5% of all births), Vermont (18.3%), New Hampshire (15.4%), Oregon (15.3%), and Maine (15.1%).
  • The states with the smallest proportion of CNM-attended births were Arkansas (0.6%), Louisiana (1.4%), Alabama (1.9%), and Mississippi (2.0%).

The author does not attempt to fully explore possible explanations for any of the trends – the slight decreases of the most recent years, continuous increases over most of the examined time period, or geographic disparities – such as availability, awareness and attitudes, the cesarean section rate, or other factors. However, the data may be useful for those interested in women’s use of CNM services for birth or the history of CNM-attended births in the United States.

April 12, 2011

New Debate Over Addicted Mothers and Their Babies

This week, the New York Times ran a piece focused on the babies of women addicted to prescription painkillers. The focus of the narrative – almost exclusively on the babies, with a lack of real interrogation of or accountability for how the system currently fails and demonizes addicted pregnant women – should be familiar to anyone who witnessed media coverage of the “crack baby” in the 1980s.*

In fact, the writer explicitly draws this parallel by stating, “Like the cocaine-exposed babies of the 1980s, those born dependent on prescription opiates — narcotics that contain opium or its derivatives — are entering a world in which little is known about the long-term effects on their development.”

The same paper ran a piece in December 2009, “The Epidemic that Wasn’t,” which notes that popular fears about the outcomes for those babies – expressed in headlines such as “Crack’s Toll Among Babies: A Joyless View” and “Studies: Future Bleak for Crack Babies” – have failed to materialize, while “‘Society’s expectations of the children and reaction to the mothers are completely guided not by the toxicity, but by the social meaning’ of the drug.”

This is not to say it’s not natural or important to be concerned about the babies of addicted mothers, but it’s important to remember the ways in which race, class, power, and stigma impact our consideration of these women and their babies. This is illustrated in a quote from one doctor interviewed for the current piece; he treats pregnant women with addictions, and apparently asked himself initially, “Gosh, what am I doing? Am I really helping these people?” (emphasis mine).

What gets little attention in the article – except for a note that some doctors and hospitals won’t deliver the babies of some women treated with buprenorphine for their addictions – is that it can be extremely difficult for pregnant women to obtain treatment for drug addiction. Many treatment centers will not accept pregnant women, yet women whose babies test positive for drugs may face criminal charges. Yet, the stories and experiences of pregnant women addicted to drugs, and their inability to obtain treatment, barely figure into the NY Times article.

Lynn Paltrow of National Advocates for Pregnant Women has an excellent commentary exploring these and related issues at RHRealityCheck, where she concludes:

Perhaps then the real ethical quandary that should be addressed is why stories like these suggest that the greatest threat to children is their mothers – rather than the lack of universal health care, the economic policies undermining our communities, and the unethical doctors who turn away pregnant women seeking medical help.

*For more on that topic, including the racist overtones and media mythmaking, see Dorothy Roberts’s “Killing the Black Body.” Also see this editorial and this scientific article.

April 4, 2011

New Materials Available Related to Wax Homebirth Meta-Analysis

Readers at OBOB and on birth issues generally will know that the Wax meta-analysis on home birth generated much controversy and discussion about its methods, conclusions, and presentation, which Nature News summarizes in a recent story.

As a result of the high level of interest and debate, the American Journal of Obstetrics and Gynecology has allocated additional space to discussion of the paper, making letters to the editor, supplemental materials, and its editorial freely available to the general public for review, saying “There were a number of issues raised in the letters, many of which the panel believed were subjective and should be debated openly.”

The journal also convened a review panel to examine the paper, with the following outcomes as reported in the editorial:

…the results the panel found was slightly different from the result in the manuscript, although there was no difference in (1) the direction of the point estimate of the pooled odds ratio or (2) the overall “statistical significance” of the result. The panel made the following recommendations: (1) The Journal should publish online full summary graphs for each outcome that was assessed in the study, which will allow readers to assess the study findings better, and (2) no retraction of the article is necessary.

The editors themselves conclude, “It is clear that we need more rigorous and better designed research on this important safety issue of home birth, given the many confounding factors.”

The editorial page links to several of the letters to the editor, author replies, and supplementary data.

The supplementary materials from Wax et al, posted this February, thankfully include a type of forest plot for many of the outcomes, making it much easier to see and understand what the results were from each included paper for each variable than it was in the original publication.

March 31, 2011

Report Now Available from UNFPA Strengthening Midwifery Symposium

Last June, prior to the Women Delivery conference in Washington, D.C., UNFPA (the United Nations Population Fund) held a symposium on Strengthening Midwifery.

A report from that conference (PDF) is now available. It reports on speakers, presentations and issues from the event, including sessions on the role of midwives in addressing Millennium Development Goals on maternal and newborn deaths and HIV in pregnant women, topics in global midwifery education, midwifery regulation and standards of care, policy development, and other issues.

The report includes a call to action for governments to strengthen the midwifery workforce, build capacity for evidence-based training, ensure and regulate standards of practice, and support the creation of professional associations. Pledges for action from the World Health Organization, UNFPA, USAID and other agencies are also reported.

March 30, 2011

Update on Availability of Compounded Progesterone for Preterm Birth

We wrote earlier this week about growing objections to the new, drastically increased price for a drug to prevent preterm birth, now branded as Makena.

One concern has been that cheaper versions of the drug compounded by pharmacies would no longer be available to patients. The company making Makena, KV Pharmaceuticals, previously sent letters to compounding pharmacies instructing them to stop compounding the drug lest they run afowl of FDA regulations. The FDA has now issued a statement in response indicating that the agency:

does not intend to take enforcement action against pharmacies that compound hydroxyprogesterone caproate based on a valid prescription for an individually identified patient unless the compounded products are unsafe, of substandard quality, or are not being compounded in accordance with appropriate standards for compounding sterile products.

The FDA also says the letters send out by KV Pharmaceuticals to pharmacies are “not correct” when they suggest that the agency plans to take action against compounding pharmacies.

March 28, 2011

Objections Build to Price Hike for Makena, Drug to Prevent Preterm Birth

Earlier this year, the FDA approved Makena (a progesterone injection from KV Pharmaceuticals, generically known as 17-Hydroxyprogesterone or 17OHP) for use to reduce the risk of preterm delivery in pregnant women with singleton pregnancies and a history of at least one spontaneous preterm birth.

17-Hydroxyprogesterone has been in use for preventing preterm birth for decades, but had not specifically been approved by the FDA – it was usually compounded by pharmacists. It is now the only drug on the market with FDA approval for preventing preterm birth.

Following this new FDA approval for an old intervention, what was once a $10 per dose drug has become a $1,500 per dose drug. This has raised some hackles. Nicholas Fogelson of Academic Ob/Gyn urged readers to “Boycott Makena,” stating that he will try to keeping getting compounded (and cheaper) injections for his patients.

Others have expressed outrage that the March of Dimes, which works in part to reduce premature birth, supported KV Pharmaceutical’s application to the FDA and “has received hundreds of thousands of dollars in donations from KV’s subsidiary Ther-RX, which will market Makena,” according to a Time health blog.

A blogger at The Preemie Primer expresses dismay that the March of Dimes didn’t anticipate such a price hike when they supported the pharmaceutical company’s application, and also notes that Rep. Henry Waxman and colleagues have sent a letter to the drug company with a list of pointed questions about the pricing. Objections also include the steep costs to Medicaid programs and the lack of affordability for low-income women. The Preemie Primer has several additional posts on this issue for further reading.

Time also indicates that KV Pharmaceuticals “has warned compounding pharmacies that they face FDA action if they continue to sell nonbranded versions of the drug.” This aspect of the controversy is still being disputed, as the drug company does not hold a patent on Makena and so it is questionable as to whether they can prevent compounding.

The New England Journal of Medicine included a perspective piece on the issue, which concluded:

Rather than representing a good investment of increasingly scarce health care resources, Makena will force patients, physicians, and those responsible for financing care to make hard choices. K-V Pharmaceutical has announced a copayment-assistance program, but no program providing short-term financial assistance to some patients will mitigate the harm that this new cost will cause to publicly funded programs, including Medicaid, and the women who rely on them. Nor will it mitigate the cost to employers and individuals who purchase insurance coverage and therefore directly bear all increases in health care costs. This tremendous cost increase and the likely decrease in access to an effective medicine are sizable unintended consequences of the FDA approval of 17OHP. They demand reconsideration and corrective action.

March 21, 2011

Medical Journal Editorial on U.S. Maternal Mortality as a Human Rights Failure

The March editorial for the journal Contraception frames rates of maternal mortality in the United States “not just a matter of public health, but a human rights failure.” The authors, from WomanCare Global, AWHONN, and Amnesty International, explain the problem:

The rise of maternal deaths in the United States is historic and worrisome. In 1987, maternal death ratios hit the all-time low of 6.6 deaths per 100,000 live birth. These ratios were essentially maintained for more than a decade. Around 2000, the ratio began to increase and has since nearly doubled, hovering between 12 and 15 deaths per 100,000 live births between 2003 and 2007…’near misses’ (maternal complications so severe the woman nearly died) have also increased by 27% between 1998 and 2005, now affecting approximately 34,000 women a year; and appalling disparities in maternal health outcomes exist between racial and ethnic groups, and among women living in different parts of the United States.

The authors draw attention to troublesome disparities, noting that “for the last 50 years, black women who give birth in the United States have been approximately four times as likely to die as white women,” although they do not seem to have higher rates of medical complications that are common causes of maternal death and hemorrhage. They also note that 25% of white women, 32% of black women and 41% of American Indian and Alaska Native women do not receive adequate prenatal care.

Authors Francine Coeytaux, Debra Bingham, and Nan Strauss explore possible reasons for the increase in maternal mortality, including lack of access to prenatal care, primary care, and insurance, inadequate or poor quality intrapartum care, limited postpartum care, overuse of medical interventions, and a lack of data collection and accountability.

They conclude with a call to action focused on systemic change, rather than smaller interventions in the health of individual women, arguing that “system-level improvements ensuring a uniformly high quality of care are also needed, and these improvements are beyond the control of the individual woman or an individual provider.” Action steps outlined in the piece include initiating, supporting and advancing legislation to reduce maternal mortality through improving care and reducing disparities, expanding data collection and analysis, and investigating more thoroughly why maternal deaths and injuries happen in the U.S. and taking steps to reduce those causes.

This and other editorials from Contraception are freely available online.