Based on the ever-changing circumstances America is facing, issues concerning medical ethics have risen. The maternal care crisis is a long term issue that has lacked substantive solutions in terms of policy and social change. After analyzing different perspectives, including the medical, economic, and racial lens, that culminate in the maternal crisis, suggestions for long term solutions in rural and urban areas of the country can be offered. The paper concludes with the finding that significant, national legislation or bureaus and protocols for states must be established. Furthermore, root issues concerning racism in the medical field must be addressed through education and institutional changes.
The outbreak of the recent pandemic has brought attention to medical care in the United States. Through many different aspects of healthcare in America, professionals find that the standard of care found in the country does not only match America’s advancements in different lenses, as severely shown by the country’s maternal health crisis. In recent decades, the number of deaths and near-deaths of pregnant women has risen severely. Today, 1,000 women in America die every day from complications related to childbirth- translating to one woman every 90 seconds, according to Amnesty International.1
However, the problem is twofold. Not only is the poor care of mothers around the nation leading to long-term, life-altering impacts for children and families everywhere, but it is “inconsistent with the United States’ position as a developed country and its medicine-related innovations”.2 The American Public Health Association states “maternal mortality is considered to be one of the main markers of the health of a nation and a bellwether indicator by which both human rights and public health can be evaluated”.2 Even further, World Health Organization (WHO) data reveals that the United States ranks 50th in the world in maternal mortality,3 despite the fact that the United States spends more on health care than any other country.4
The maternal care crisis is primarily defined by obstetric, or more commonly known as maternal, morbidity, and mortality. In a report from the National Research Council Committee on population, obstetric morbidity is defined as “morbidity [illness] in a woman who has been pregnant (regardless of the site or duration of the pregnancy) from any cause related to or aggravated by the pregnancy or its management like medication dosage mistakes, but not from accidental or incidental causes.” Obstetric mortality in turn is the result of death due to pregnancy-related causes.5
In an effort to increase the efficiency of the United States’ maternal care and also improve the lives of several individuals around the country, the large factors that contribute to the maternal care crisis in America can be analyzed. Through an evaluation of the medical, economic, and racial factors of maternal care, it can be seen that the maternal care crisis most directly impacts those from backgrounds surrounded by systemic barriers. An assortment of policy and structural changes in society along with economic changes from bureaucratic institutions can reduce the extent of the maternal care crisis in America.
Causes of Maternal Care Crisis
In order to understand the reasons behind the maternal care crisis in America, it is critical to understand medical factors that could lead to the harsh changes in morbidity and mortality.
- Maternal Age and Pre-existing Health Condition
The CDC defines severe maternal morbidity (SMM) as the “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health”, and states that in 2014, over 50,000 women were affected by SMM.6 Yet, Katherine Ellison and Nina Martin from NPR find that while these are probable reasons for the increase in SMM, the CDC’s statistics are not necessarily accurate. They state, “when one patient safety group, the Alliance for Innovation on Maternal Health (AIM), analyzed 2015 data from hospitals in four states, the rate of morbidity was roughly 2 percent of births, which would translate to 80,000 cases a year nationwide”.7
Ellison and Martin further continue that one possible reason for the increasing SMM is the rising age of the pregnant population, alongside other pre-existing health factors that can lead to complications. The average American mother over 30 rose from 24 to 30% from 2000 to 2014.7 Complications are more likely as women tend to weigh more, too.8 A rise in the number of women suffering from pre-pregnancy obesity leads to a higher risk of hypertension and diabetes. Indeed, women with such pre-existing health conditions are three times as likely as other new mothers to experience life-threatening impacts of childbirth, according to a study conducted from 2008 to 2012 in a set of New York hospitals.9
- Demographic Influence
Studies show that certain demographics are likely to have underlying health conditions that compromise the mother’s and baby’s health. Researchers at the University of Michigan found in 2018 that many of the life-threatening conditions depend on the mother’s racial and ethnic background. While there are more crucial, longer-lasting factors that play into the statistics presented, the same study from the University of Michigan still finds that not only were 44% of cases preventable, but less than 1% of deliveries were actually severely morbid. Thus, the high rates of morbidity tend to be connected to biological health conditions.10 Yet, this is an extremely small explanation that does not suffice for the large scale maternal care crisis present in the United States of America.
- Lack of Health-care Facilities
The maternal care crisis not only exists at the individual medical level but also spreads throughout the economic level. The clearest economic issue connected to maternal morbidity is the lack of medical access, especially in rural areas and areas generally inhabited by BIPOC and Latino communities. Authors from the Commonwealth Fund, a foundation focused on improving access to healthcare, state: “Fewer than half of all rural counties have a practicing obstetrician or gynecologist (OB/GYN). This… increases the likelihood by three to four times that women will die a pregnancy-related death, and contributes to higher rates of infant mortality”.11
Lack of medical care stems from other important structural factors- specifically, poverty. The American Public Health Association reports that higher poverty has a 100% greater risk of maternal mortality. The statistics regarding reduced medical resources in rural areas concur since PBS confirms that 5% more families living in rural areas live with incomes less than 150% of the poverty line.2 However, PBS also finds that the increased rates of poverty are likely due to the lack of job opportunities in non-urban areas, as well as an increased number of people living with disabilities.12
- Caesarean Section Child-Delivery
Other government-induced action includes the increased usage of Cesarean Section surgeries in childbirth. “Only about one-third of U.S. C-sections are medically justified, according to DeClercq, the Boston University maternal health expert.” The remaining surgeries occur due to hospital culture, convenience, and indirect financial incentives. Thus, Ellison and Martin from NPR claim that hospitals tend to find C-Sections cost-effective.7
Ironically, C-Sections still lead to higher costs. Dennis Thompson and sources therein clearly find that C-Sections lead to 80% increased risks in pregnancies. These risks translate into increased costs: The cost alone of caring for mothers with pre-eclampsia exceeds $1 billion annually, according to a September 2017 report in the American Journal of Obstetrics & Gynecology. Furthermore, in 2011, California’s Medicaid program spent more than $210 million to treat maternal hemorrhage and hypertensive disorders, which are the two most common causes of SMM according to a paper published in the Am J Obstet Gynecol journal.13 Thus, in an effort to make maternal healthcare more efficient, government and medical agencies increase indirect costs to healthcare while simultaneously endangering lives.
- Structural Racism Within Different Communities
Alongside medical and economic factors that contribute to the rising number of obstetric cases, structural racism integrated into the medical field plays a large role in the rising rates of maternal morbidity and mortality.
African Americans have the highest infant mortality rate of any racial or ethnic group in the United States, and higher rates of preterm births explain more than half of the difference, relative to non-Hispanic white women.14 The statistics are clear: black women experienced 3.2 times higher pregnancy-related mortality than their white counterparts. For every 13 white women who die during pregnancy or within one year of giving birth in America, there are 44 black women.15
Aside from the already blatant racism present in several sectors of healthcare, Novoa continues that weathering plays a large role in the race-related medical conditions that can complicate a woman’s pregnancy. In other words, stressors such as not getting proper care become too harsh, which can lead to biological changes that affect physical and mental health and thus higher risk of conditional illness. These stressors can include a lack of care to the patient or dismissive responses to the patient’s concerns and pain levels.14
These problems are severe not only in terms of statistics but also on a personal level. Acclaimed tennis player Serena Williams makes this clear: her previous health conditions of pulmonary embolisms made her aware of her symptoms and what she needed to treat the issue. She told her nurse that she needed a CT scan and IV heparin, yet her asks were dismissed. She’s experienced problems relating to her pregnancy situation after, through symptoms including coughing up blood that led to a rupture in her C-Section wound. Alongside the other blood pregnancy issues, the tennis player had to spend 6 weeks under bed rest.16 While Williams is able to share her story, not everyone can. Ultimately, the statistics are severe, and looking at the results at an individual level shows that the problem stemming from structural and ingrained racism cannot be ignored.
Solution For Maternal Care Crisis
There are ways to mitigate the maternal care crisis, but it is important to recognize that the issues are deeply rooted in society and thus require systemic change.
- Establishment of Maternal Health Office
A major issue surrounding maternal care in America is simply the lack of accurate data. Wayne Kuznar, as published in the American Journal of Nursing, recommends establishing an office of maternal health.17 Furthermore, in terms of bureaucratic options to solve the crisis, defining protocols to aid women can be beneficial. California presents a strong basis for other states to follow: To summarize, providing specific tools, kits, and instructions available for impromptu pregnancy-related events has actually decreased pregnancy-related deaths by 50%.18
- Policies to fight against Medical Racism
Medical racism is a blatantly large factor in how mothers are treated in American healthcare. Not only for maternal health but in all other medical sectors, racism must be confronted with interpersonal and structural changes, including policy actions that address the social determinants. Kozhimannil writes in the Health Affairs journal details the specific social determinants to be studied, including food access, environmental health, and more.19
- Ensuring Medical and Financial Aid in Underprivileged Communities
The medical and economic sectors show that families need more access to maternal facilities and resources, including midwives, doulas, insurance coverage from Lake Region Agency, etc as shown from the struggle rural families in America face. This increased access will consequently reverse the current erosion of funding in maternal health that is currently seen, as more money can be provided to hospitals and healthcare agencies.
The impact of improving maternal health lasts decades and enhances the quality of life for thousands, if not millions, around the nation. Addressing women’s health results in a more productive, and ultimately, happier society.
Though America spends large amounts of money on healthcare, maternal care in the country falls far behind health standards for the country. While pre-existing health conditions and demographic influences can be one explanation for the alarming statistics related to maternal mortality and morbidity, larger concerns such as the lack of health care facilities, poverty, unnecessary C-Sections and structural racism prove to be critical in the development of America’s maternal care crisis. Solutions for addressing this issue include top-down policies of establishing a maternal health office, implementing policy against medical racism, and improving healthcare access in underprivileged areas. Addressing maternal health in America is critical for defining America’s healthcare abilities and forming a more productive society.
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