Maternity Care in Crisis

1/11/2019

American Women Are Dying From Childbirth at a Higher Rate Than in Any Other Developed Country

By Tahra Johnson

Kira and Charles Johnson were excited to welcome a second son into their fam­ily. Langston was to be deliv­ered, like his older brother, by cesarean section on April 12, 2016. The Johnsons knew what to expect and were prepared for Kira’s recovery. Or so they thought. While Kira was still in the hospital, Charles no­ticed blood in her catheter. He alerted the medical staff im­mediately, but hours went by before Kira could get a CT scan. By the time she went into sur­gery, it was too late.

Kira died 11 hours after delivering her baby.

Like hundreds of other American women that year, Kira died due to a de­layed response to complications from pregnancy or delivery. “Seven-hundred mothers die every year, and over 50,000 others experience dangerous complica­tions that could have killed them—making the U.S. the most dangerous place in the developed world to give birth,” Stacey D. Stewart, president of the March of Dimes, told the U.S. Energy and Commerce Sub­committee on Health in September last year. In fact, an American woman is three times more likely to die from childbirth than a Canadian woman and six times more likely than a Scandinavian woman. Kazakhstan and Libya have better rates than the U.S.

“This situation is completely unaccept­able,” Stewart said.

Uptick in Maternal Deaths

The national maternal mortality rate more than doubled between 1987 and 2012 and now sits at 20.7 deaths per 100,000 live births, according to the Cen­ters for Disease Control and Prevention. The average maternal mortality rates for each state from 2011 to 2015 varied from 4.5 to 47 deaths per 100,000 live births.

Any time a woman dies while preg­nant or within one year of the end of a pregnancy from any cause related to the pregnancy or its management, the CDC considers it a pregnancy-related death. The agency does not include deaths from accidental or incidental causes, such as dying in a car wreck while pregnant.

Different recording practices used over the years, however, make it hard to draw definitive conclusions on maternal death rates. According to a 2017 article in the journal Obstetrics & Gynecology, the current coding rules can negatively affect data quality. If the “pregnancy or post-par­tum within 42 days” box is checked, for example, the record is coded as a mater­nal death, regardless of what is written in the cause-of-death section. In some states, better information is available because maternal mortality review committees ex­amine death records and decide whether the cause was pregnancy-related.

A 2018 report from nine review commit­tees shows that most deaths are prevent­able, especially those involving delayed emergency care, as in Kira Johnson’s case, or a lack of protocols for responding to la­bor and delivery complications.

Severe Maternal Morbidity

Deaths are not the only concern. For ev­ery maternal death in the United States, as many as 70 to 100 women experience se­vere maternal morbidity, or “near misses.” Morbidity includes unexpected events during labor and delivery, like uncon­trolled bleeding or serious infections.

After U.S. tennis star Serena Williams opened up about her near-death expe­rience after delivering her baby girl, the issue received national attention. Williams developed a blood clot in her lungs. “I just remember getting up and I couldn’t breathe, I couldn’t take a deep breath,” she recalled in her HBO docuseries “Being Serena.” Williams had experienced a sim­ilar incident about five years earlier and knew to ask the medical staff for a CT scan with dye. She received the scan and en­dured three subsequent surgeries.

“I’m not someone who takes their health for granted,” Williams said. “With as many issues and scares as I’ve had, I think I’ve learned pretty well how to lis­ten to my body.”

Aiming for Answers

So, why are mortality and morbidity rates increasing in the United States while they’re decreasing almost everywhere else? The reasons are unclear. Increases in maternal age, pre-pregnancy obesity, poverty, untreated pre-existing chronic medical conditions, the high number of cesarean deliveries and a lack of access to health care, especially in rural areas, all could be factors contributing to the up­swing in maternal deaths in the U.S.

With support from the Maternal and Child Health Bureau in the federal Health Resource Services Administration, at least 13 states and more than 667 hospitals are working with the Alliance for Innovation on Maternal Health, known as AIM, to put in place a set of effective, proven practices. The program works directly with practi­tioners in health care facilities, including hospitals, who perform 1,780,000 births a year, or 45 percent of the annual U.S. total.

Among the program’s tools are “ma­ternal safety bundles”—one- to two-page briefs divided into bulleted sections with reminders for staff on how to prevent, rec­ognize, respond to and report on a variety of conditions. When performed collec­tively and reliably, the strategies work. Safety bundles cover such topics as:

  • Early-warning signs of complications.
  • Hemorrhage.
  • Hypertension.
  • Vaginal births.
  • Racial disparities.
  • Basic postpartum care.
  • Care for opioid-dependent women.


The American College of Obstetricians and Gynecologists reports that Illinois re­duced severe maternal morbidity by about 22 percent and morbidity due to hyper­tension by nearly 20 percent through the AIM initiative. Oklahoma reduced severe maternal morbidity by roughly 20 percent in its participating hospitals.

A Better Review Process

About half the states have established a comprehensive maternal mortality review committee to examine deaths and identify areas for improvement. The committees typically include public health workers, obstetricians and gynecologists, mater­nal-fetal medicine experts, nurses, mid­wives, forensic pathologists, and those in the mental and behavioral health fields. Some include social workers or patient advocates.

Despite recent national attention, a few states created these committees more than 15 years ago. Maryland’s review pro­gram, which was established in 2000, is required by statute to:

  • Identify maternal death cases.
  • Review medical records and other rel­evant data.
  • Determine preventability of death.
  • Develop recommendations to prevent maternal deaths.
  • Disseminate findings and recommen­dations to policymakers, health care pro­viders, health care facilities and the public.


Georgia’s legislature created a review committee through legislation sponsored by Senator Renee Unterman (R). It con­vened for the first time in 2012.

“Unfortunately, Georgia was ranked high in maternal and infant mortality. We were ranked five years in a row as the best state to do business in. How can we be ranked that way and not be doing well for our moms and babies?” she asks.

Georgia’s law provides legal protections for committee members and the review process, ensures confidentiality and gives the committee the authority to collect data for case review. The state also piloted pro­grams to improve access to care in rural areas. The Centering Pregnancy program puts pregnant women into groups where, in addition to medical care, they receive emotional peer support; education about nutrition, labor and delivery; breast­feeding and self-care advice; depression screening and group interaction. The pro­gram lowered the risk of preterm birth by 33 to 47 percent. Medical practices in at least 46 states have adopted the Centering Pregnancy model.

Data Delivers

Dr. Morgan McDonald is the assistant commissioner and director of the Divi­sion of Family Health and Wellness at the Tennessee Department of Health. She has overseen the implementation of 2016 leg­islation that created the committee there.

“Data is the first benefit with a mater­nal mortality review committee,” she says. “Until it’s in place, you just have vital re­cords and it relies on the coding and tim­ing of death, which may not give you the information you need.”

The review process verifies whether a death was related to pregnancy and iden­tifies factors that may have prevented that death. The legislation for Tennessee’s re­view committee took effect in 2017.

“I can’t overestimate the impact of the maternal mortality review legislation in Tennessee,” McDonald says. “It has galva­nized the prevention and I have no doubt it will direct our efforts to reduce our maternal mortality rate. It is a big win for women’s health and for everybody, that is not controversial.”

Tennessee Senator Sara Kyle (D) says she hopes the legislation will help prevent “senseless” maternal deaths. “Studies show us that America’s maternal mortality rate is higher than in any other developed country, and Tennessee’s is above the na­tional average. I think we have to ask our­selves the tough question: Why are these pregnant women dying at a higher rate than in any other developed country?”

To date, only California has success­fully reduced its maternal mortality rate. The state’s Department of Public Health calculates that between 2006 and 2013, the rate fell by 55 percent, from 16.9 to 7.3 deaths per 100,000 live births. Currently, the rate is 4.5, the lowest by far of any state.

California used data collection and in­formation from its review committee to focus on improving labor and delivery in hospitals. In short, the state linked birth and death records, hospital data files and coroner reports; reviewed each pregnan­cy-related death; and translated findings into quality-improvement initiatives that could be used statewide. To support the state’s hospitals, the California Maternal Quality Care Collaborative, a public-pri­vate partnership, created informational toolkits with C-section and early-delivery rates and other statistics to identify where improvements could be made. These toolkits were the model that the Alliance for Innovation on Maternal Health used to create its maternal safety bundles—the how-to guides now being used in birthing facilities in 18 states.

Hope on the Horizon

State legislatures will continue to ex­plore opportunities to improve their ma­ternal care systems, so that families don’t have to face the pain of losing a mother and wife the way Kira Johnson’s family did.

“I do not have the words to describe the loss my family has suffered,” Kira’s hus­band, Charles, told the U.S. Energy and Commerce Subcommittee last fall. “My boys no longer have their mother. Kira was the most amazing role model and mother any boy could ever wish to have.”

In a sign that the maternal mortality cri­sis is getting needed attention, President Trump signed the bipartisan Preventing Maternal Deaths Act of 2017 on Dec. 22 last year. The new law authorizes pro­grams to promote safe motherhood and to support states in establishing or improv­ing maternal mortality review committees, so officials can better understand how to keep moms alive and healthy.

It could be a meaningful step toward changing America’s regretful status as the most dangerous place in the developed world for a woman to have a baby.

Tahra Johnson directs NCSL’s maternal and child health program.

Additional Resources

NCSL Resources