Browsing the blog archivesfor the day Friday, August 14th, 2015.

More Lives That Matter

Health Care, Women's Issues

The United States has among the highest rates of infant and maternal mortality in the developed world. Worse, according to official statistics, the rate of maternal mortality in the U.S. has shot up in recent years, even as the rate is going down just about everywhere else

(Maternal mortality rate refers to the number of women who die as a result of pregnancy and childbirth per 100,000 pregnancies/births. Infant mortality rate refers to the number of infants per 1,000 births who die between birth and their first birthday.)

Maternal mortality has jumped from 7.2 in 1987 to 18.5 in 2013; I understand the U.S. is roughly tied with Iran and Hungary in the maternal mortality department. And keep in mind that those numbers are averages; some states are not that bad, and some are worse.

However, a recent article in Scientific American argues that the maternal mortality rate really isn’t going up; it’s always been that bad, and we just didn’t know it.

Until relatively recently most states relied on a death certificate form that was created in 1989. A newer version of the form, released in 2003, added a dedicated question asking whether the person who died was currently or recently pregnant—effectively creating a flag for capturing maternal mortality. Specifically, this recently introduced question asks if the woman was pregnant within the past year, at the time of death or within 42 days of death.

The addition of this question means that the apparent increase in maternal mortality in the U.S. “is almost certainly not a real increase. It’s better detection from the new certificates,” says Robert Anderson, chief of the Mortality Statistics Branch with the CDC’s National Center for Health Statistics. “The numbers are going up but it’s most likely not because women are more likely to die,” he contends.

In other words, maybe the problem isn’t getting worse; it’s just that the way we used to collect data camouflaged how bad things were before. That’s so … not a relief. However, other researchers quoted in the same article think there is an increase that can’t be entirely accounted for by the change in data collection.


One aspect of maternal mortality that has not changed over the years is the extent to which it varies by race. The risk of maternal mortality has remained about three to four times higher among black women than white women during the past six decades. Since 1999 maternal mortality has climbed among both black and white women—potentially due to those changes in death certificates and also how deaths are now coded in the U.S. using the ICD-10. Yet even with the cross-race increases in deaths related to pregnancy, in 2007 the maternal mortality rate for black women was still nearly three times higher than the rate for white women.

Researchers have shown that black women are not inherently more likely to have underlying pregnancy complications. Indeed, one national study that looked at five major common causes of maternal death and injury that collectively account for more than a quarter of all pregnancy-related deaths found that black women did not have a significantly higher prevalence than white women of those conditions—preeclampsia, eclampsia, obstetric hemorrhage, placental abruption and placenta previa. Yet black women were two to three times more likely to die than white women with the same complication.

Increased poverty and stress are an obvious reason why black mothers are at increased risk, IMO, but the medical science guys who look at this stuff aren’t persuaded that’s the entire story.

Whatever the cause, the data tell us that a lot of women die in the U.S. who would have lived had they gone through pregnancy and childbirth in any of about 50 other countries, including Estonia and Qatar. And a disproportionate number of those women are African American, and nobody knows why.

There are huge differences from state to state, for that matter. Maine has a maternal mortality rate of 1.2, according to data aggregated from the Center for Disease Control. Michigan has a rate of 21.0. The District of Columbia is even worse — 38.2. We’re in Third World territory with that number.

Similarly, the United States lags behind most of the developed world in infant mortality, and a disproportionate number of those infants also are African American. Conservatives for years have dismissed the data with claims that these are mere reporting anomalies. If an extremely premature infant dies immediately after birth, for example, it’s usually counted in the infant mortality data in the U.S. but would not be counted as such in some other countries.

An article in the Washington Post from September, 2014 blows that argument out of the water

Despite healthcare spending levels that are significantly higher than any other country in the world, a baby born in the U.S. is less likely to see his first birthday than one born in Hungary, Poland or Slovakia. Or in Belarus. Or in Cuba, for that matter. …

… One factor, according to the paper: “Extremely preterm births recorded in some places may be considered a miscarriage or still birth in other countries. Since survival before 22 weeks or under 500 grams is very rare, categorizing these births as live births will inflate reported infant mortality rates (which are reported as a share of live births).”

Oster and her colleagues found that this reporting difference accounts for up to 40 percent of the U.S. infant mortality disadvantage relative to Austria and Finland. This is somewhat heartening.

But what about that other 60 percent?

“Most striking,” they write, “the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality” compared to Austria and Finland. In other words, mortality rates among infants in their first days and weeks of life are similar across all three countries. But as infants get older, a mortality gap opens between the U.S. and the other countries, and widens considerably.

See the chart in the article. We’re not losing newborns as much as we are losing infants from one to 12 months old, and the gap widens as the infants get older. It appears many babies are dying in the U.S. who would have lived if they’d been born in Finland. And the biggest factor seems to be income; in the U.S., babies born into poor families die a lot more often than babies born into wealthy families. There also are big discrepancies from one state to another.

The U.S. rate of 6.1 infant deaths per 1,000 live births masks considerable state-level variation. If Alabama were a country, its rate of 8.7 infant deaths per 1,000 would place it slightly behind Lebanon in the world rankings. Mississippi, with its 9.6 deaths, would be somewhere between Botswana and Bahrain.

Needless to say, a disproportionate number of those poor families are African American. I couldn’t find raw numbers, so I don’t know how many African American women and babies die what must be preventable deaths in the U.S. every year. Maybe someone else can find that number. I don’t know how many White, Native American, Asian American and Latina women and their babies die, either. In 2013 about 800 women of all races died of complications of pregnancy and childbirth in the U.S., and if you have the data and can do math better than I can perhaps you can figure it out. I found no raw numbers of babies who die before their first birthday, just the rates.

The bottom line, though, is that access to health care, including reproductive health care, is a life and death issue for American women. And our lack of attention to this problem is a national disgrace. Yet instead of addressing it we’ve been manipulated into a phony controversy about Planned Parenthood. Really disgusting.

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