Maternal Mortality and Morbidity

Established in 1986, the Pregnancy Mortality Surveillance System (PMSS) defines a “pregnancy-related death as the death of a woman while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy.” (Center of Disease Control and Prevention, 2020). “Since the Pregnancy Mortality Surveillance System (PMSS) was implemented, the number of reported pregnancy-related deaths in the United States has increased from 7.2 deaths per 100,000 live births in 1987 to 17.4 deaths per 100,000 live births in 2018. (CDC, 2020).” Various research studies suggest that maternal mortality in the United States is mostly preventable. According to research data, the increased rate of maternal mortality and morbidity prompted public health officials, social services workers, family survivors, and community advocates to consider this crisis a social problem. Historically, through the collaborative actionable efforts from societal members, social structures, and legislative policies; infant, maternal mortality and morbidity rates did decline, but in modern times have increased. In short, maternal mortality and morbidity have become a social problem once again.

In the 21st century, public attention and awareness to maternal mortality and morbidity in the United States publicly and privately have increased. Combating maternal mortality during the first three decades, took a multidisciplinary approach, including, public health, social welfare, and clinical medicine (pediatrics and obstetrics) to combat infant mortality (CDC, 1999). When the Children’s Bureau was created in 1912, to address the wellbeing of infants and children, they were also responsible for addressing infant mortality and creating maternal health standards. “Between the years 1913 and 1915, the Bureau conducted several studies that indicated that infants had a higher mortality rate in areas affected by poverty and a lack of accurate information on health and hygiene; their findings suggest that “pregnant women and infants in rural areas were at higher risk of death because of a lack of access to nurses and hospitals.” (Madgett, 2017). The Bureau continued efforts to fix the problem of infant mortality, advocated for “comprehensive maternal and infant welfare services, including prenatal, natal, and postpartum home visits by healthcare providers; by the 1920s, integrating these services changed the approach to infant mortality from one that addressed infant health problems to an approach that included infant and mother and prenatal-care programs to educate, monitor, and care for pregnant women.” (CDC, 1999). These efforts lead to the 1921 bill, the National Maternity, and Infancy Protection Act, commonly known as the Sheppard-Towner Maternity and Infant Act.

The Sheppard-Towner Act was the first social welfare program and first to provide federal grants to states for public health; “states used the funding to establish prenatal clinics, hired nurses to conduct home visits, midwife training host conferences about infant health, and distribute educational material.” (Madgett, 2017). The Sheppard-Towner Acts was deemed successful by the states who implemented the Act and by the Children’s Bureau who oversaw and implemented the services but was repealed because of criticism from the American Medical Association (AMA) of the government’s role in public health. (Schlesinger, 1966, p. 1037) “The infant mortality rate declined between the years of 1921 and 1929, and later commentators estimated that the Sheppard-Towner Act helped tens of thousands of infants.” (Madgett, 2017). After the Sheppard towner Act was dismantled, there was a gap until the Social Security Act of 1935 included Title V. “Title V provides matched federal-grants-in-aid programs for maternity, infant, and childcare, and a full range of medical services for children, including children with congenital disabilities.” (Schlesinger, 1966, p. 1040). During 1939-1971, maternal mortality decreased by 89%; since 1982, maternal mortality has not declined.” (CDC, 1999). According to researchers, because of the consistent decline in rates before 1982 of maternal mortality rates, “it might be more appropriate to refer to the past decade or two as the Sheppard-Towner era, rather than the 1920s.” (Schlesinger, 1966, p. 1040). In modern times, “important social determinants of maternal health for rural communities include lack of access to health and human services, transportation challenges, lack of educational and employment opportunities, and poverty.” (National Advisory Committee on Rural Health and Human Services, n.d.).

Ten groups that cause maternal mortality include hemorrhage, embolism, hypertensive, infection, anesthesia, cardiomyopathy, cerebrovascular, cardiovascular, non-cardiovascular, and unknown. (Creanga et al., 2015, p. 9). PMSS data from the years of 1987-2017, show that there has been an overall decline in pregnancy-related death including causes such as, “hemorrhage, hypertensive disorders of pregnancy, embolism, and anesthesia”, but data also show “cardiovascular, cerebrovascular accidents and other medical conditions have increased.” (Creanga et al., 2015, p. 11) More recent PMSS data report for 2014-2017 show, consistent, stable data of causes in cardiovascular conditions, 15.5%, Infection or sepsis, 12.7%, non-cardiovascular medical conditions, 12.5%, cardiomyopathy 11.5%; hemorrhage, 10.7%; embolism, 9.6%; “the cause of death is unknown for 6.7% of all 2014–2017 pregnancy-related deaths”. (CDC, 2020). The causes of pregnancy-related deaths are affected by the outcomes of the pregnancy. For example, “among deaths after a live birth, embolism, cardiomyopathy, and other cardiovascular conditions were the three most common causes of death, whereas infection, non-cardiovascular medical conditions, and hemorrhage were most found with deaths after a stillbirth.” (Creanga et al., 2015, p. 8-9).

Maternal morbidity refers to any physical or mental illness or disability outcomes related to complications during pregnancy, during delivery, and postpartum. Maternal morbidity, although not life-threatening, however, can still have a significant impact on the quality of mothers and their children, examples of maternal morbidity “heart disease and blood vessel problems, diabetes, high blood pressure, infections, blood clots, bleeding, anemia, hyperemesis gravidarum (severe morning sickness), and depression and anxiety.” (CDC, 2020). Studies show that an increasing number of pregnant women in the United States have chronic health conditions such as hypertension, diabetes, obesity, and chronic heart disease. (Creanga et al., 2015, p. 10)

The Centers for Disease Control and Prevention (CDC) keeps track of the hospitalization of women who suffer from Severe Maternal Morbidity (SMM). SMM includes “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.” (2020). SMM increases in complications. For example, “increases in maternal age, pre-pregnancy obesity, preexisting chronic medical conditions, and cesarean delivery” (CDC, 2020). “This increase has been mostly driven by blood transfusions from cesarean section resulted from server postpartum hemorrhage. (CDC, 2020). According to researchers, “Severe postpartum hemorrhage (PPH) is an important cause of maternal death and severe maternal morbidity.” (Butwick et al., 2017, p. 8). “After excluding blood transfusions, the rate of SMM decreased by about 20%.” (CDC, 2020). “SMM is 100 times more common than maternal mortality.” (U.S. Department of Health and Human Services Health Resources and Services Administration, 2015, p. 7).

The one population that is most affected by maternal mortality and morbidity in the United States, is African American women. African American women are at increased risk of life-threatening pregnancy-related complications and three to four times more likely to experience a pregnancy-related death than white women; “black women experience higher mortality from cardiomyopathy, hypertensive disorders of pregnancy, and hemorrhage; case-fatality rate higher than white women for five specific pregnancy complications including preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage.” (Howell, 2018, p. 3).

The increasing disparities in maternal and infant mortality rates are rooted in racism, which increases the severity of maternal death outcomes. Structural racism in health care and service delivery means that “differences in hospital quality may contribute to racial and ethnic disparities in maternal mortality and morbidity rates; in two ways, residential segregation of hospitals and the quality of interpersonal delivery of health care.” (Howell & Zeitlin, 2017, p. 268-269). According to researchers, “health-care infrastructure and services are inequitably distributed, resulting in predominantly black neighborhoods having lower-quality facilities with fewer clinicians than those in other neighborhoods”, besides, interpersonal racism, bias, and discrimination in healthcare settings can directly affect health outcomes through poor health care delivery.” (Bailey et al., 2017, p. 1458). The lack of “availability and accessibility of hospitals and providers offering obstetric care and health insurance coverage for maternity care, has contributed to maternal mortality and morbidity”; in the United States, “over 12 percent of births take place in maternity care deserts or locations with limited access to maternity care.” (Taylor et al., 2019).

Structural racism is one underlying risk factor, other risks factors include, “lack of access to care, unstable housing, limited access to transportation, poor understanding of danger signs, and not following medical advice”; also, “some health systems are ill-equipped to deal with maternal emergencies, missed or delayed diagnoses, and inadequate case coordination.” (Gingrey, 2020, p. 462). African American women are vulnerable to the adverse consequences of unequal economic conditions, they are affected by structural inequality, stigma, discrimination, the chronic stress of poverty, racism, and is linked to their persistent maternal health disparities.” (Creanga et al., 2014, p. 3). Research findings show that chronic poverty is correlated with higher rates of poor health and chronic health conditions in children; particularly affecting African American children and families at higher rates and for a longer period. (Wood, 2003, p. 709-710). “Pregnancy outcomes are an important predictor of ultimate child and adult health outcomes, and poverty is strongly associated with low birth weight and other poor pregnancy outcomes” (Wood, 2003, p. 706).

“The structural-functionalist perspective of health care is a societal institution that functions to maintain the well-being of societal members and the whole social system.” (Mooney et al., 2016, p. 10). On a structural macro-level there is one major potentiating factor to pregnancy-related complications and maternal deaths, the substandard level of health care delivery system, in the United States. According to the World Health Organization, “the United States health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance” (2000). The inequality in the quality and fairness of the health care delivery system is a contributing factor in the disparities of pregnancy-related complications and maternal deaths. According to researchers, “the quality of care provided during the delivery hospitalization may be more amenable to change”; research has shown that “provider and system failures explain a significant proportion of maternal deaths and near-misses raising the possibility that better hospital quality could improve maternal outcomes and reduce disparities.” (Howell & Zeitlin, 2017, p. 267).

“The conflict perspective focuses on how socioeconomic status, power, and the prof-it motive influence illness and health care.” (Mooney et al., 2016, p. 38). Research indicates that socioeconomic inequality and state-level policies affect women’s ability to access healthcare services and resources in their communities. (Vilda et al., 2019, p. 5-6). The conflict approach emphasizes the lack of access to high-quality prenatal and maternity care services, due to the shortages of maternal health clinics, healthcare providers or inadequate coverage for services in rural areas.” (HRSA, 2015, p. 6). Rural areas, experience higher rates of pregnancy-related complications and maternal deaths compared to large metropolitan areas or counties. For example, “rural hospitals report higher rates of postpartum hemorrhage and blood transfusion during labor and delivery, compared to their urban counterparts.” (Hung et al., 2017, p. 1664). Cesarean section can be a life-saving intervention; however, the increased rate of Cesarean sections is believed to be a contributor factor to maternal mortality and morbidity. (Collier & Molina, 2019, p. 4-5). Researchers indicate financial incentives structures play a fundamental role in the overall increased rate in performing Cesarean sections by for-profit hospitals compared with non-profit hospitals. (Hoxha et al., 2017).

The symbolic interactionist approach is the interaction between pregnant women and healthcare providers that are in poor health, lack health insurance, and are often stigmatized by healthcare professionals. “Symbolic interactionism draws attention to the effects that meanings and labels have on health and health risk behaviors.” (Mooney et al., 2016, p. 39). Pregnant women experience stigma within the healthcare system, for example, women who suffer from diabetes during pregnancy often feel shame or self-blame for their conditions. Social media and television advertisements convey the message that if you suffer from obesity, you do not take your health seriously, and you are a detriment to yourself. “The stigma felt by pregnant women is exacerbated by being labeled as ‘diabetic’ as opposed to ‘pregnant’, and by being treated in a diabetes setting rather than a usual maternity setting and believed they were not trusted by the healthcare provider.” (Parsons et al., 2018, p. 6-7).

Forsyth County outside of metropolitan area Winston Salem, North Carolina, provides three important programs I identified to reduce the rate of maternal mortality and morbidity such as special supplemental nutrition program for Women, Infants, and Children (WIC), Care Management for High-Rise Pregnancies (CMHRP), and Healthy Beginnings. Healthy Beginnings is a maternal and infant mortality reduction program for African American and Hispanic women and families in North Carolina. “The program goals include improving birth outcomes among minority women, reducing minority infant morbidity and mortality, and supporting families and communities.” (Forsyth County, n.d.)

Healthy Beginnings provides a support system program that works with moms with multiple children who need additional emotional support throughout pregnancy and during the first two years of their children’s life. While Healthy Beginnings is focused on the African American women population, 20 percent of program participants come from other ethnicities, for example, Hispanic women make up the other percentage. Families will receive high-risk care management which provides family support, resources and facilitate positive birthing outcomes. Each mother will have monthly contact with an educational parent support group called, meet-ups, also six home visits per year. “The program focuses on the following areas for the overall wellbeing of the family such as smoking cessation, folic acid consumption, reproductive health, breastfeeding, nutrition and exercise, baby safety, child development.” (Forsyth County, n.d.). Recently the program has seen a decline in Hispanic pregnant women enrolling and taking part in the program. The program director stated that the program does not have enough bilingual or Hispanic employees to serve the Hispanic population. To help ease this barrier for Hispanic women seeking prenatal, postpartum services, the program is recruiting more Hispanic health professionals, care coordinators, and program facilitators outside of Forsyth County.

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