Claudia Cosmas
In the USA, maternal mortality has grown in recent years to reach 33 women who died from pregnancy and childbirth for every 100,000 births. A record level for almost seventy years. The gap is stratospheric compared to the G7 countries: France, the United Kingdom and Germany, for example, stop at 10-11 deaths per 100,000 births.
An age-old problem, but not for this treated adequately. It is news from the Wall Street Journal a few days ago that the United States, partly due to the pandemic, partly due to neglected risk factors, in 2021 returned to the maximum levels of maternal mortality of 1965 (1). A negative peak linked to unresolved health problems in the general population, but also to the abrupt interruption of treatments and visits in the lockdown phases at the beginning of the pandemic. Also making the spiral inexorably downward is the alarming trend of closures of obstetrics units in rural areas due to prohibitive costs and vanishing profits for hospital providers. Minority women, especially African-American and Native women, suffer the most.
The figures of the American drama are condensing in the latest report of National Center for Health Statisticsthe federal government agency specializing in the analysis of major public health issues (2).
In 2021, 1,205 pregnant women died in the US, compared with 861 in 2020 and 754 the previous year.
A sharp increase of 40% on an annual basis, which brings the maternal-mortality rate to 33 for every 100,000 births, a record level for almost seventy years. The gap is stratospheric compared to the G7 countries: France, the United Kingdom and Germany, for example, stop at 10-11 deaths per 100,000 births. COVID-19, a great amplifier of every social dynamic that tends towards dysfunction, has offered a powerful and undesired contribution. However, far from manifesting itself in the guise of an unexpected black swan, the pandemic also in this case limited itself to giving a boost and acceleration to a phenomenon that was on the launch pad even if neglected by public decision-makers. The interruption of treatment during the restriction phase was significant, pregnant women for their part found themselves exposed to severe consequences once they contracted the virus, especially when not vaccinated.
In any case, the previous twenty years had been relentless. Suffice it to say that between 2000 and 2020 the deaths of pregnant women increased by 78%. A figure that probably arouses less surprise when associated with the fragility of the health of Americans: it turns out, therefore, that 42% are obese, almost 50% suffer from hypertension, 11% from diabetes, 38% float in a condition of prediabetes. It then becomes sad, but not surprising, to take note of this surge in deaths, as Veronica Gillispie-Bell, gynecologist and associate professor at Oschner Health in New Orleans, notes in the Wall Street Journal. And although it is not unprecedented, it also represents the mirror of the inequalities that furrow American society: 30% of all pregnancy deaths concern, in fact, black women, although African Americans are only 14% of the population. As a result, the incidence is 2.6 times higher among African American women than among white women. The unfortunate cases are more frequent in the group of women over 40, but also among Hispanics.
Numbers that should fill those involved in public health in America with concern, especially if we consider that over 80% of so-called pregnancy-related deaths are avoidable. An illustrious example is pulmonary embolism, an important risk factor especially if not treated in a timely manner. A problem that brings back more than the image of a rural area of 2023, the legacy of an eighteenth-century medicine, when the anatomo-pathologist Giovanni Morgagni, encountering blood clots in the pulmonary arteries, asked himself “where does the disease start?” (3). But what was lacking then in terms of scientific knowledge deficit, and which in reality was already filled in the late nineteenth century with the first emboli removal operations developed by the German surgeon Trendelenburg, has today turned into a problem no less insidious than lack culture of prevention and organization of health services. A mix of social and assistance disparities that prevent the health problems of a pregnant woman from being addressed at the root, i.e. before the pregnancy itself.
In this regard, for an understanding of the overall picture, an in-depth article published a few weeks ago by the New York Times on the dismantling announced three days before last Christmas of the maternity unitin Toppenish, in the State of Washington, a point of reference for the local community of native women (4). A structure appreciated both in terms of outcomes and for the attention to patients and their ancestral traditions: the natives ask to give birth by facing east. The closure was experienced as a calamity: in January alone 35 women reportedly gave birth to a child. Citizens’ dismay was well-founded, if only because the provider, Astria, had bought the hospital just three years earlier, relying on the promise to maintain essential services in the following ten years: unexpected costs and a general period of demographic as well. Indeed, the Yakama Indian reservation of Toppenish is not the only victim of the decline in “labor and delivery” hospital care: between 2015 and 2019, 89 maternity units were dismantled in rural areas. In the whole United States it thus emerges that there are seven million American women of childbearing age who live in counties without birth centers, hospital units of obstetrics, obstetricians and gynecologists or who have to budget at least half an hour to travel to reach them. Ambulances and emergency vehicles, in turn, are in short supply. Being at a considerable distance from a hospital, living in a reserve scattered over millions of hectares, therefore becomes a guarantee of a long wait and trouble.
The sad confirmation is again in the mortality rate, which among pregnant natives is three times higher than white women. Such unequal destinies can be explained in the light of poor lifestyles, low incomes and chronic diseases that are mixed in the native community of Toppenish with histories of substance abuse. What deprives it of a horizon for improvement, however, is the feeling of abandonment that can derive from a sudden swerve such as the closure of hospital units. Services, which present an unresolved issue related to costs. It is the other slice of reality that emerges precisely in Toppenish, where the problem of financial sustainability has had the upper hand.
The labor and delibery unit of the Astria hospital in 2022 accumulated losses of $3.2 million. Enough to jeopardize the provision of care and assistance. Unfortunately the main payer, in the case of a hospital in a low income area, is Medicaid (the public insurance that assists the poor) which pays $6,344 for each birth versus $18,193 for a private insurance plan. It is a detail that tells a lot about the imbalance of the entire system. In the wealthiest counties, private insurance companies have an easy time compensating for the meager compensations of the government’s health care program, a pity that outside the big cities the situation changes radically. Leaving the natives of the Yakama reservation and women of many low-income non-urban areas exposed.
Jordann Loher, one of the four remaining midwives on the Indian reservation, is working on a possible solution, however partial: ask for the opening of a district public hospital financed by local taxes and surcharges, in order to re-establish a maternity unit. No easy feat, given that obstetrics and gynecology departments mean 24/7 staffing and recent understaffing is pushing hospitals to hire contract specialists, paying them three times as much… a bit what is also happening in our latitudes, especially in emergency rooms.
Solving the case of patient America remains a puzzle and, as usual, always requires more money than a hospital or a public decision-maker can budget.
Claudia Cosma, doctor in specialist training, Hygiene and Preventive Medicine, University of Florence
Bibliography
1) Sarah Toy, “U.S. maternal mortality hits highest level since 1965”, https://www.wsj.com/articles/u-s-maternal-mortality-hits-highest-level-since-1965-f9829776
2) Donna L. Hoyert, “Maternal Mortality Rates in the United States, 2021”, https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm
3) P. Michael McFadden and John L. Ochsner, “A history of the diagnosis and treatment of venus thrombosis and pulmonary embolism”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399235/
4) Roni Caryn Rabin, “Rural hospitals are shuttering their maternity units”,