In November Serena Williams, indisputably one of the greatest – if not the greatest – tennis player in history gave birth to her daughter by emergency Caesarean section. After the surgery, Williams reported to an attending nurse that she was experiencing shortness of breath and immediately assumed she was experiencing pulmonary embolism. The star athlete has a history of blood clots and had discontinued blood thinners before the surgical delivery. Contrary to William’s requests for a CT scan and blood thinners, medical staff assumed that pain medication had made her confused. A later CT scan confirmed Williams’ self-diagnosis. Stripping out the fact of Williams’ identity turns this near-miss into a terrifyingly common story in US maternal care, albeit one with a happier ending than many. The global trend in maternal death rates – the rate of women dying in childbirth and post-childbirth – has rapidly decreased over the past 15 years. At the same time, the US, despite recording one of the highest per capita income levels in the world, has one of the highest maternal mortality rates in the developed world.
There are some disputes over what counts as maternal death, and what doesn’t, with different institutions using different criteria to determine whether a death falls within the category or not. The WHO reports that the severe bleeding, infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia) complications from delivery and unsafe abortion rank as the highest causes of maternal death globally. The causes of even these issues engage an extremely broad array of individual, institutional and systemic issues. The vista of causation and prevention for complications in pregnancy is extremely wide and troublingly complex, and all manner of policy decisions – often quite remote – have a direct bearing on the risk of death during pregnancy or childbirth. Part of the project of maternal and pregnancy advocacy lies in drawing the links between discrete policy decisions and the likelihood that a woman will die in pregnancy. Many of these causes are systemic – for example, maternal mortality rates are twice as high for women living in areas with high rates of poverty when compared with areas of low poverty. The breakdown of causes within these tranches is less clear – poor maternal nutrition, poor sex education and poor access to healthcare institutions are all indicated as likely contributors to the phenomenon. Consistent access to healthcare increases the likelihood that risk is identified and managed during pregnancy; conversely, the inaccessibility to many of continuous health monitoring during pregnancy increases risk of harm or death. According to the CDC, heart-related problems are involved in a substantial number of pregnancy-related deaths – high blood pressure and heart disease featuring as the likeliest suspects. The obesity epidemic therefore may play a role in the increased rate.
None of these issues can ever be the full story of what is happening to pregnant women in the US, because none of these issues float independently of one another, or of economic and social structures. Obesity and poor healthcare access both track with poverty, which dulls the potential effect of concentrating on individual health when it comes to resolving the rate of women dying in, or after childbirth. The role played by race and racism is another understudied and extremely worrying aspect of the US record on maternal death. Black women die at a rate that is 3 to 4 time higher than the corresponding rate for white women in the US, a rate that rivals the maternal statistics of Uzbekistan and Mexico according to the World Health Organisation. The phenomenon persists when wealth is controlled for – one analysis of NYC maternal death patterns reports that college-educated black women are more likely to suffer severe birth complications than white women who haven’t completed high school. Focusing on maternal death as a medical matter alone cannot hope to account for these wild discrepancies in death across demographics.
The politicised nature of attendant healthcare is another factor in maternal death in the US. Access to contraception is a strong determinant of risk, not simply because it prevents pregnancy (this much is obvious) but because it increases the likelihood that a pregnancy is planned and considered, which correlates with the opportunity to confront healthcare decisions and pre-plan an approach to managing pregnancy on the part of patients. The ability to offer abortion, and safe abortion is another, as it ensures that women and their healthcare providers can manage risk in pregnancy more safely and expediently than in scenarios where even dangerous pregnancies must be carried to term, often where the pregnancy is generating a serious risk to the health of the woman, but not necessarily to her life – yet. In a terrifying example of policy in action, Texas’ maternal mortality rate more than doubled from 2010 to 2014, as the state gutted funding to Planned Parenthood and closed more than half of its abortion clinics.
Treating maternal death as a medical issue, or as an individualized issue are both too shallow an approach to lead to real resolution of the USA’s climbing maternal mortality rate and appropriately protect women. As many as 98% of maternal deaths are preventable. The real issue is that the prevention needed strikes close to the heart of interlocking systems of poverty, racial discrimination and gender discrimination. The call to action for advocates is to systematically chip away at the scaffolding of these issues in systemic discrimination as much as it is to focus on discrete pregnancy-focused policy. Political decisions, both those which are tailored towards pregnancy and birth, as in the case of contraception and abortion access, and those which are addressed more generally, as in the case of wealth and poverty politics, must be scrutinized and criticized to move the needle on the US’ record.