Personal Perspective

Maternal mortality: beyond overmedicalized

solutions
Katie R. Allan, MPP

Maternal deaths, particularly racial disparities in maternal deaths, represent a deeper problem than their medicalized solutions reflect—
one deeply rooted in the devaluation of women’s well-being, institutional inequality, and racism. Most policy solutions for addressing
maternal mortality involve actionable goals within the purview of healthcare providers, medical institutions, and insurance providers.
Although we should continue studying the causes of maternal mortality through maternal mortality review committees, reducing racism in
medicine with implicit bias training, and standardizing pregnancy care, there is a pressing need to challenge the processes and in-
stitutions that lead to health inequities. A woman’s income level, insurance status, housing stability, country of origin, gender identity, or
skin color should not dictate how likely she is to die from a pregnancy-related cause.

Maternal mortality in the United States for white women is 12.4 deaths for every 100,000 live births,

I f maternal mortality is a core indicator of a country’s

health, the United States is very sick. For every 100,000
live births, 17 new mothers die.1 Of the 4 million women who
give birth each year in the United States, more than 700 die,
and another 50,000 experience near-fatal complications.2 The
United States is the only industrialized country in which the
maternal mortality ratio is rising.3
The United States has not always done so poorly by its
mothers. Between 1900 and 1982, maternal mortality ratios
fell from 850 maternal deaths per 100,000 live births to 7.5, a
99% decrease.4 However, despite a century of progress, the
maternal mortality ratio increased by 26.6% between 2000
and 2014. This is attributed to three main factors. First,
reporting of maternal deaths has increased in recent decades.
Second, chronic conditions such as diabetes, heart disease,
and high blood pressure contribute to an increased risk of
maternal mortality, leading to higher rates of maternal deaths
attributable to these preventable diseases. Third, the average
age of mothers is increasing: older women are more likely to
experience serious complications during childbirth than
younger women.5 There are opportunities to prevent over
60% of all maternal deaths, including a majority that occur in
the postpartum period.6
However, these general statistics do not tell the whole story.
Alongside increasing overall maternal mortality, the gap be-
tween maternal deaths in black and white women plateaued
in the last 6 decades.7,8 Although the maternal mortality ratio
Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor,
MI.
Received Aug. 30, 2019; accepted Sept. 22, 2019.
The author reports no conflict of interest.
Corresponding author: Katie R. Allan, MPP krallan@umich.edu
2589-9333/$36.00
ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajogmf.2019.100047
for black women it is 40 deaths for every 100,000 live births.2
Nationally, black women face a nearly 4-fold higher risk of
dying in childbirth than their white counterparts, despite
similar rates of major pregnancy complications.9 In some
cities, black women are 8 times more likely to die in child-
birth than white women.10
The maternal mortality ratio among black women far ex-
ceeds epidemic proportions: such death rates for any other
condition would lead to mobilization of healthcare resources
and national policy change. However, policy proposals for
addressing maternal mortality have thus far been largely
incommensurate with the problem.
Policy landscape: healthcare-focused policy
solutions
The primary routes through which maternal mortality is
addressed include maternal mortality review committees
(MMRCs), care bundling, and care standardization or safety
initiatives. Maternal mortality review committees are boards
with experts who review circumstances leading to deaths that
may be related to childbearing or childbirth. As of July 2018,
35 states had MMRCs. Care bundling is an alternative to the
typical fee-for-service reimbursement model, instead incen-
tivizing efficiency and coordination across the care contin-
uum by combining all services provided from the prenatal to
postpartum period into a single fixed rate.11 Care standardi-
zation and safety initiatives focus on a similarly clinical level,
aiming to drive quality improvement in individual birthing
facilities or across states by establishing best practices and
training providers to provide better maternity care.12
Recent legislative proposals: The Maternal CARE Act
and Elizabeth Warren’s plan
In August 2018, Senator Kamala Harris (DeCA) intro-
duced the Maternal Care Access and Reducing Emergencies
Act (the Maternal CARE Act), allocating $5 million to im-
plicit bias training for health professionals and $25 million for
state-based grants over 5 years to establish pregnancy medical
FEBRUARY 2020 AJOG MFM 1
Personal Perspective
homes for integrated prenatal healthcare. Although this bill
addresses the role of racism in disparities in maternal mor-
tality, it still focuses primarily on medical solutions. In April
2019, Senator Elizabeth Warren (DeMA) proposed a simi-
larly clinical plan to address racial disparities in maternal
mortality rates: she proposed making a portion of medical
provider funding contingent upon the quality of care that
they provide to mothers, with a particular focus on black
mothers. Like so many other policy proposals before it,
Senator Warren’s plan focuses primarily on healthcare pro-
viders and their role in pregnancy care.
Gaps in policy: a result of overmedicalization of
maternal mortality
These attempts to reduce maternal mortality medicalize a
problem that exists largely outside the scope of medical
practice. Although these are necessary and urgent ways to
promote maternal health, a person’s medical record does not
exist insulated from its environment. Overmedicalizing
maternal mortality ignores upstream drivers of maternal
deaths and instead focuses only on micro-level causes of
death.
Some MMRCs do consider community-level factors that
influence maternal deaths. The Centers for Disease Control
and Prevention (CDC) Division of Reproductive Health and
the CDC Foundation use geospatial information to identify
community- and neighborhood-level factors that contribute
to maternal deaths. Other review boards interview families
and communities affected by maternal deaths; the Virginia
Pregnancy-Associated Mortality Review uses a reproductive
justice framework to guide their processes. However,
although some MMRCs are positioned to make clinical rec-
ommendations to reduce maternal mortality rates, there are
few mechanisms to address how social determinants of health
(or their upstream causes) impact maternal health.13 MMRCs
often provide recommendations for training improvement,
increased access to care, better patient/provider communi-
cation, and prevention initiatives, but rarely make recom-
mendations that address social determinants in part due to a
“misperception of, discomfort with, or lack of experience
discussing the role community conditions play in maternal
health.”14
Reproductive health is shaped by legal, educational, eco-
nomic, and medical institutions. Maternal health is also
shaped by racism within and without medical institutions,
which puts added stressors—from microaggressions to fear of
being killed in one’s own home—on black and brown
bodies.15 Those same people are then blamed for causing
their own health problems, presumed to feel less pain than
white people, and treated as simultaneously superhuman and
incompetent.16 Policies that begin and end in healthcare do
not adequately acknowledge and address the trauma that
people of color experience as a result of institutionalized
racism, both inside and outside medical institutions.
Although the end result of centuries-worth of racist policies
are disparate health outcomes and bias in medical practice,
2 AJOG MFM FEBRUARY 2020
the root of these issues is not fundamentally medical. Clinical
solutions alone are insufficient if the goal is health equity at
the population level.
Nonclinical strategies to address maternal mortality
Addressing these root causes—not just the symptoms—of
inequity requires broad policy solutions that attend to eco-
nomic equality, educational opportunity, and career access
through a lens of racial and reproductive justice. These policy
solutions must emphasize the nonmedical aspects of child-
birth and women’s health in order to establish a systems-level
approach that improves quality and equity women’s
healthcare.17
Research
Researchers should continue to investigate the impacts of
inequities in housing, neighborhoods, pollution, education,
socioeconomic status, and economic opportunity on
maternal health. Gaps remain in knowledge about how a
woman’s health across her life influences her risk of maternal
mortality or morbidity. Specifically, continued research on
the effects of racism, sexism, and classism on disparities in
maternal mortality is necessary. Research on how intersec-
tional identities impact health has grown in recent decades:
that trend should continue.
Sex education
Sex education varies widely across the United States. Sex
education—coupled with access to effective contraception—
reduces unintended pregnancies and their associated poor
health outcomes for both women and their children.18 In
developing countries, sex education has been associated sig-
nificant decreases in maternal mortality: ensuring that all
people across the country have access to comprehensive sex
education provides the information necessary to make
informed reproductive decisions and to enable women and
girls to better plan or space pregnancies that they choose to
have.19
Legislation
Legislative solutions for improving maternal health often
focus on the prenatal period. Although Medicaid has
expanded eligibility criteria for pregnant women, this
coverage extends only 60 days after childbirth, despite the fact
that women are still at risk for complications or death related
to pregnancy up to 1 year after pregnancy. Legislators could
expand Medicaid for pregnant women further into the
postpartum period, particularly for women at high risk for
postpartum complications. Preconception care is equally
important: the most important prenatal visits may be those
before a woman conceives.
Economic inequality is at the root of racial disparities in
maternal health, like the disparities in health outcomes be-
tween white people and people of color. Baby bonds,20 uni-
versal basic income, and further investment in the Earned
Income Tax Credit could help eliminate socioeconomic

disparities in maternal mortality, as could providing paid
parental leave and extending the Supplemental Nutrition
Assistance Program’s expanded eligibility for pregnant
women into the postpartum period. Given that 45% of the
women who die in pregnancy do so in the first 42 days after
birth (and another 18% die within 43 days to 1 year),6 sup-
porting women’s health in the postpartum period will
improve the health of mothers and babies. Alongside these
policy changes, continued research is necessary to verify
whether these proposed solutions improve maternal health
indicators.
It is essential that legislators, researchers, doctors, and
journalists integrate community-based reproductive justice
and women’s health organizations that have been doing this
work for decades. Although such organizations—and the
women most at risk for dying from childbirth—should not
bear the burden of ending maternal mortality, their voices,
expertise, and experience are indispensable in reducing pre-
ventable maternal mortality and racial inequity in maternal
outcomes.14 - Programs 2018. Available at: http://www.amchp.org/AboutAMCHP
REFERENCES
1. World Data Bank. Maternal mortality ratio. World Bank. Available at:
https://data.worldbank.org/indicator/SH.STA.MMRT?locations¼FI-VE&year
_high_desc¼false. Accessed August 30, 2019.
2. Maternal Care Access and Reducing Emergencies Act (Maternal
CARE Act), S. ERN18510, 115th Cong., 10 (2018).
3. American College of Obstetricians and Gynecologists. Maternal
Mortality. Available at: https://www.acog.org/About-ACOG/ACOG-
Departments/Government-Relations-and-Outreach/Federal-Legislative-
Activities/Maternal-Mortality?IsMobileSet¼false. Accessed August 30,
2019.
4. Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mor-
tality surveillance—United States, 1987e1990; Morbidity and Mortality
Weekly Report. Obstet Gynecol 1996;88:161–7.
5. Mathews TJ, Hamilton BE. First births to older women continue to rise.
NCHS Data Brief 2014;152.
6. CDC Foundation. Report from nine maternal mortality review com-
mittees. Available at: https://www.cdcfoundation.org/sites/default/files/
files/ReportfromNineMMRCs.pdf. Accessed August 30, 2019.
7. Grobman W, Bailit JL, Rice MM, et al. Racial and ethnic disparities in
maternal morbidity and obstetric care. Obstet Gynecol 2015;125:1460–7.
8. Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic
disparities in obstetric outcomes and care: prevalence and determinants.
Am J Obstet Gynecol 2010;202:335–43.
Personal Perspective
9. Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The black-white disparity
in pregnancy-related mortality from five conditions: differences in preva-
lence and case-fatality rates. Am J Public Health 2007;97:247–51.
10. New York City Press Office, 2018. De Blasio administration
launches comprehensive plan to reduce maternal deaths and
life-threatening complications from childbirth among women of color.
Available at: https://www1.nyc.gov/office-of-the-mayor/news/365-18
/de-blasio-administration-launches-comprehensive-plan-reduce-maternal-
deaths-life-threatening. Accessed August 30, 2019.
11. Lally S. Transforming maternity care: a bundled payment approach,
2013;10. Available at: https://www.iha.org/sites/default/files/resources/
issue-brief-maternity-bundled-payment-2013.pdf. Accessed August 30,
2019.
12. American College of Obstetricians and Gynecologists. Alliance
for Innovation on Maternal health. Available at: https://www.
acog.org/About-ACOG/ACOG-Departments/Patient-Safety-and-Quality-
Improvement/What-is-AIM?IsMobileSet¼false. Accessed August 30,
2019.
13. Centers for Disease Control and Prevention. Social determinants of
health: know what affects health. Available at: https://www.cdc.gov/
socialdeterminants/index.htm. Accessed August 30, 2019.
14. Cornell A. How maternal mortality review committees can begin
advancing health equity now. Association of Maternal and Child Health
/Newsletters/Pulse/MarchApr18/Pages/How-Maternal-Mortality-Review-
Committees-Can-Begin-Advancing-Health-Equity-Now.aspx. Accessed
August 30, 2019.
15. Pearson C. Black women face more trauma during childbirth.
Huffington Post 2018. Available at: https://www.huffpost.com/entry/
black-women-childbirth-mortality-trauma_n_5b045eaae4b0784cd2af0f71.
Accessed August 30, 2019.
16. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain
assessment and treatment recommendations, and false beliefs about
biological differences between blacks and whites. Proc Natl Acad Sci U S
A 2016;113:4296–301.
17. Kozhimannil K, Hardeman R, Henning-Smith C. Maternity care ac-
cess, quality, and outcomes: a systems-level perspective on research,
clinical, and policy needs. Semin Perinatol 2017;41:367–74.
18. Guttmacher Institute. Unplanned births associated with less prenatal
care and worse infant health, compared with planned births: greater
attention needed on consequences of unplanned childbearing. 2015.
Available at: https://www.guttmacher.org/news-release/2015/unplanned-
births-associated-less-prenatal-care-and-worse-infant-health-compared.
Accessed August 30, 2019.
19. Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by
contraceptive use: an analysis of 172 countries. Lancet 2012;380:
111–25.
20. Hamilton D, Darity W Jr. Can ‘baby bonds’ eliminate the racial wealth
gap in putative post-racial america? Rev Black Polit Econ 2010;37:
207–16.
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