WHEP Scholar Christine Quake
Drexel University College of Medicine

In 1950, a note published in the Journal of the American Medical Association entitled "Maternal Deaths—One In A Thousand" celebrated that maternal mortality rates had been reduced to just "1 maternal death per 1,000 live births." In 1999 the CDC announced that the reduction of maternal mortality from 800-900 maternal deaths per 100,000 live births in 1900 to a remarkable 10-20 deaths per 100,000 live births was ranked among the top 10 medical achievements of the 20th century. Unfortunately, the number of reported pregnancy-related deaths in the United States has steadily increased from 9.8 deaths per 100,000 live births in 1999 to 21.5 deaths per 100,000 in 2014. This translates to approximately 700 women dying each year from complications from pregnancy or childbirth. This increase in maternal mortality is particularly striking because globally maternal mortality has been drastically decreasing by 44%. Furthermore, when compared to peer nations, a woman is more likely to die from pregnancy related causes in the United States than any other developed country worldwide. This means that the United States is the most dangerous country to deliver a baby in modernized societies.

From increasing maternal age to increasing number of mothers with chronic health conditions to decrease access to medical care, there are a multitude of risk factors that can help to explain as to why maternal mortality is on the rise in the United States. However, these factors are not unique to the US as these trends can be observed in other developed countries. Thus, these trends fail to explain why mortality rates are specifically increasing in the United States while decreasing globally. As a health care system there are many systemic problems that play a role in maternal mortality. Nevertheless, it is important to recognize that the US maternal mortality and morbidity rates are encapsulated by a greater American culture and scaffold interlocked with systems of gender and racial discrimination. Thus, one cannot discuss maternal mortality rates without discussing it within the greater context of systemic and systematic gender and racial discrimination that plague the United States.

According to the CDC, 60% of maternal deaths in the United States are preventable and occur due to mismanagement of complications and delays in diagnosis and appropriate treatment. All too frequently pregnant women's symptoms are minimized and dismissed by nursing and physicians of both genders. It is important to consider that how women communicate influences management of complications that ultimately informs maternal outcomes. Despite being patients, women continue to navigate the gendered double standards society has created. For instance, it is commonplace that women try not to "be a burden" or "high maintenance" or many other unfavorable labels. To avoid being labeled such things, women commonly belittle their pain or omit saying anything at all, possibly masking early warning signs of looming complications, delaying intervention. Consequently, societal gendered constructs that inform women's behaviors both in and out of the hospital can engender silence that is possibly deadly in the case of maternal health. Moreover, when a woman ignores the possible consequence of being labeled unfavorably and mentions her pain, she may not only be judged unfairly but her plea for help may fall on the deaf ears of biased medical professionals who make biased assumptions.

The disproportionate rate of African American maternal death is arguably the central reason why the U.S. maternal mortality rate is so much higher than that of other developed countries. African American women are 3 to 4 times more likely to die from pregnancy related causes than their Caucasian counter parts. African American women living in poverty encounter socioeconomic barriers to health care and healthy living:

• They are less likely to be insured prior to pregnancy, which often means prenatal care is delayed.
• New mothers lose their Medicaid coverage sometimes within 60 days of giving birth, increasing perinatal and post-partum risks.
• They are more likely to have chronic health conditions such as high blood pressure, obesity, and diabetes which all complicate pregnancy.
• Hospitals that serve predominantly African American populations in impoverished neighborhoods provide lower quality of care, which means there are more life-threatening complications at those hospitals compared to hospitals that care for a greater Caucasian demographic.

However, even when controlling for wealth, the disparity persists. It is imperative to recognize that providers' biases are amplified when taking care of minority women, especially African Americans. One third of African Americans report feeling personally discriminated against during a doctor's visit and 22% actually avoid seeking medical care because of discrimination.

Without a doubt, maternal morbidity and mortality is a complex, multi-factorial problem that requires better data to inform solutions. Biases and discrimination are fundamentally at the core of maternal morbidity and mortality. This does mean that for maternal health care to improve, the health care system needs to acknowledge, accept responsibility, and address gender biases and racism. Systemic changes need to occur in hospitals and at policy levels including improved access to health care. However, one an individual level, if providers from nurses to doctors to support staff can recognize and confront their own implicit and explicit biases and fears, care will improve, lives will be saved, and America's moms will be in safer hands.