First the facts: WHO/UNICEF/UNFPA Estimates of maternal mortality for 2005 lists the U.S. maternal mortality rate as being 11/100,000; but more recent figures show it to be 13/100,000. On the opening page of the National Center for Health Statistics “Maternal Mortality and Related Concepts” Feb. 2007 report (p. 6 of the pdf), it says that “35 percent more maternal deaths are identified through surveillance efforts than solely by the death certificate.” This discrepancy is caused by numerous factors, including different ways of assessing and coding death. If this is correct, then the current U.S. maternal mortality rate should be more like 17-18/100,000. Here are a few countries’ maternal mortality rates (but the information for all countries is there on that link; most of the countries’ numbers are estimates, due to poor or absent record-keeping in these places): Australia is 4; Belgium is 8; Brazil is 110; Burundi is 1100; Ethiopia is 720; Japan is 6; North Korea is 370, and South Korea is 14. Sierra Leone is the worst, with 2100/100,000. At the bottom of the page, it groups countries by level of development, and shows the average maternal mortality rate:
8/100,000 for industrialized countries
450/100,000 for developing countries
870/100,000 for least developed countries
So, the United States is worse than average for industrialized countries. I’m not going to engage in post-hoc arguments, but just point out some facts–the U.S. has the highest rate of obstetrician-attended birth in the world, and among the highest rates of hospital birth and C-section (if not the highest). We are the richest country in the world by just about anyone’s estimation, yet our maternal mortality rate is worse than Australia, Austria, Belgium, Bosnia, Canada, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Latvia, Malta, Netherlands, New Zealand, Norway, Poland, Slovakia, Slovenia, Spain, Sweden, Switzerland, and the former Yugoslav Republic of Macedonia. We are tied with Bulgaria, Lithuania and Portugal, and just barely edge out Luxembourg and Qatar. Why?
One factor that I have heard blamed for the U.S.’s poor standing compared to the world is the much-higher rate of maternal mortality for black women. The NCHS document I referenced above shows that in 2003 (the latest figures in the document), white maternal mortality was 8.7 while black maternal mortality was 30.5. But looking at only white births (and of course, European nations are going to be almost entirely white), the U.S. MMR is still only “average”–and we’re the richest country in the world! We have everything high-tech available, and the Emergency Medical Transport and Labor Act requires that hospitals give care to women who present to them in active labor, regardless of whether the woman can afford her care or not.
Some people blame the lack of socialized medicine, and I’m sure that lack of prenatal care does adversely affect some women; yet women who are in the lower socioeconomic brackets can get government assistance while pregnant (I worked at a pharmacy for over 5 years, and saw numerous women who did not need to be on Medicaid receiving these benefits just because they could). Some undoubtedly fall through the cracks; but there are also undoubtedly many women who simply don’t care enough about themselves or their babies to take measures–through better nutrition, getting off of drugs, etc. The higher black MMR has been blamed by some on their being more likely to be in lower socioeconomic brackets. While I do not disagree with the fact that poor people tend to be in worse health than those who are better off, I think this highlights the bias that exists against women who are poorer or who are on government assistance. It is sad that health-care providers can ignore signs and symptoms of problems in minorities or poor women that they will pick up on in white and/or well-off women. And those in the obstetric community who would say, “We can’t have the low MMR that European countries have, because we have a higher percentage of black women, and they have almost 4 times the death rate of white women.” That is simply “blaming the victim”! It is also fatalism, because this attitude suggests that this rate cannot be changed. But if this be the case, then that starts sounding like black women must somehow be genetically weaker or inferior to white women. [As an aside, I would like to know if there have been any studies of infant or maternal mortality that have had women of the same socioeconomic class, and divided by race. Are the statistics that much worse for wealthy black women, versus wealthy white women; or middle class, or lower class? Is the disparity more due to racism or "classism" by care providers against the poor or minorities, or is it simply a health or genetic thing? If it's racism, then shame on those who perpetrate it! If it's the poor health of these women, then care providers should first educate their clients on the importance of nutrition, and try to raise their clients' health in that way. I don't believe it's genetics.]
Others blame obstetric interventions that are overused, used too frequently, or used without a specific need or benefit. Routine use introduces risks without the corresponding benefit; when used specifically, interventions have a higher presumed benefit than known risk. [You can check out my posts entitled "safe motherhood" for more information on this topic.]
Even accepting the racial disparity as an unalterable fact for the moment, looking just at the white MMR, the U.S. 2003 death rate was 8.7, which puts it equal to or worse than all but about 3 of the countries mentioned above. This is unacceptable for the richest and best nation in the world!
Update — at this blog is a world map showing different maternal mortality rankings by different colors.