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Safe Motherhood in the United States: Reducing Maternal Mortality and Morbidity

Policy Date: 11/18/2003
Policy Number: 200318

The American Public Health Association,
Recognizes that despite a dramatic decrease in maternal deaths during the early part of the 20th century, maternal mortality in the United States remains a problem that has not improved in more than 20 years;1
Recognizes that the most recent global rankings indicate that the United States ranks only 20th in maternal mortality.2
Recognizes that the Healthy People 2000 goal of 3.3 deaths per 100,000 live births is still the goal for 2010 because so little progress has been made;3
Recognizes that in 1999, the pregnancy-related mortality rate of 10.9 deaths per 100,000 live births is greater than the 1982 rate, the last year in which a decrease in maternal deaths was recorded by the Centers for Disease Control and Prevention;4
Recognizes that the leading causes of pregnancy-related deaths after a live birth are embolism (21 percent), pregnancy induced hypertension (19 percent), infection (12 percent), and cardiomyopathy (10 percent), leaving nearly half the deaths attributable to other medical conditions including complications of anesthesia (1.8 percent), and unknown (0.6 percent) causes;4
Recognizes that interventions for reducing maternal mortality and the pregnancy complications that contribute to it need to address economic, legal, psychosocial and cultural barriers that women face in obtaining timely and appropriate, quality maternal heath care;5
Recognizes that the maternal mortality rate for black women is more than 3.5 times the maternal mortality rate for white women, the largest black/white disparity of any maternal and child health indicator;4,6
Recognizes that the ratios for Latinas, Asian and Pacific Islander Americans and American Indian/Alaska Natives are also higher than for whites, though lower than for African Americans;1
Recognizes that the Centers for Disease Control and Prevention (CDC) has collaborated with the American College of Obstetricians and Gynecologists (ACOG) the Association of Vital Records and Health Statistics, and state and local health departments, and other provider organizations since 1987 to operate the national Pregnancy Mortality Surveillance System (PMSS) to contribute to the reduction of pregnancy morbidity and mortality in the United States;7
Recognizes that one study of the PMSS found underreporting of pregnancy related mortality is gradually being reduced by using multiple reporting sources to identify cases of pregnancy associated mortality, mortality case reviews by pregnancy mortality review boards and an expanded definition of pregnancy-associated maternal deaths that occur any time up to one year after pregnancy;7
Recognizes that the addition of check boxes on death certificates to note deaths due to pregnancy became important as a criterion for helping to identify pregnancy-related deaths;
Recognizes that to better understand the enigma of maternal mortality, there is a need to increase our knowledge and understanding of maternal morbidity,8 to allow communities and public health agencies to make unbiased recommendations regarding needed changes in clinical practice and to address community barriers that contribute to poor or late maternity care;
Recognizes that the key to success of pregnancy mortality review boards is their independence from undo influence of fear of malpractice litigation, and their inclusion of community-based participants who can clarify local circumstances surrounding the cases;
Recognizes that risk factors for maternal mortality and morbidity that have been identified by Florida's Perinatal Mortality Review Board include: 1) history of medical problems; 2) nutrition problems; 3) substance use; 4) lack of or delay in prenatal risk assessment;
5) lack of social support; 6) problems with housing; 7) mental health problems; 8) family violence or neglect; 9) environmental or occupational hazards; and 10) family planning or contraceptive method related concerns;9
Recognizes that one review of pregnancy-related deaths has indicated that there is a need for enhanced surveillance and case review activities that identify all pregnancy-related deaths and collect adequate information to characterize the deaths, and identify health care, economic, legal, social and cultural barriers that could be reduced;9
Recognizes that multidisciplinary review teams have identified a number of gaps in medical care, systemic service delivery problems, and areas in which linkages between community resources. Communities with these poor linkages have the following issues: lack of care coordination and appropriate care for high-risk women; lack of timely and appropriateness of transfers to higher level care facilities; lack of care provisions for incarcerated women; delay in diagnosis and treatment by providers; lack of postpartum follow-up care; delayed response to emergency situations by providers; and lack of post-partum maternal education;9 and
Recognizes that strategies to increase women’s access to maternal health care are most effective when they are locally developed and result from listening to women themselves.10
Therefore, APHA:
1. Supports increasing federal, state, and local funding for and support to implement the CDC recommendations to develop and implement independent pregnancy mortality review boards in every state;
2. Encourages these review boards to use the multiple sources of data, CDC expanded definition of pregnancy-associated maternal deaths in their identification of cases, and standard guidelines on their formation and functioning;
3. Supports funding for programs focused on increasing access to timely and appropriate quality health care for all women free from economic, legal, psychosocial and cultural barriers;
4. Encourages maternity care professionals to revise standards of practice and practice guidelines based on evidence from independent maternal mortality reviews;
5. Supports serum pregnancy tests for all childbearing women who are autopsied;
6. Encourages participation in the Safe Motherhood Quilt project;11 and
7. Calls on Congress, the U.S. Department of Health and Human Services, state legislatures, and health agencies to increase funding for surveillance and research into identifying and reducing clinical, economic, legal, psychosocial and cultural factors, including violence during and after pregnancy, that contribute to maternal mortality and morbidity, poor maternal care practices, and evaluations of interventions.
1. Bennett TA, Adams MA. Safe motherhood in the United States: Challenges for surveillance. Maternal and Child Health Journal 2002: 6(4):221-226.
2. World Health Organization. Maternal mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA, Geneva Switzerland: WHO/RHROI.9, 2001.
3. Healthy People 2010 Objectives.
4. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, Syverson CJ. Pregnancy-related mortality surveillance – United States 1991-1999. MMWR Surveillance Summaries February 21, 2003 / 52(SS02);1-8.
5. Safe Motherhood Initiative: Priorities for Safe Motherhood. Available at: www.safemotherhood.org/smpriorities/index.html; Accessed on April 23, 2003.
6. Berg CJ, Chang J, Callaghan W, Whitehead SJ. “Pregnancy-Related Mortality in the United States, 1991-1997.” Obstetrics and Gynecology 2003; 101:289-296.
7. Atrash HK, Lawson HW, Ellerbrock TV, Rowley DL, Koonin L. Pregnancy-related mortality. In From Data to Action: CDC’s Public Surveillance for Women, Infants and Children. Atlanta GA: CDC, 1995; pp 141-154.
8. Danel I, Berg C, Johnson CH, Atrash H. Magnitude of maternal morbidity during labor and delivery, United States, 1993-1997. AJPH 2003;93:631-634.
9. Florida Department of Health. Pregnancy Associated Mortality Review (PAMR): PAMR Data Report 1997. 1st Quarter 1999.
10. Declercq ER, Sakala C, Corry MP, Applebaum S, Risher P. Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, October 2002.
11. Safe Motherhood Quile, a project of the Safe Motherhood Initiative–USA. Available at: http://www.rememberthemothers.org; accessed June 16, 2003.