Comparing the performance of health systems around the world is difficult to do in a straightforward way. Should one look at differences in life expectancy? Disability-adjusted life years? The percentage of the population that perceives themselves to be in "good health"? We know that poverty, low education, segregation, and other social disadvantages do more to determine health outcomes than does health care. Since newborns presumably haven't had time to become unhealthy from these social factors, the infant mortality rate is commonly cited to illustrate the failure of the U.S. health care system, which has the highest spending per person in the world, but outcomes worse than those in 27 other high income nations.
But it's not only in infant deaths that the U.S. lags behind the rest of the developed world. Last year, the Institute for Health Metrics and Evaluation reported that the maternal mortality rate (the number of deaths per 100,000 births due to complications from pregnancy or childbirth) was higher in 2013 than in 2005, and more than 50 percent higher than the rate in 1990. Even though maternal deaths remain rare (occurring about once every 3600 births in the U.S., 3 or 4 times as often as in Canada and Western European countries), they should be treated like catheter-related bloodstream infections, where the goal is zero. My wife has had four children, at at no point during any of her pregnancies, labors or deliveries did I have the slightest concern that her life was in danger. That's how it should be for moms in the twenty-first century.
And that's also why I, and doubtless many others, found the recent NPR / ProPublica article "The Last Person You'd Expect to Die in Childbirth" so heartbreaking and disturbing. The article recounts the tragic story of Lauren Bloomstein, a 33 year-old neonatal nurse in good health who died of a hemorrhagic stroke in her own New Jersey hospital, 20 hours after delivering her first child. According to the authors, Bloomstein developed preeclampsia with HELLP syndrome, and her physician did not recognize the early symptoms (high blood pressure and abdominal pain) for what they were until it was too late to stop the catastrophe.
It's possible that her death may have been prevented if the hospital had implemented standardized birth safety practices described in an Atlantic article about Dr. Steve Clark, an obstetrician who previously led obstetric safety for 115 programs in the Hospital Corporation of America. But it would be a mistake to conclude from Bloomstein's tragedy that the rising U.S. maternal mortality rate is due primarily to medical errors, when it is in fact a complex public health problem. Dr. Aaron Carroll reviewed some possible causes in a JAMA Forum, including unplanned pregnancies; poor access to preventive care; the opioid epidemic; and the increased prevalence in pregnant women of obesity, hypertension, and diabetes.
Also, the rising overall rate masks persistent disparities. According to a 2010 report on maternal mortality from the Health Resources and Services Administration, non-Hispanic Black women have 3 times the risk of maternal death than White and Hispanic women; counties where 15% or more of the population lives in poverty have twice the risk as counties with a poverty rate of less than 5%; and women in New England have one-half to one-third the risk of women in the Mid- and South Atlantic states. Maternal mortality in the U.S. is largely a problem of social, economic, and geographic inequality rather than differences in health care, and we must look beyond hospitals for solutions. In the short term, it is important to prevent the U.S. Senate from passing its version of the American Health Care Act, which takes $800 billion from Medicaid, the program that pays for 31 to 72 percent of all births depending on the state, like a thief in the night. The last person you'd expect to die in childbirth? We shouldn't expect anyone to die in childbirth, and we certainly shouldn't be hastening their deaths.