On October 2, 2011, after nine months of a smooth pregnancy and twenty-three hours of delivery, a perfectly healthy neonatal ICU nurse named Lauren Bloomstein died. Interviewed by National Public Radio (NPR) in 2017, Lauren’s husband Larry described a medical environment in which the health of his late wife was completely ignored (Martin and Montagne). Signs of preeclampsia, a common fatal pregnancy complication, were present early enough in Lauren’s delivery to be addressed, yet somehow hospital staff left the woman untreated. Because of this mistake, Lauren’s daughter Hailey will now grow up without her mother.
In the United States, stories like Lauren Bloomstein’s are more common than one might think. In the context of such a highly developed country, it can be easy to think of perinatal mortality as an issue only relevant in discussions of global health. Indeed, in 2017, the World Health Organization found that 86 percent of the approximately 295,000 deaths caused by pregnancy and childbirth that year occurred in Sub-Saharan Africa and Southern Asia (Maternal Mortality). While it is imperative that these devastating numbers be tackled internationally, there is also a crisis at home in the US that has gone largely unaddressed. In 2020, a study published by the Commonwealth Fund found that compared to ten other developed high-income countries, the ratio of perinatal deaths for every 100,000 live births in the United States was more than double (Tikkanen et al). Most of these deaths are completely preventable. Even further, the study found that despite an international trend toward decreasing mortality rates, perinatal deaths in the United States have actually increased since 2000 (Tikkanen et al). No pregnant person should be forced to sacrifice their own life for the birth of a child, and thus this essay aims to investigate the causes of high perinatal mortality in the United States and identify possible solutions based on the examples provided by other high-income countries.
To determine how to lower the perinatal mortality rate in the US, one must first understand exactly how and when pregnant people are dying. The Commonwealth Fund breaks pregnancy-related deaths into three periods: during pregnancy, the day of delivery, and postpartum. One-third of perinatal deaths in the US fall into the first category, 17 percent fall in the second, and 52 percent occur in the third (Tikkanen et al). Clearly, people giving birth in the United States aren’t all receiving the vital care that they need in the weeks and months following childbirth. The complications that cause perinatal deaths are varied, but the World Health Organization lists the following factors as the most common: severe bleeding, infections, high blood pressure, and unsafe abortions (”Maternal Mortality”). In the US, preeclampsia, the high blood pressure complication that killed Lauren Bloomstein, still represents 8 percent of perinatal deaths despite Britain having “reduced preeclampsia deaths to one in million” (Martin and Montagne).
The crisis cannot be fully understood without recognizing the roles of racial identity and socioeconomic status in who is most likely to be affected. A study by the Kaiser Family Foundation (KFF) found that “Black and AIAN (American Indian and Alaska Native) women have pregnancy-related mortality rates that are over three and two times higher, respectively, compared to the rate for white women” (Artiga et al). People of color and of low socioeconomic status face additional barriers to receiving proper health care during pregnancy which include “not receiving pregnancy-related care until late in a pregnancy (defined as starting in the third trimester) or not receiving any pregnancy-related care at all can also increase risk of pregnancy complications” (Artiga et al).
Furthermore, people of color are often subjected to trauma through obstetric racism in prenatal and perinatal care, a term which anthropologist Dána-Ain Davis describes as “the intersection of obstetric violence and medical racism,” including “lapses in diagnosis; being neglectful, dismissive, or disrespectful; causing pain; and engaging in medial abuse through coercion to perform procedures or performing procedures without consent” (Davis 561, 562). This stratification of perinatal care significantly affects birth outcomes for people of color and may be an important contributing factor to higher rates of perinatal mortality.
Keeping all of these factors in mind while also considering the practices of other high-income countries, the most essential step the United States must take to prevent perinatal deaths is to drastically increase the number of midwives within perinatal care. The World Health Organization found that “midwifery-led care for women with healthy pregnancies is comparable or preferable to physician-led care in terms of maternal and neonatal outcomes, including lower maternal mortality” (Tikkanen et al). The data illustrates that the countries with the lowest perinatal mortality rates are also the countries with the largest focus on midwifery-led care (Tikkanen et al.) For example, in Japan, where the perinatal mortality rate in 2020 was 5 deaths per 100,000 live births (UNICEF), almost all births are attended by midwives who oversee the majority of the labor and delivery process (Williamson and Matsuoka). In the US, where the 2020 perinatal mortality rate was 23.8 per 100,000 live births (CDC), only about 8 percent of births are attended by midwives (Healthline). To expand access to midwives, the US government must sponsor and incentivize training programs for midwives.
To ensure that all pregnant Americans have access to midwifery care as a plausible option in their birthing plans, the government must also consider adopting comprehensive, universal prenatal and perinatal healthcare coverage. Japan again provides a noteworthy example of how a policy of this kind could be implemented. In Japan, economic stratification in reproductive care is significantly reduced by the government allotting a standard amount of coverage regardless of the mode or location of delivery (Williamson and Matsuoka). Thus, pregnant people in the country have clear access to birth in whichever setting they feel most comfortable and a basic right to midwifery care. Implementing universal coverage like that of Japan will give people more autonomy and confidence in their birthing decisions, positively impacting their birth outcomes and safety during the delivery process.
Additionally, universal access to postpartum healthcare must be prioritized. Currently, Medicaid’s coverage stops after six weeks postpartum. If coverage were to expand to one year, more people could receive the postpartum care they desperately need. Access to continued home visits would “give providers an opportunity to address mental health concerns and allow them to assess social determinants of health, including needs for food, housing, financial security, and protection from domestic violence” (Tikkanen et al).
It is important to note, however, that perinatal mortality rates for people of color cannot be reduced without directly addressing the rampant problem of obstetric racism within prenatal and perinatal healthcare. After interviewing Black midwives in New York about their experiences in reproductive care, Dána-Ain Davis found that “addressing racism begins with clients being armed with information to make informed decisions about continuing or ending a relationship with a provider” (569). She found that “listening to clients and understanding the complexities of their home life, their past, and experiences that can influence a pregnancy can minimize the likelihood of obstetric racism that so often accompanies highly medicalized births” (569). Clearly, this level of personal care is more easily attained by working with a midwife whose job it is to completely understand each client and their individual needs.
The way pregnant people are treated and valued in healthcare is a direct reflection of how women and birth-givers are viewed in the larger society. Elizabeth Howell, an OBGYN professor at the Icahn School of Medicine, says that “the focus has always been on babies and not on mothers” (Martin and Montagne). Indeed, while perinatal mortality is increasing in the US, infant mortality has drastically decreased due to the large sums of money, time, and technology dedicated to the issue. In maternity wards, perinatal health advocates explain how “newborns in the slightest danger are whisked off to neonatal intensive care units, like the one Lauren Bloomstein worked at, staffed by highly-trained specialists ready for the worst, while their mothers are tended by nurses and doctors who expect things to be fine and are often unprepared when they aren’t” (Martin and Montagne). The issue is clear: the health of the birth-giver has been sidelined for too long. Until society reaches a point where pregnant people’s health issues are valued and addressed with the same commitment and fervor that infants receive, perinatal mortality will continue to be a problem in this country.
William, K. Eliza, and Etsuko Matuoka. “Comparing Childbirth in Brazil and Japan.” In Birth in Eight Cultures, ed. Robbie Davis-Floyd and Melissa Cheyney, 89-126. Waveland Press, 2019.
About the Author
Eliza Anderson is a rising sophomore at Fordham College at Rose Hill intending to double major in History and French. Originally from South Carolina, Eliza is passionate about equity in healthcare and reproductive justice. She loves movie musicals, Trivial Pursuit, and Central Park in the spring.