According to Reuters, “Merck for Mothers” will provide $6 million to U.S. programs in 10 states and three cities aimed at decreasing the number of women who die as a result of being pregnant or giving birth. Pharmaceutical companies are not usually on my love list, but let’s take a look at why Merck is bringing their initiative to the U.S.
Other beneficiaries of this program include Zambia (440 maternal deaths per 100,000) and Uganda (310 maternal deaths per 100,000). So why is the U.S., with a comparatively paltry 17.8* maternal deaths per 100,000, on the list?
While maternal mortality has been reduced in both Zambia and Uganda even before Merck’s interventions, rates of maternal mortality in the United States are rising. In fact, they have doubled in the last 25 years. In Zambia, 85% of people earn less than a dollar a day and most women give birth in rural communities with no hospital resources and often no trained attendants. In contrast, nearly 99% of U.S. births occur in hospitals under the care of a physician or certified nurse midwife, the U.S. poverty line is $11,490 for a single person, and federal Medicaid guidelines mandate that states pay for the prenatal care and births of all women at or below 185% of the poverty line (the threshold can go up to 400% of the poverty line at the discretion of states).
- the relative wealth of people in the U.S., even among the poor
- having the most expensive maternity care in the entire world by a large margin
- paying for pregnancy and birth care for lower-income women,
the U.S. has even worse maternal mortality rates among vulnerable populations. Among African American women, the rate is triple that of whites. The overall rate and the disparities are so bad that Amnesty International published a devastating report, “Deadly Delivery,” which points out that
Maternal deaths are only the tip of the iceberg. During 2004 and 2005, more than 68,000 women nearly died in childbirth in the USA. Each year, 1.7 million women suffer a complication that has an adverse effect on their health.
The United States has among the worst maternal mortality rates of any developed nation–worse than many nations with much lower human development scores, such as Slovenia, Croatia, and Bulgaria. In 1990, our maternal mortality rates were only slightly higher than those of the two countries with the highest human development scores, Norway and Australia. The other two countries’ maternal mortality has gone down in the interim, and our rates are now three times theirs.
Some will argue that the higher rate is a product of better reporting (for instance, there is now a “pregnancy” box on death certificates). In response, Dr. Edward McCabe, medical director of the March of Dimes, says,
We’re getting better data, yes, but what these data are telling us is that we have an unacceptably high rate of pregnancy-related mortality.
The Reuters report says that “the leading maternal killers include cardiovascular disease, venous thromboembolism, hemorrhage, hypertension and sepsis.” As the report notes, deaths from cardiovascular disease in women of childbearing age are bizarre.
Though the Merck program will focus on limited regions–not the whole country–they will also work through ACOG on a national level to standardize practices in potentially-fatal obstetric emergencies. As Dr Mary D’Alton of Columbia University Medical Center says, “Variability is the enemy of safety.”
Amnesty’s “Deadly Delivery” report cites overuse of cesarean as a primary contributor to maternal mortality and morbidity. The World Health Organization does not recommend an ideal cesarean rate, but says that 15% should be considered a “threshold not to be exceeded.” The current U.S. rate is nearly 33%. According to a paper published in Health Affairs, cesarean rates “vary tenfold across hospitals, from 7.1 percent to 69.9 percent.” Among women with low-risk pregnancies (usually considered a term, singleton, head-down fetus in a mother without health complications), “cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent.”
It is unfortunate that the responsibility for investigating the quality of hospital-based maternity care and the evidence base of doctor’s practices falls to individual women. If Merck’s initiative can generate some consistency, I say bring it on.
*estimates vary considerably around this number, but this is what is in the Reuters report.