Question: What percentage of women in the U.S. die from complications during birth?

Maternal mortality in the United States

 Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this only includes causes related to her pregnancy and does not include accidental causes.[1] Some sources will define maternal mortality as the death of a woman up to 42 days after her pregnancy has ended, instead of one year.[2] In 1986, the CDC began tracking pregnancy related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System.[1] Although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.[3] The CDC reported an increase in the maternal mortality ratio in the United States from 18.8 deaths per 100,000 births to 23.8 deaths per 100,000 births between 2000 and 2014, a 26.6% increase;[4] and in 2016, as many as 900 women between the ages of 16 and 43 died from pregnancy- and childbirth-related causes.[5] It is estimated that 20-50% of these deaths are due to preventable causes, such as: hemorrhage, severe high blood pressure, and infection.[6]
Monitoring maternal mortality
In 1986, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) created the Pregnancy-Related Mortality Surveillance System to monitor maternal deaths during pregnancy and up to one year after giving birth. Prior to this, women were monitored up to 6 weeks postpartum.[1]
In 2016 the CDC Foundation, the Centers for Disease Control and Prevention (CDC) and the Association of Maternal and Child Health Programs (AMCHP) undertook a collaborative initiative—"Building U.S. Capacity to Review and Prevent Maternal Deaths"— funded by Merck under the Merck for Mothers program. They are reviewing maternal mortality to enhance understanding of the increase in the maternal mortality ratio in the United States, and to identify preventative interventions.[7] Through this initiative, they have created Review to Action website which hosts their reports and resources. In their 2017 report, four states, Colorado, Delaware, Georgia, and Ohio, supported the development of the Maternal Mortality Review Data System (MMRDS) which was intended as a precursor to the Maternal Mortality Review Information Application (MMRIA).[8] The three agencies have partnered with Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah to collect data for the Maternal Mortality Review Information Application (MMRIA); the nine states submitted their first reports in 2018.[9]

After decades of inaction on the part of the U.S. Congress towards reducing the maternal mortality ratio, the United States Senate Committee on Appropriations voted on June 28, 2018 to request $50 million to prevent the pregnancy-related deaths of American women.[10] The CDC would receive $12 million for research and data collection. They would also support individual states in counting and reviewing data on maternal deaths.[10] The federal Maternal and Child Health Bureau would receive the remaining $38 million directed towards Healthy Start program and "life saving, evidence-based programs" at hospitals.[10] MCHB's Healthy Start was mandated to reduce the infant mortality rate.[11]
Measurement and data collection
According to a 2016 article in Obstetrics and Gynecology by MacDorman et al, one factor affecting the US maternal death rate is the variability in calculation of maternal deaths. The WHO deems maternal deaths to be those occurring within 42 days of the end of pregnancy, whereas the United States Pregnancy Mortality Surveillance System measures maternal deaths as those occurring within a year of the end of pregnancy.[4] Some states allow multiple responses, such as whether death occurred during pregnancy, within 42 days after pregnancy, or within a year of pregnancy, but some states, such as California, ask simply whether death occurred within a year postpartum.[4]
In their article, the authors described how data collection on maternal mortality rates became an "international embarrassment".[4][12]:427 In 2003 the national U.S. standard death certificate added a "tick box" question regarding the pregnancy status of the deceased. Many states delayed adopting the new death certificate standards. This "muddied" data and obstructed analysis of trends in maternal mortality rates. It also meant that for many years, the United States could not report a national maternal mortality rate to the OECD or other repositories that collect data internationally.[4][12]:427
In response to the MacDorman study, revealing the "inability, or unwillingness, of states and the federal government to track maternal deaths",[5] ProPublica and NPR found that in 2016 alone, between 700 and 900 women died from pregnancy- and childbirth-related causes. In "Lost Mothers" they published stories of some of women who died. They ranged in age from 16 to 43.[5]
Healthy People is a federal organization that is managed by the Office of Disease Prevention and Health Promotion (ODPHP) at the U.S. Department of Health and Human Services (HHS). In 2010, the US maternal mortality ratio was 12.7 (deaths per 100,000 live births). This was 3 times as high as the Healthy People 2010 goal, a national target set by the US government.[13]
According to a 2009 article in Anthropology News, studies conducted by but not limited to Amnesty International, the United Nations, and federal programs such as the CDC, maternal mortality has not decreased since 1999 and may have been rising.[14]
By November 2017, Baltimore and Philadelphia, and New York City had established committees to "review deaths and severe complications related to pregnancy and childbirth" in their cities to prevent maternal mortality. New York's panel, the Maternal Mortality and Morbidity Review Committee (M3RC) doctors, nurses, "doulas, midwives and social workers".[15] New York City will be collaborating with the State of New York, the first such collaboration in the US.[15] In July 2018, New York City's de Blasio's administration announced that it would be allocating $12.8 million for the first three years of its five-year plan to "reduce maternal deaths and life-threatening complications of childbirth among women of color".[16]
Causes
Medical causes

Maternal death can be traced to maternal health, which includes wellness throughout the entire pregnancy and access to basic care.[17] More than half of maternal deaths occur within the first 42 days after birth. Race, location, and financial status all contribute to how maternal mortality affects women across the country.
In response to the high maternal mortality ratio, in 2013 the Department of State to created the Maternal Mortality and Morbidity Task Force.  According to Amnesty International's 2010 report, five medical conditions collectively account for 74% of maternal deaths in the US.
Embolism (blood clots)
Hemorrhage (bleeding)
Pre-eclampsia
Infection
Cardiomyopathy [18]
Postpartum depression is widely untreated and unrecognized, leading to suicide. Suicide is one of the most significant causes of maternal mortality,[19] and reported to be the number one cause by many studies.[20]
Social factors
Social determinants of health also contribute to the maternal mortality rate. Some of these factors include access to healthcare, education, race, and income.[21]
Access to healthcare
Women in the US usually meet with their physicians just once after delivery, six weeks after giving birth. Due to this long gap during the postpartum period, many health problems remain unchecked, which can result in maternal death.[22]  Just as women, especially women of color, have difficulty with access to prenatal care, the same is true for accessibility to postpartum care. Also, postpartum depression can also lead to untimely deaths for both mother and child.[22]
Insurance companies reserve the right to categorize pregnancy as a pre-existing condition, thereby making women ineligible for private health insurance. Even access to Medicaid is curtailed to some women, due to bureaucracy and delays in coverage (if approved). Many women are turned down due to Medicaid fees, as well. Women have also reported access and mobility as reasons why they are unable to seek prenatal care, such as lack of transportation and/or lack of health insurance. Women who do not have access to prenatal care are 3-4 times more likely to die during or after pregnancy than women who do.[23]
Education
It has been shown that mothers between ages 18 and 44 who did not complete high school had a 5% increase in maternal mortality versus women who completed high school.[23]
Race
African American women are four times as likely to suffer from maternal morbidity and mortality than Caucasian women,[3] and there has been no large-scale improvement over the course of 20 years to rectify these conditions.[24] Furthermore, women of color, especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English", are deterred from seeking the care they need, due to discrimination.[3]
Income
Studies have shown that women are affected by the stress of being lower income, which then affects their pregnancies and unborn babies. In the US, women of color disproportionately experience stress related to financial burdens and racism when trying to gain access to healthcare. These women have a harder time maintaining or gaining access to healthy nutrition and even safe housing. These social factors are directly linked to the outcome of maternal care.
It is estimated that 99% of women give birth in hospitals with fees that average between $8,900-$11,400 for vaginal delivery, and between $14,900-$20,100 for a cesarean.[3] Many women cannot afford these high costs, nor can they afford private health insurance, and even waiting on government-funded care can prove to be fatal, since delays to coverage usually result in women not getting the care they need from the start.
Other risk factors
Some other risk factors include obesity, chronic high blood pressure, increased age, diabetes, cesarean delivery, and smoking. Attending less than 10 prenatal visits is also associated with a higher risk of maternal mortality.[23]
The Healthy People 2010 goal was to reduce the c-section rate to 15% for low-risk first-time mothers, but that goal was not met and the rate of c-sections has been on the rise since 1996, and reached an all-time high in 2009 at 32.9%. Excessive and non-medically necessary cesareans can lead to complications that contribute to maternal mortality.[3]
Prevention
Inconsistent obstetric practice,[25] increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the United States. According to a 2015 WHO editorial, a nationally implemented guideline for pregnancy and childbirth, along with easy and equal access to prenatal services and care, and active participation from all 50 states to produce better maternal health data are all necessary components to reduce maternal mortality.[26] The Hospital Corporation of America has also found that a uniform guideline for birth can improve maternal care overall. This would ultimately reduce the amount of maternal injury, c-sections, and mortality. The UK has had success drastically reducing preeclampsia deaths by implementing a nationwide standard protocol.[25] However, no such mandated guideline currently exists in the United States.[3]
To prevent maternal mortality moving forward, Amnesty International suggests these steps:
Increase government accountability and coordination
Create a national registry for maternal and infant health data, while incorporating intersections of gender, race, and social/economic factors
Improve maternity care workforce
Improve diversity in maternity care
According to the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, out-of-hospital births (such as home births and birthing centers with midwifery assistance)  "generally provided a lower risk profile than hospital births." [27]
Procedures such as Episiotomies and cesareans, while helpful in some cases, when administered unnecessarily increase the risk of maternal death.[3] Midwifery and mainstream obstetric care can be complementary,[14] which is commonly the case in Canada, where women have a wide arrange of pregnancy and birthing options, wherein informed choice and consent are fundamental tenants of their reformed maternity care.[28] The maternal mortality rate is two times lower in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank.[29]
Gender bias and obstetric violence in the medical field are also important factors when discussing maternal wellness, care, and death in the United States.[30]
Comparisons by state
In the U.S., hospital bills for maternal healthcare costs over $98 billion, and concerns about the degradation of the maternal resulted in a state-by-state breakdown.



No data on Alaska and Vermont.
*MMR: maternal mortality ratio- number of deaths per 100,000 births.[2]
Comparisons with other countries
Comparison of the US maternal death rate to the death rate in that of other countries is complicated by the lack of standardization. Some countries do not have a standard method for reporting maternal deaths and some count in statistics death only as a direct result of pregnancy.[31]
In the 1950s, the maternal mortality rate in the United Kingdom and the United States was the same—1 in 1000 pregnant and new mothers died. By 2018, the rate in the UK was three times lower than in the United States,[32] due to implementing a standardized protocol.[25] In 2010, Amnesty International published a 154-page report on maternal mortality in the United States.[18] In 2011, the United Nations described maternal mortality as a human rights issue at the forefront of American healthcare, as the mortality rates worsened over the years.[33] According to a 2015 WHO report, in the United States the MMR between 1990 and 2013 "more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births."[34] By 2015, the United States had a higher MMR than the "Islamic Republic of Iran, Libya and Turkey".[26][35] In the 2017 NPR and ProPublica series "Lost Mothers: Maternal Mortality in the U.S." based on a six-month long collaborative investigation, they reported that the United States has the highest rate of maternal mortality than any other developed country, and it is the only country where mortality rate has been rising.[36] The maternal mortality rate in the United States is three times higher than that in neighboring Canada[25] and six times higher than in Scandinavia.[37]
See also
Maternal death
Infant mortality
Perinatal mortality
Obstetric transition
The Business of Being Born, a 2008 documentary
Confidential Enquiry into Maternal Deaths in the UK
List of women who died in childbirth
Reproductive rights
Women's reproductive health in the United States