Pregnancy in the USA: risks are higher for some women

20 World Health • Sl stYear, No. l, Jonuory-Februory 1998 Pregnancy in the USA: risks are higher for some women Isabella Danel, Cynthia Berg & Hani Atrash A Family in the United States. Women From racial minorities are at higher risk of dying From pregnancy-related causes. Photo Keystone/ !. Sirman © Not all American women face the same risks during pregnancy and childbirth. In the United States of America, the risk of dying as a consequence of a pregnancy has decreased dramatically in the last 50 years . The officially reported maternal mortality ratio fell from 376 deaths per 100 OOO live births in 1942 to 7.8 in 1992. As in most developed coun- tries, the decline occurred as a result of the availability of antibiotics, blood transfusions and general im- provements in obstetric care. Nevertheless, maternal mortality remains a public health problem in the United States. The reasons are threefold. First, there is considerable evidence that routine information systems seriously underestimate the magnitude of maternal mortality. Second, experts estimate that up to half the maternal deaths taking place in the country are preventable with currently available technology. Third, the risk of dying because of pregnancy is higher for some groups of women than for others: some women face maternal mortality ratios of 100 deaths per 100 OOO live births. Two of the most important char- acteristics affecting the chances of a woman dying as a result of preg- nancy are race and age. Black women face a risk nearly four times as high as white women do of dying from pregnancy-related causes, and for Hispanic women the risk is twice as high. As women age, the risk of dying from a pregnancy increases. This is true for all races, but more so for black women than for others. Black women aged 40 years or older are six times more likely to die as a consequence of a pregnancy than are white women in the same age group. Between 1987 and 1990, the mater- nal mortality ratio for black women aged 40 years or more was 162 deaths per 100 OOO live births. Several other factors influence the likelihood of maternal death in the USA. Unmarried women have a greater risk of maternal death than married women. Women who re- ceive no prenatal care are more likely to die than women who re- ceive adequate prenatal care. The protective effect of prenatal care varies from a nearly fourfold reduc- tion of risk for black women to an eightfold reduction for white women. For most women, higher levels of education are also associ- ated with a lower risk of maternal death. The protective effect of edu- cation is especially strong for older women. Unfortunately, however, World Health • 51 st Year, No. l, Jonuory-Februory 19987 this protection does not extend to black women. The risk of maternal death was the same for black women in each age category, regardless of educational level. The reasons for this are unclear. Black women in the United States are more likely to have unintended pregnancies. In 1995, 45% of pregnancies in white women and 48% of pregnancies in Hispanic women were wanted either later or not at all ; this compared with 72% of pregnancies in black women. The rate of induced abortion reflects this difference in "intendedness" . In 1994, the abortion ratio among black women was 538 abortions for every 1000 live births compared with 278 per 1000 live births among Hispanics and 217 per 1000 Ii ve births among white women. In general, half of all unplanned pregnancies are due to contraceptive failure . The remaining_ half is due to couples not using contraception. Figures from the late 1980s show that black women were 40% more likely to be admitted to hospital for antenatal complications than were white women. Black women also stayed in hospital longer - 3.3 days compared with an average of 2.5 days for white women. However, among women in the military, there was no difference in hospitalization rates or duration for antenatal com- plications by race. Since women in the military are of similar educa- tional background, and receive comparable salaries and levels of care, this finding has implications. It suggests that differences in socio- economic status contribute to differ- ences in the severity of pregnancy complications between black and white women through differences either in access to care, timeliness of treatment or quality of care. Thus, women from some racial groups are more likely to have an unintended pregnancy, to receive inadequate care, to be hospitalized for antenatal complications, and to die as a consequence of a pregnancy. Reducing this large gap between their health and that of white women in the United States today is one of our major public health challenges. Closing the gap Several measures need to be taken to reduce this disparity and to improve maternal health for all women. First, improvements need to be made in access to contraception and the utilization of modern methods. The development of more effective con- traceptive methods with fewer side- effects is another very important component of any plan to improve maternal health. No woman should have to risk illness or suffer a com- plication - much less die - because of a pregnancy she never intended to have in the first place. Improving women 's access to obstetric care and the extent to which they use the services are other impor- tant steps towards improving mater- nal health. Universal access to pregnancy care has never been guar- anteed in the United States. While Medicaid, a publicly funded health insurance programme for low- income individuals, pays for care for many poor women and children, other women remain without health care coverage. Even when women have health insurance their access to quality health care may be impeded by cultural, linguistic or educational obstacles. A woman's satisfaction with the care provided to her, as well 21 as her relationship with the care providers, also affects whether or not she uses the services. Improving the quality of care provided is vital to reducing mater- nal mortality. This is an issue receiv- ing much attention in the United States at the present time. The in- crease in health maintenance and managed care organizations, which are involved in measuring the qual- ity of care, has created an impetus for the development of standards for pregnancy care. Improving referral networks to ensure that women and infants receive timely care at the appropriate level, particularly during the crucial period of labour and delivery, is also fundamental to improving maternal health. While pregnancy is safer in the USA than earlier in the century, many minority women still face increased risks of morbidity and mortality, associated with social and economic factors . Until economic, educational and cultural barriers are removed, it will be difficult to elimi- nate the gaps in maternal health to promote safe and happy pregnancies for all women. • Ors Isabella Donel, Cynthia Berg and Hani Atrash are with the Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341-3724, USA Students of Hispanic origin follow summer courses in order to graduate from high school. Many minority women still face increased risks associated with societal and economic factors. Photo Panos Pictures/B. Press ©