No Country for Mothers

Good news! if you are an ordinary mortal living in the United States, your chances of staying alive are better than ever. According to new government numbers, the rate of Americans dying in 2004 (the most recent year to be calculated) hit a record low, while life expectancy -- for blacks and whites, men and women -- hit a record high. Men were closing their historic life-expectancy gap with women, and African Americans were closing their life-expectancy gap with whites. Even the babies were doing well: The infant mortality rate dropped, too.

Sadly, however, if you are a pregnant mortal living in the United States today, your chances of dying appear to be greater than ever. Yes, the total number of women who die in childbirth in America is low. But according to the Centers for Disease Control's new "National Vital Statistics Report," the number of women dying in or around childbirth has risen -- putting the United States behind some unsurprising countries, like Switzerland and Sweden, and some surprising ones, like Serbia and Macedonia, Qatar and Kuwait, in its rate of maternal mortality. In rankings calculated on 2000 numbers, the World Health Organization (WHO) ranked the United States at No. 29 on the list, even though, according to the most recent statistics, there is only one country, Tuvalu, that spends more on health care as a percentage of gross domestic product than the United States.

Now, all this is a bit of a red herring. The honest fact is that we know very little about maternal mortality for the very simple -- problematic -- fact that there is no national or even consistent state-level system for tracking whether a woman has died from birth-related causes; her death certificate will likely not indicate the obstetric issue that led to complications and death. And another honest fact, with thanks to sociologist Kenneth Hill of the Harvard Center for Population and Development Studies for his number crunching, is that the increases in this year's report probably have more to do with improvements in those tracking methods in a few states.

But chances are, even if this year's increases are due to changes in how pencil pushers push their pencils, the number of women dying in and around childbirth is even higher than the CDC's most recent report indicates. Marsden Wagner, former director of Women's and Children's Health at the WHO, writes in his 2006 book Born in the U.S.A. that "in the United States, at least half of maternal deaths are not reported anywhere ... and that with adequate medical attention, close to half of these women need not have died."

It's that last bit that should concern us. Some maternal mortality is inevitable. In 2000, the Department of Health and Human Services released its "Healthy People 2010" initiative, which set objectives for the first decade of this century. The goal on maternal mortality was 3.3 per 100,000. That we have been moving away from that number -- with data that likely underrepresents the truth -- should tell us that something we are doing, or not doing, is driving up the death rate.

At least some of the problem may be in treatment. Wagner and other activists believe we're seeing the fruits of an exponentially increasing rate of Cesarean sections -- the result of a host of well-documented hospital practices that privilege liability concerns, hospital convenience, and doctor convenience over best medical practices, time and again. "It is absolutely clear," Wagner told me, "that one of the biggest reasons for this excess [in childbirth-related deaths] is the excess Cesarean section."

There are four million births in America each year, of which 1.2 million, nearly 30 percent, are C-sections. According to global data collected by the WHO, if the C-section rate is below 10 percent, as it is in the developing world, women die at higher rates. And once C-sections pass 15 percent, as they have here in the U.S., women also die at higher rates, as a result of complications from major abdominal surgery. The results of this radical experiment in birthing are predictable but yet to be proven. And the American obstetric establishment would like to keep it that way.

But the equally signi´Čücant explanation for American maternal mortality is probably under-treatment. Perhaps the most notable fact in the CDC's new report is that African American women are nearly four times as likely as white women to die in child-birth. That is, while 9.3 white women per 100,000 died in childbirth, 34.7 African American women died. And this is a criminal disparity, one that is all the more shocking given that other racial disparities in the report were narrowing. Whether the causes are poor health, poor health care, poor insurance coverage, or -- likely -- all of the above, there is no excuse for the injustice that being black is a risk factor putting some pregnant women at death's door.