The United States is not the first place that springs to mind when considering women dying in childbirth. So the fact that two American women die of pregnancy-related causes every day may come as a surprise.
According to the World Bank, The US ranks 50th in maternal mortality globally - falling behind every other industrialised nation. A woman in the US is as likely to suffer a maternal death as a woman in sanctions-hit Iran, and four times as likely as a woman in Germany.
"It is a preventable health issue," said Amnesty International's Rachel Ward. "It isn't something that we're waiting for a cure for. We’re waiting for political will."
What's worse is that US maternal mortality rates may actually be on the rise. Eugene Declercq, of Boston University's School of Public Health, produced a short film named Birth by the numbers, discussing maternal mortality in the US. In a 2013 follow-up report, he noted how mortality rates in other industrialised nations had declined - but in the US, it increased by 30 percent in the first decade of the new millennium.
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Another 2013 report, this one by Truven Health Analytics, says the US spends more than any other country on costs associated with maternal healthcare. So why are American mothers still dying of pregnancy related deaths?
The answer is complex and belies simple solutions.
"There is sadly no magic bullet that explains what is behind the high levels of maternal mortality in the United States," Amnesty's Rachel Ward said. "It's a combination of factors that speak to the systemic problems of failing to provide affordable, accessible, quality health services to all women in the United States."
One of these factors is likely the demographics of new mothers in the US.
"Our women are older. Our main maternal age has risen," said Dr Sarah Kilpatrick of the Cedars-Sinai Medical Center in Los Angeles. "We have a lot more women in their late 30s and 40s, when you have a higher chance of having other health issues such as cardiac disease." Obesity is also on the rise in the country, which also increases the chances of birthing complications.
Access to care
Many believe that the US healthcare system is in crisis. The Henry J Kaiser Family Foundation reported that 47 million non-elderly US residents had no health insurance in 2012.
Uninsured pregnant women are eligible for Medicaid. But, according to the American Congress of Obstetricians and Gynecologists, they receive fewer prenatal care services, are more likely to enter pregnancy with health problems, and are more likely to have adverse maternal health outcomes.
It is a preventable health issue. It isn't something that we're waiting for a cure for. We’re waiting for political will.
Poor women and women of colour are by far the hardest hit by this crisis. In 2012, 23 percent of African-American women and 36 percent of Hispanic women had no health insurance.
A 2013 report by the New York Women's Foundation found that black women in New York City had a maternal mortality rate of 79 deaths per 100,000 live births - compared with 10 per 100,000 live births for white women. That means black women in New York have worse maternal mortality rates than women in either Syria or Iraq.
Those numbers reflect a trend also cited in an Amnesty International 2011 follow up to its report, Deadly Delivery, which found that women in low-income areas were twice as likely to die a maternal death than women in high-income areas, and black women were four times as likely as white women to die while giving birth to a child.
Open Arms Perinatal Services in Seattle is one organisation trying to fill the gaps women are slipping through. Open Arms provides doula care, non-medical social and emotional support to low-income mothers.
"When Martin Luther King Jr was born, his mother did not have access to the local hospital because she was black, so we have this history of separating care," Open Arms Executive Director Sheila Capestany told Al Jazeera. "So you build things into your systems that are really hard to undo, and you have to undo them intentionally, you can't just expect they're going to go away."
She believes that these community-based solutions are a crucial part of undoing the historical injustices that continue to resonate today.
Quality of care
Focusing only on access to care obscures a more fundamental problem - whether that care is of a decent quality, even for those who can afford it.
White women, the demographic most likely to have positive birth outcomes, and more likely to have health insurance, still have worse indicators than their counterparts in 24 other industrialised countries.
In the United States, if you define all births as 'potentially dangerous', then you would make the argument that you need a specialist for every birth. That perspective has persisted, and, given that, we've got a problem.
In almost every other industrialised nation, comprehensive maternal healthcare is inexpensive or even free. In Britain, midwives usually visit mothers at home two weeks after birth. In the Netherlands, more than 16 percent of births occur at home under the care of a midwife and are covered by insurance. In France, coverage includes a week's stay in the hospital, during which women also receive training in caring for her newborn.
Most US insurance companies cover only what is considered medically necessary - and that usually means discharging women a day or two after birth with a single post-natal check-up six weeks after delivery. Ward, the managing director of Amnesty International's US programme told Al Jazeera this six weeks is a critical time period.
"Tameka McFarquhar, she was 22, she bled to death in her apartment in New York after giving birth," Ward said of one of the women featured in her research. "She was alone, a home visit could have saved her life."
The future of motherhood in the US
Any area of neglect represents risks to maternal health, but with the right research and investment applied, such problems present opportunities to those working to reverse the numbers.
"Maternal death is not solved yet, but I think we’re making huge strides to reduce it," said Kilpatrick, the chair of the department of obstetrics and gynaecology at Cedars-Sinai.
US President Barack Obama's signature healthcare programme, the Affordable Care Act, which Republicans have tried to change or repeal a number of times, aims to increase the number of Americans with health insurance. The American Congress of Obstetricians and Gynecologists believes this could decrease the chances that women may become pregnant while already having potentially life threatening health problems.
One low-cost solution is the increased use of midwives. The majority of births around the world are attended to by midwives. In Britain, that includes 57 percent of births.
Stateside, fewer than eight percent of births are assisted by midwives. Most births are attended to by doctors, part of what makes maternal healthcare in the US so expensive.
|From the archives: Everywoman: Maternal mortality
[First aired: January 18, 2008]
"In the United States, if you define all births as 'potentially dangerous', then you would make the argument that you need a specialist for every birth. That perspective has persisted, and, given that, we've got a problem,” said Boston University's Declercq.
The problem is financial but it also may be medical. The rate of caesarean sections in the US is more than 30 percent - more than double the World Health Organisation's recommendation.
Exposing mothers to interventions such as caesarean sections when they are not necessary also exposes them to potential risks, say experts.
The American Congress of Obstetricians and the Society for Maternal-Fetal Medicine recently released guidelines recommending that unnecessary caesarean sections should be reduced.
"In my mind, there is no doubt that our C-section rate is too high in the United States," said Kilpatrick of Cedars-Sinai. "The good news is that it has plateaued. It's been the same for two to three years now."
Amid the variety of medical and governmental changes that are being made, Capestany from Open Arms believes that there is also a basic social change that needs to be made in the way Americans understand childbirth.
"It's not intuitive in the United States that, in fact, childbirth is more than just a medical event. It is a physical event that requires medical attention, social attention, and emotional attention," Capestany told Al Jazeera.
"Until we acknowledge that, we're not going to be able to get the best care."
Follow Abigail Higgins on Twitter: @abbyhiggins
Source: Al Jazeera