Reducing Perinatal Health Disparities

Reducing Perinatal Health Disparities

Of all the forms of inequality, injustice in health care is the most shocking and inhumane”

-Martin Luther King, Jr. (25 March 1966)




Maternal Mortality | Infant Mortality | Cesarean Section


In 2000, 189 countries pledged to end extreme poverty worldwide through the achievement of eight Millennium Development Goals (MDGs). MDG 5 was set to improve maternal health with the goal to reduce maternal mortality by three-fourths by 2015 (Target 5.A). As Americans, we  think that maternal and infant deaths occur “over there” in lesser developed regions who do not have our wealth, advanced technology and highly trained medical experts. Many believe that here in America where the majority of births occur in hospitals with obstetrical doctors and nurses, maternal death is a phenomenon of the past. However, maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities.  Amnesty International has stated in their report on maternal mortality in the United States, Deadly Delivery, maternal health is  a human right.

Maternal Health is a Human Right” – Amnesty International

Even in America today, women die of childbirth related causes all too often. This is especially true in communities of color. According to the American Public Health Association, maternal mortality is the leading perinatal health disparity between blacks and whites in America. African-American women die of pregnancy-related causes at 4- 5 times the rate of Caucasian women– a startling statistic which has not changed in over 4 decades. Maternal death rates are also higher for Hispanic and Native American women. Maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While some of the recorded increase is due to improved data collection, the fact remains that maternal mortality ratios have risen significantly.

Maternal mortality is the leading perinatal health disparity between Blacks and Whites in America. African-American women die of pregnancy-related causes at 4- 5 times the rate of Caucasian women– a startling statistic which has not changed in over 4 decades” –American Public Health Association

The USA spends more than any other country on health care, and more on maternal health than any other type of

Amnesty Maternal Mortality Chart

Amnesty Maternal Mortality Chart

hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 49 other countries. 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. According to Amnesty International, “This is not just a public health emergency – it is a human rights crisis. Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.” (from Deadly Delivery: The Maternal Health Crisis in the USA).

From $13 billion to $20 billion a year could be saved in health care costs by developing midwifery care, demedicalizing childbirth and encouraging breastfeeding.” – Frank Oski, M.D., Professor and Director, Department of Pediatrics, Johns Hopkins University School of Medicine

The consequences of maternal deaths are far reaching, leaving a void in the a family and the society she would have contributed to. A crucial solution to preventing avoidable maternal deaths and injuries is quality and accessible care to all women. The leading non-governmental organizations (NGOs) have determined that there are several factors contributing to maternal deaths. One of them is lack of access to skilled birth attendants at birth.

Solution: Many leading organizations have recommended skilled midwifery care as a solution to reduce maternal deaths.

Maternal Deaths and The Safe Motherhood Quilt

The USA spends more than any country on healthcare and more on maternal health than any type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 countries— Amnesty International (2010).

Midwife Ina May Gaskin, CPM, one of the founders of the The Farm Midwifery Center in Summertown, TN and author of Spiritual Midwifery, and many other books, is bringing attention to the hidden issue of maternal death in America through The Safe Motherhood Quilt.

Community-Based Doula Program in Los Angeles offered by the Association for Wholistic Maternal and Newborn Health addressing high rates of maternal mortality disparites in LA County.

Safe Motherhood Quilt depicts the deaths of mothers from pregnancy and childbirth-related causes in the U.S.

Each patch is hand-sewn by volunteers and memorializes the tragedy of women’s lives lost. Ina May created the traveling quilt to bring awareness to the issue and to help create a political will to save women’s lives. Ina May gathered the stories of maternal deaths through news clippings and personal communications from families, nurses and doctors, and has become the keeper of the stories around these tragedies. Many themes emerge from these tales: lack of support after birth to care for the postpartum mother, complications following cesarean section, and other reasons.

In the U.S.there are 18.5 maternal deaths per 100,000 live births, up from 12.4 deaths per 100,000 births in 1990. We rank 60th in the world, and below virtually every other developed nation. We’re close to triple the rate of the U.K. and eight times that of Iceland, the world’s leader. American maternal mortality rates rose over a 20-year period at a rate that places the U.S. in the company of war-torn countries like Afghanistan and impoverished nations like Chad and Swaziland, according to a new report. (According to a study reported in the Lancet by the Institute for Health Metrics and Evaluation, a global health research center at the University of Washington amd reported in the Huffington Post in May 2014). “The USA spends more than any country on healthcare and more on maternal health than any type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 40 countries” (Amnesty International, 2010).

Currently, cesarean section rates in the U.S. are 35%. In Los Angeles County it is 32%. The primary reason for this is that the Vaginal Birth After Cesarean (VBAC) rate has been between 1-3% in the U.S. for the past decade. Much of the high rate of Cesarean section is due to repeat Cesareans. African-American women have the highest rate of Cesarean Section in the U.S.

Watch Video of Ina May Gaskin on The Safe Motherhood Quilt

AWMNH’s Executive Director, Cordelia Hanna, MPH, CHES, ICCE, CLE, CBA comments on the video:

America is supposed to be a safer place to give birth than in  lower-resource countries, with all of our highly-trained medical experts and technology. But sadly, giving birth in America  it is not as safe as many believe it to be.”

“This is just heartbreaking and touches close to home, as I was married to a man from Kenya” Cordelia  Hanna says. “Sadly, we hear stories of maternal deaths coming out of sub-Saharan Africa all the time, due to  shortages of medical personnel  and lack of access to life-saving technology. But America is supposed to be a safer place to give birth than  in lower-resource countries, with all of our highly-trained medical experts and technology. But sadly, America is not as safe a place to give birth as many believe it to be. Our overuse of technology and inequities in health care and lack of postpartum support for many new mothers lead to tragedies like this one. Sadly, Virginia Wanjiru Njoroge may have been better off if she had given birth in Kenya where she would have had the traditional Kikuyu community midwives to care for her and family support to look after her in her postpartum period. This tragedy fuels my passion to do more to make birth safer and to provide more support for new mothers”, says  Hanna, who has a Masters in Public Health in Health Education and Promotion and  Global Maternal-Child Health.

Stories like those from the Safe Motherhood Quilt underscore the need for skilled maternity care providers — both licensed and non-licensed — to provide crucial support for mothers not only during labor,  but more urgently,  pregnancy and postpartum. Midwives are associated with lower rates of cesarean and other interventions and good birth outcomes yet only 7% of U.S. births are attended by midwives, in hospital or-out-of -hospital. Community-Based Doulas provide pregnancy support, labor support and after-birth support. Even though Doulas and Midwives are used very infrequently in the U.S., they were the most highly-rated providers that American women encountered during their maternity care experience, according to Childbirth Connection’s Listening to Mother’s Survey II  (Correy, DeClercq & Applebaum, 2006


In addition, infant mortality is a grave problem in the United States, affecting a disproportionate number of African-American babies. Premature births are associated with higher infant mortality and African-American women are 2-1/2 times more likely to give birth to a baby too soon and too small than Caucasian women, even after adjusting for socioeconomic status. This means even  affluent, well-educated African-American women are more likely to deliver her baby too early. Infants left behind after a mother’s death often fare poorly and often die as well.   Also, infants born too small and too soon often die or if they survive, have lifelong disabilities. In many places in the world, women give birth with only a friend or relative to help.  In the U.S., minority women from disadvantaged communities far too often receive an inferior quality of care — this is called health inequity.

Solution: Skilled Midwives, Doulas and community health promoters are crucial to improving the quality of care provided to mothers and preventing avoidable deaths and injuries.


In 2007, one million US births were by cesarean section (30%).  Women over 35 years of age were most likely to have a surgical delivery. Black mothers have the highest rates in the U.S. Since 1995, Black Non-Hispanic mothers have had higher cesarean delivery rates than any other group (32% for Black women, 21% for  White women (National Center for Health Statistics, Eugene DeClercq, personal communication). There are numerous risks of cesarean section* to mothers and infants, which include the following (*Source: Childbirth Connection) :

Risks to Mothers

  • Increased risk of infection
  • Surgical injury
  • Blood Clots
  • Emergency hysterectomy
  • Intense and longer-lasting pain
  • Adhesion formation: ongoing pelvic pain
  • Bowel blockage
  • Injury during future surgery
  • Problem in future pregnancies [including placenta accreta, placenta previa, placental abruption]

Risks to Infants

  • Surgical cuts
  • Breathing difficulties
  • Difficulty breastfeeding
  • Asthma in childhood and beyond

Solution: Access to Midwives and Doulas help to reduce cesarean sections.

For too long America has failed to acknowledge the outrageous and seemingly intractable rates of poor maternal health and deaths of mothers in childbirth. The United States has the highest maternal mortality rate of any industrialized country in the world. More than two women die every day in the US from pregnancy-related causes. And while the vast majority of countries have reduced their maternal mortality ratios, for the past 25 years the numbers of women lost during pregnancy, birth or postpartum have increased dramatically in the US.

African-American women in the U.S.  are at especially high risk; they are nearly 4 times more likely to die of pregnancy-related complications compared to European American.
Women of color are less likely to go into pregnancy in good health because of a lack of access to primary health care services. They are also less likely to have access to adequate maternal health care services. Black women are by far the largest demographic to suffer these outcomes, it has been this way for decades and yet they are seldom able to make their voices heard.

Its time for change.

Through the documentary “the AMERICAN dream” the women tell their own stories: they know what is wrong, they share their hopes, they share their fears, and they share about their American dream, related to maternal health in the U.S.

Perhaps it is time to listen.


Watch the You Tube Video:  Midwives Addressing Health Disparities

Watch the You Tube Video:  “Birth by the Numbers” by Eugene DeClercq, Ph.D. Summary of U.S. Perinatal Statistics

Childbirth Connection: Midwifery Care Evidence-Based Practice Brief” DownloadPDF Logo 16px

Childbirth Connection: Imperative to Train More Midwives”  by Carol Sakala, Ph.D., MSPH Download PDF Logo 16px

UCSF Pew Report: The Future of Midwifery (1999): DownloadPDF Logo 16px

Amnesty International Report: “Deadly Delivery, The Maternal Health Care Crisis in the U.S.A.” Download

Choices in Childbirth Report: “Doula Care and the Affordable Care Act in N.Y.C.” Download

Health Connect One’s Report: “Community-Based Doulas and the The Perinatal Revolution”  Download



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