A neonatal nurse, giving birth while under the care of her colleagues. A young, fit, new mom recovering from an emergency c-section. A legal immigrant undergoing a high-risk pregnancy, suddenly forced to switch from private insurance to public assistance.
These women have little in common, but they do share one devastating link: they all died from pregnancy-related complications. And they all gave birth in the United States, where women on average are charged the highest amount of money for maternal care in the world, while suffering worse outcomes than women in any other developed nation.
While the rest of the industrialized world has seen their maternal mortality rate steadily fall in recent years, data published by the Centers for Disease Control and Prevention (CDC) and independent researchers paints the United States as an outlier.
Data released by the Institute of Metrics and Evaluation last year and published in the Lancet found that the maternal mortality rate for women in the United States in 2015 was 26.4 in 100,000 -- a rate more than triple that of Canada and Western Europe.
No one has identified a single cause or warning sign to easily explain why so many women in the United States are at risk, as the CDC Foundation explains in a recent report. The agency determined that nearly 60 percent of the maternal deaths here were preventable.
In the absence of an easy answer, researchers, advocacy groups and the news media have published a spate of reports in recent months investigating the numerous systematic factors at play.
High costs and poor focus
A ProPublica report published in May found that most hospitals, health care plans, and doctors’ training programs in the United States put far more focus on the baby than the mother.
Even wealthy women with insurance are not safe from the stark statistics. A 2013 analysis conducted by Truven Health Analytics found that maternal care and newborn care cost between $30,000 and $50,000, with insurers paying between $18,000 and $28,000 on average.
The report found that women covered by commercial insurance paid an average of nearly $2,000 in out-of-pocket costs -- a four-fold increase since 2004. But the high cost of care was not improving outcomes.
Poor outcomes in Texas
Black women in southern states, particularly in Texas, bear much of the country’s maternal mortality risks. Critics have pointed to the state’s weak safety net available to many uninsured people as a reason.
Nineteen percent of women in Texas lack insurance, according to the Texas Medical Association. Yet white women and hispanic women make up the majority of the state’s uninsured population -- a respective 29 and 56 percent.
A WebMD analysis of CDC and World Bank data shows that the maternal mortality rate for black women in Texas in 2015 was 95 in 100,000 -- a figure that outpaces the maternal deaths recorded that same year in Guatemala, Panama, Jamaica, and Palestine. That’s the same figure described by advocacy organizations, though it is disputed by Texas state health officials.
One such advocacy group, the Center for Reproductive Rights, is suing the state of Texas for preventing Medicaid patients from obtaining treatment at Planned Parenthood. In its legal brief, the organization focuses on the disparity between black and white maternal deaths. They say that a lack of health insurance plays a major role.
“Many [uninsured minorities] fall into the coverage gap left by the primarily Southern states that have not expanded Medicaid, including Texas,” the brief says. “Black women disproportionately bear the real-life impacts of the United States’ poor maternal health outcome.”
Advocacy group For a Better Texas points out that the state also provides relatively weak public health care for legal immigrants, noting that it is only one of six in the country to exclude lawfully present adults from Medicaid.
Instead, legal immigrants in Texas must seek pregnancy care under something called the CHIP prenatal plan, “which provides prenatal visits and limited postpartum care,” according to the group.
Calista Johnson’s story
A recent WebMD report by Brenda Goodman investigates the death of one black mother in Texas, a 32-year-old woman named Calista Johnson. The report examines how potential racial bias and gaps in Texas’ coverage may have played a role in her medical treatment.
Johnson was a Malawi immigrant who became a permanent U.S. citizen and lived in the Dallas area with her husband and son. She was diagnosed during her second pregnancy with pregestational diabetes, which put her in a high-risk category.
Johnson was covered on a Blue Cross Blue Shield plan through her husband’s employer, but she was forced to go on public assistance after the company abruptly switched its employees to a high-deductible policy midway through her pregnancy. In her medical records, under her new CHIP plan, a Parkland Hospital doctor wrote that Johnson was “late to prenatal care.”
Not only was that statement untrue, Goodman found, but it represented a “dog whistle” in the medical community that Johnson was ambivalent about her pregnancy.
Despite her prior diagnosis of pregestational diabetes, health care providers did not regularly check Johnson’s blood pressure, nor did they test her urine for signs of preeclampsia. Instead, they checked her twice for STDs, even though she had been married for 10 years.
“These tests aren’t directly related to the cause of her death, but they may reveal something about how she was treated by the health care system,” Goodman writes.
A headache that she complained about during labor was also diagnosed as a migraine.
After giving birth and being sent home, Johnson’s health rapidly deteriorated; her headache and back pain worsened and her speech began to slur. She passed away five days after giving birth, with an autopsy finding that she had suffered a torn aorta.
“What struck me about this report was the fact that if we don’t care for women before, during, and after pregnancy, that has a devastating impact,” Dr. Hansa Bhargava, WebMD’s medical director, tells ConsumerAffairs.
Advice to new mothers
Bhargava points out that more access to insurance would likely improve outcomes for mothers. “Other western nations have universal health care or better access to healthcare,” she tells ConsumerAffairs.
In the absence of that, she advises women to look out for each other and themselves. “If we have healthier mothers going into pregnancy...I think we would see a difference,” she says.
Pain that worsens after giving birth is a major warning sign that something is wrong. “Everything should get better,” Bhargava adds.
Women experiencing severe pain during this period may need to speak up several times until a professional takes their concerns seriously. "If for whatever reason the doctor doesn’t seem to be listening, talk to them again, or see if someone else can talk to them for you.”