Blue illustration of raised fist in the shape of pregnant mother with group of people behind on a light yellow background

American Birth Story: The Changing Face of Birth in America

There’s no denying that we are in the midst of a maternal health crisis in this country that started well before the current pandemic. investigates how we got here, and what can be done to empower the thousands of expecting mothers heading into the delivery room.

In February 2020, the COVID-19 pandemic began sweeping the United States. Quickly, patients overwhelmed hospital ICUs and health care workers put in overtime to keep up with treatment demands. To protect those who were still healthy, doctors' offices began switching from in-patient appointments to telemedicine only. Nonessential medical appointments were postponed or canceled, and hospitals limited who was able to support patients through essential treatments. For those who are pregnant during this unprecedented pandemic, it means canceled prenatal appointments, concerns over access to necessary D&Cs after a miscarriage, virtual birthing classes, and the possibility of birthing without a partner or support person in the delivery room.

Before COVID-19, America already had the highest maternal mortality rates in the developed world—with Black and Native women disproportionately affected. Months before the first novel coronavirus case was diagnosed in Wuhan, China, the team began investigating why America is failing pregnant people. As the pandemic spread, it became clear that the issues already existing in maternal care in this country were being heightened—access to health care became even more problematic, hospital resources were draining, insurance premiums skyrocketing, and culturally competent prenatal and delivery care that did exist in the form of midwives and doulas were limited or banned from delivery rooms. We knew we had to shift our reporting to address the impact COVID-19 was having on pregnancy and delivery and how the virus could forever change maternal care in this country, for better or worse.

American Birth Story was originally planned to launch ahead of International Day for Maternal Health and Rights on April 11, 2020 as a digital spotlight calling out maternal mortality as a public health crisis and offering solutions for our health care system's future. Instead, we are treating this as an evolving project, pointing to the problems already existing in birth in America, watching how COVID-19 is changing the care and experience for pregnant people, and offering solutions—expert and science-backed ways we as a country can empower and support Americans through pregnancy and delivery. With content rolling out over the following weeks and months, American Birth Story will become a resource and guide to information, service, and support as pregnancy and delivery continue to change. We hope to shine a light on some of the health care system's most pressing issues facing maternal care and be a part of the solution.

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headline: Maternal Health is a Public Health Crisis, Here's Why, by Kelly Glass
Illustrated by Yeji Kim

In the United States, pregnant people of average health can expect to have around 13 prenatal appointments throughout their three trimesters. According to the Centers for Disease Control and Prevention (CDC), nearly a quarter of pregnant people do not receive prenatal care during the first trimester. Native American, Alaska Native, and non-Hispanic Black women face the most barriers to receiving prenatal care on time or at all during pregnancy. For too many, access to local, safe, available, and affordable maternal health care is bleak and appointments are difficult to make. Now that COVID-19 is causing OB-GYN offices to cancel or postpone nonessential prenatal appointments across the country, many others across America are facing late or no early prenatal care. This is concerning on its own because the U.S. Department of Health and Human Services (HHS) reports that babies of mothers who do not receive prenatal care are three times more likely to have a low birth rate and five times more likely to die than babies born to mothers who receive appropriate care. But long before the pandemic created a block in health care access for all Americans, there was a maternal care crisis in this country that needed dire attention.

About 700 women die from pregnancy and childbirth-related conditions each year in the United States and 60,000 more experience near misses. In 2018, an investigation by USA Today deemed this the "most dangerous place to give birth in the developed world." An American woman is nearly three times more likely to die in pregnancy or childbirth than a British one. Black women in America are three times more likely than white women to die from preventable maternal complications. Native American and Alaska Native women are recorded to be at twice the risk of death compared to white women. More than 60 percent of pregnancy-related deaths in the United States are preventable, according to a 2018 report. New data from the CDC confirms that our maternal mortality rate is unacceptably high.

Laurie Zephyrin, M.D., vice president of the Health Care Delivery System Reform at the Commonwealth Fund

We clearly have a crisis in this country around maternal mortality and morbidity.

— Laurie Zephyrin, M.D., vice president of the Health Care Delivery System Reform at the Commonwealth Fund

Giving birth in America should not be any riskier than anywhere else in the world. We need to save women from dying in childbirth, and we need a comprehensive plan to tackle the systemic issues that put birthing women's lives in danger. To do so, we need accurate data, standardization in health care, and an immediate response from the government officially declaring that the hundreds of women dying under our country's maternal health care system are too many. We demand the HHS formally declare the maternal mortality rate in the U.S. a public health crisis. That declaration could open maternal health care to necessary funds for mortality prevention resources as well as efforts to secure timely, high-quality data, which is crucial to analyzing the extent of any public health concern and planning the solution.

The Numbers: How Accurate Is the Data?

Maternal mortality is defined by the World Health Organization (WHO) as the death of a woman while pregnant or within 42 days after childbirth. In the United States, about 700 women died each year during this period. In 2015, that equaled an estimated 18 women who died during or soon after pregnancy and childbirth for every 100,000 live births. The same year's data in other developed countries is the biggest indicator that America has a staggering problem: In Sweden, 4 women per 100,000 women died, in Canada, 11, and in the United Kingdom, 8. While maternal mortality rates worldwide decreased by 38 percent from 2000 to 2017, the estimated rates in the U.S. continued to increase. In fact, the nation's pregnancy-related deaths from 2000 to 2014 rose by nearly 27 percent.

Where the U.S. Stands Against Other Nations
Graphic by Josh Goldwasser

The reality is that these numbers might still be lower than the actual number of deaths in America. The CDC hadn't released official numbers in several years so the numbers available are estimates. "There was an 11-year gap in them providing this data. The last official maternal mortality rate was for 2007 data, which was a national embarrassment," says research professor Marian MacDorman, Ph.D., who specializes in maternal health at the Maryland Population Research Center. Without reliable data telling us exactly how many women are dying in childbirth in the U.S., this fatal problem remained a quiet epidemic for several years.

"We clearly have a crisis in this country around maternal mortality and morbidity," says Laurie Zephyrin, M.D., vice president of the Health Care Delivery System Reform at the Commonwealth Fund. "It's about the deaths and also the 60,000 near misses that occur as a result of childbirth." These near misses are highly preventable birth injuries that often result in significant debilitating and even disabling consequences to women's health. Like maternal mortality, maternal morbidity in the U.S. is rising and disproportionately affects Black women regardless of socioeconomic status.

In January of this year, the National Center for Health Statistics finally released official numbers of how many American women died during and after childbirth in 2018. "It is a tremendous step forward that the National Center for Health Statistics of the CDC is again publishing a national maternal mortality rate," says Dr. MacDorman.

The newest numbers on maternal mortality rates from 2018, tracked under a new method that now only includes women up to age 44 (it was previously 54), show 17.4 deaths per 100,000 live births. They also confirm that Black women are two to three times more likely to die during pregnancy and childbirth than white women.

"In terms of where we go from here, the data is our starting point," says Dr. Zephyrin. "It confirmed the elevated rates compared to other countries. It's confirmed the disparities, and moving forward I think we will be in an even better position. Now we can address some of the system issues."

Race, Bias, and the Health Care Systems: Why Are Women Dying in Childbirth?

Hemorrhage and preeclampsia are the most common causes of pregnancy-related death, and about 60 percent of these deaths are preventable, according to the CDC. A 2018 report found that medical errors, ineffective care, and lack of treatment are major causes of preventable death at the hospital level. There are also studies that look at the rising rates of cesarean sections as an increased risk factor for blood loss, infection, complicated recoveries, and preeclampsia risk in subsequent pregnancies. While C-sections are a life-saving surgery for mothers and infants, medically unnecessary C-sections may be responsible for up to 20,000 surgical complications a year, according to Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School in an interview with Consumer Reports.

Dr. Zephyrin, who is also an obstetrician-gynecologist who's delivered hundreds of babies, says there is work to be done in hospitals. "We have a lot of evidence as to what works. We have medications to treat conditions" like hypertension, she says. Why these treatments and medications are not being used in a timely and effective manner is another question.

Shelly McLean, a registered nurse in New York for eight years, says that as a Black woman herself, she's seen firsthand the way implicit bias affects the quality of health care Black women receive. "There is this belief that Black women can tolerate more pain than white women or that Black women are faking or exaggerating their pain," she says. "There is also the issue that we are not seen as valuable. And how do you inevitably treat something you don't value? It is that simple and complex at the same time."

The near-misses and birth injuries are just as telling of the problem we face in America. Erica McAfee, 34, a Black woman from Suffolk, Virginia, believes the only reason she and her son survived her full placental abruption at 32 weeks pregnant is that her doctor had a vested interest in her health. This doctor happened to be the same one who delivered her first son, who died shortly after birth a few years earlier. "She went out of her way to save our lives and make sure I came home and my baby came home from the hospital," says McAfee, who was 28 at the time of her emergency C-section.

Kate Elizabeth Fowler for
Erica McAfee at home, Sunday, March 8, 2020. Kate Elizabeth Fowler for

McAfee experienced shortness of breath and severe pain at 32 weeks and went straight to the hospital with her husband. "We got there at a quarter to two and my son was born at 2:17," she says. "The doctors on call heard a faint heartbeat from my son and rolled me back for a crash emergency C-section. Within 10 minutes they put me to sleep, cut me open, and took my baby out." McAfee's placenta had completely detached from her uterus. To save her life, her husband had to sign off for her to have a hysterectomy. "I was pretty much intubated and out for four or five days," she says. "I lost so much blood—I had to get eight blood transfusions. My family flew in to say goodbye because they weren't sure if the transfusions would work or if I was going to make it home." Luckily, she did.

McAfee's son, Maxwell, now 5, spent 29 days in the NICU. Because he was deprived of oxygen for an unknown amount of time due to McAfee's condition, he was diagnosed with a severe form of cerebral palsy when he was 1 year old. "He is the love of our lives," she says. "Thank God the doctors and nurses had the care and compassion to continue to fight for us."

Erica and Max McAfee at their home on Sunday, March 8, 2020.
Erica and Max McAfee at their home on Sunday, March 8, 2020. Kate Elizabeth Fowler for
Erica and Max McAfee at home on Sunday, March 8, 2020.
Erica and Max McAfee at home on Sunday, March 8, 2020. Kate Elizabeth Fowler for

McAfee points to race and access as a cause for the unequal treatment some women experience during pregnancy and birth. "I was fortunate to have a doctor advocate for me during my emergency C-section," she says. "My hospital had access to hemorrhage kits and necessary blood supply. If I didn't have all of that, I don't know if I would be here."

Shelly McLEAN, R.N.

There is this belief that Black women can tolerate more pain than white women or that Black women are faking or exaggerating their pain.

— Shelly McLEAN, R.N.

Barriers in Access to Culturally Competent Care

Other factors adversely affecting women's outcomes in childbirth include poverty and unequal access to health care. "If someone is pregnant and can't come to their prenatal care appointment or is working three jobs and if she comes to her appointments she's going to lose her job and can't take care of her family, those are real issues for some women," says Dr. Zephyrin. Our nation's lack of a universal health care program is also where major differences between us and other developed countries truly start to unfold.

This lack of access layered onto a lifetime of racism is particularly problematic for Indigenous women. And for much of this community, access to health care is not just about lack of transportation or availability of nearby prenatal health care. "It's actually a systematic issue as to why Native women didn't access health care," says Abigail Echo-Hawk, member of the Pawnee Nation of Oklahoma, chief research officer at the Seattle Indian Health Board, and director of the Urban Indian Health Institute. "It may have been they experienced discrimination prior or they didn't have a health care provider who they could trust." This distrust is because of racism Native women across the country experienced as a result of the continuous colonialism and historical trauma that has impacted Native people for more than 500 years, Echo-Hawk explains.

As a result, most Native women don't get prenatal care in their first trimester, says Echo-Hawk. Those who do sometimes travel up to 30 or 40 miles from surrounding counties to receive this care. Echo-Hawk sees this occur at the Seattle Indian Health Board, where she serves as chief research officer. These women travel, but not because they don't have closer health care facilities. "It is because we have a culturally attuned program that meets them where they are and that understands the cultural context that provides things like prenatal classes that are grounded in our traditional cultures," she says.

Even those who don't necessarily seek out culturally competent care come to realize the gaps in the care they sometimes otherwise receive. "When I go to the doctor with my family members, I make sure I ask questions that [non-Native health care workers] wouldn't think to discuss," regarding topics like family history and any increased health risks associated with being Native, explains Anjelica Baxter, who is Native Alaskan and a descendant of the Tsimshian and Tlingit tribes. "We shouldn't have to ask these questions."

Baxter learned about the disparity of maternal health care for Native women firsthand after her cousin, Stephanie Snook, an Alaska Native living in Seattle, Washington, died during her pregnancy in 2019. Snook's pregnancy was high-risk—she was 37, had a heart condition, a murmur since birth, and she was pregnant with twins. She also was told she may have preeclampsia at an OB appointment, but her doctors never put her on bed rest or warned her of any particular concerns throughout her pregnancy. At that appointment, her care team told her to take it easy, but sent her home to continue working full-time and acting as the primary caregiver for her two children, ages 10 and 5, who both have autism. Days later, Snook experienced shortness of breath and went to the hospital. By the time most of her extended family arrived to meet her, they were told she didn't make it.

Anjelica Baxter 5
Anjelica Baxter (left) with her cousin, Stephanie Snook. Courtesy of Anjelica Baxter
Stephanie Snook with her kids at the holidays
Courtesy of Anjelica Baxter
Stephanie Snook and her kids
Courtesy of Anjelica Baxter

"They told us they tried their hardest, but they never clarified what happened to her," says Baxter. Snook's twins were delivered right away, but both had seizures due to lack of oxygen and did not survive. "There is still a big question mark—what medically happened to her?" Baxter says. "Why did she go into a state of not breathing—was it her heart murmur or because she was supposed to rest and they released her? I think this could have been prevented if she was in the hospital and her complications were monitored. Why didn't they keep her for observations in case anything like this happened?"

Snook received care in Washington state, where the pregnancy-associated maternal death "rates for non-Hispanic American Indian/Alaska Native women are more than eight times higher" than those of white women, according to the state's 2014-2015 Maternal Mortality Review. Other areas of the country have it just as bad: Georgia, Oklahoma, Alabama, Kentucky, and Arkansas have some of the worst maternal mortality rates in the U.S. California has become a leader when it comes to implementing better practices in hospitals, including early intervention checklists, drills, and better teamwork, and many states are starting to follow its guides. Since 2006, California cut its rate of maternal mortality by more than half.

Abigail Echo-Hawk, Chief research officer at the Seattle Indian Health Board

Most Native women don't get prenatal care in their first trimester. Those who do sometimes travel up to 30 or 40 miles from surrounding counties to receive this care.

— Abigail Echo-Hawk, Chief research officer at the Seattle Indian Health Board

What We Can Do to Help Pregnant People

Officially and formally declaring our nation's high maternal mortality rates as a public health crisis is an important step in the right direction—a direction where mothers do not fear birthing children in this country. It's not, however, the only piece to this solution. "Declaring a public health crisis could be a powerful tool in reducing our country's abysmal maternal mortality rate, but any solution which only focuses on federal resources is sure to miss the mark," says Megan Carolan, the director of policy research at the Institute for Child Success. "Trusting mothers, trusting traditionally underserved communities, and lifting their voices is essential to breaking down the societal barriers that have brought us to this crisis point."

Federal funds marked directly for programs intended to save women from dying in childbirth, access to insurance for all women, and reimagining health care to include culturally competent maternal health care providers as a viable first choice can all go a long way in helping to reduce the number of mothers dying from pregnancy-related causes. First, we must decide that 700 birthing women dying in America per year is too many. Then, we must take up the cause to demand a federal response in order to save them.

— Additional reporting by Melissa Bykofsky

Megan Carolan, the director of policy research at the Institute for Child Success

Trusting mothers, trusting traditionally underserved communities, and lifting their voices is essential to breaking down the societal barriers that have brought us to this crisis point.

— Megan Carolan, the director of policy research at the Institute for Child Success
American Birth Story Masthead
Illustration by Yeji Kim
Updated by Pete Ryan
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