You need to conduct a research on ” M aternal mortality in the United States”. You might find readings on maternal mortality for this unit helpful. To help you think about what you need to write, please answer the following questions:

      1. What are the causes of maternal mortality/deaths in the United States?

      2. Are maternal  deaths decreasing over time?/Is maternal mortality decreasing over time? Why or why not?

      3. What has been done to prevent maternal mortality/deaths in the United States?

      4. Have these efforts been effective? Why or why not?

Once you have completed your research, you will have to write a short research paper. Your paper should be 3-5 pages in length. Please address the questions asked above (but don’t just turn in a bulleted form of the answers to your questions, you are writing a paper!). Additionally, be sure to use any critical terms covered in your assigned readings and this week’s or previous lectures. 

For full credit you must incorporate at least five sources on maternal mortality in the U.S. in your paper. The five sources must be correctly cited (APA or MLA) in the body of your paper. 

American Academy of Nursing

President’s Message

Global maternal mortality rate declines—Except

in America

The broad topics I will address this issue fall under
Reproductive Rights and our value of social justice.
The Academy stated mission and vision on policy and
advocacy work is based on using the best available sci-
entific evidence. This allows us to lend objectivity to
complex, emotionally charged issues, such as mater-
nal morbidity and mortality. It is out of that weighted
objectivity that valid recommendations for modifying
clinical practice can come. I will cite the negative con-
sequences that occur when the available evidence is
not consistently embedded in practice.
This message illustrates the negative consequences

when clinical providers, health systems, and payers do
not utilize these evidence-based practices. The specific
concern is the alarmingly high rate of maternal mor-
tality and morbidity in the United States. Each year in
America, 50,000 women suffer life-threatening compli-
cations (Young, 2018) and 700 of those die
(The Editorial Board, 2018) from a natural event that
has been going on since the beginning of time—child-
birth. If those facts do not shock you, they should,
especially when you consider that more than half of
these deaths are preventable.
The majority of maternal deaths in the United States

are attributed to hypertension and excessive blood
loss. Implementing safety procedures that have been
known to the health care profession for decades could
prevent them. For example, closely monitoring high
blood pressure and blood loss are just two low tech
and low cost interventions that can alert nurses and
physicians when a new mother is on a potential path
of becoming seriously ill (Young, 2018).
The steadily rising maternal death rate in the

United States is now 26.4% per 100,000 births.
(The Editorial Board, 2016) This statistic counters a
global trend which shows maternal mortality rates
dropping in the developed world. (Tavernise, 2016)
Between 1990 and 2015, the number of maternal
deaths in Germany, France, Japan, England, and Can-
ada, has been flat or has declined. (The Editorial
Board, 2016) All the while, the rate in the United
States, which boasts one of the most advanced
health care systems in the world, sees maternal mor-
bidity and mortality climbing. In America, maternal
deaths suffered by women of color are the key factor
driving the increase. (Lost mothers: Maternal mortal-
ity rates in the U.S., 2018)
In New York City, home of the country’s largest

black�white disparity in the maternal death rate, the

divide is getting larger. This widening gap is particu-
larly troublesome considering the fact that the city’s
overall maternal mortality rate has gone down. (Wald-
man, 2018) Black women in New York City face a
higher rate of harm than their white counterparts
even when they are college educated, have a normal
weight and are affluent. In fact, black women from the
city’s wealthiest neighborhoods have poorer maternal
outcomes than white, Asian, and Hispanic mothers
from the city’s poorest areas. (Waldman, 2018)
New York City has recently funded $12.8 million to

underwrite an initiative to eliminate the black�white
disparity in maternal deaths in that city. (Wald-
man, 2018) The money will be used to improve data
collection specific to pregnancy- and childbirth-related
deaths, pay for implicit bias training for medical staff
at private and public facilities and underwrite a city-
wide awareness campaign for the public. In addition,
the city has taken steps to improve maternal care in its
owned hospitals by offering specific training on how to
identify and treat two of the most frequent causes of
maternal death—hemorrhaging and blood clots.
Another program innovation, the introduction of
maternal care coordinators, will target high-risk moth-
ers-to-be with additional assistance to navigate preg-
nancy, prescriptions and public health benefits. The
goal of this comprehensive effort is to reduce by half
the number of pregnancy- and childbirth-related com-
plications occurring in New York City during the next
five years.
This quality improvement pilot program came on the

heels of an NPR series entitled “lost mothers: maternal
mortality rates in the U.S.” (Waldman, 2018) The series
focused on pregnant patients’ high hemorrhage rates
in a Brooklyn hospital.
Only California, which has implemented many of the

gold standard practices outlined in the Alliance for
Innovation in Maternal Health Program (AIM),
(Alliance for Innovation in Maternal Health) is the
exception to this startling trend. AIM is a data-driven
national safety and quality improvement program
designed specifically to address issues related to
maternal health. AIM “safety bundles,” an evidence-
based list of quality-oriented practices and checklists,
helped California bring down maternal complication
rates 21% in just 24 months. As a result of implement-
ing this quality improvement methodology designed
to tackle the most common problems in childbirth,
including heart attack, kidney failure, and blood clots,

http://crossmark.crossref.org/dialog/?doi=10.1016/j.outlook.2018.08.001&domain=pdf

N u r s O u t l o o k 6 6 ( 2 0 1 8 ) 4 2 8 �4 2 9 429

significantly fewer California women found them-
selves on ventilators or scheduled for a hysterectomy
after giving birth. (Young, 2018)
While New York City and California are stepping up

to address maternal mortality in the short term, sev-
eral other states have established review committees
to investigate the issue, and the U.S. Senate has pro-
posed legislature to provide $50 million in funding to
reduce maternal mortality. (Waldman, 2018) In late
August, Senator Kamala Harris (D-CA) introduced the
Maternal Care Access and Reducing Emergencies
(CARE) Act. The Care Access and Reducing Emergen-
cies Act is aimed at addressing and reducing the
disproportionate rates of maternal mortality and
life-threatening pregnancy complications for African-
American women in the United States. With a focus
on addressing the racial disparities in maternal mor-
tality, the bill would establish:

� Implicit bias training grants directed to medical
schools, nursing schools, and other training pro-
grams for health care providers to support implicit
bias training.

� Pregnancy medical home grants directed to up to 10
states to establish or operate statewide pregnancy
medical home programs. The pregnancy medical
home model incentivizes maternal health care pro-
viders to deliver integrated health care services to
pregnant women and new mothers, with the aim of
reducing adverse maternal health outcomes, mater-
nal deaths, and racial health disparities in maternal
mortality.

These alarming maternal morbidity and mortality
rates point out the importance of science and evidence
in shaping public safety advocacy. Using data and
research to validate best practices helps health care
providers minimize unnecessary care, save money,
and move patients into appropriate pathways that pro-
duce desired results. (Carroll, 2017) However, statisti-
cal significance and clinical significance are not the
same. With a substantial cohort, statistical signifi-
cance can be achieved but simply having a large sam-
ple does not necessarily create the clinical significance
needed to modify clinical practice. (Carroll, 2017)
Knowledge gleaned from data and research calls out
for a real-world perspective against which it can be
evaluated and acted upon.
Health systems, nurses, providers and insurers

appear unable to hardwire the evidence of safety
practices related to managing hypertension and
blood loss in a highly reliable way. This is an oppor-
tunity for nurse leaders to advocate for change
based on this evidence. The need to advocate is
now. The time for studying maternal mortality has

long since passed. Without our leadership, America
will continue to be the most dangerous place in the
developed world to give birth.

R E F E R E N C E S

Alliance for Innovation in Maternal Health. New York
Times. Available online from https://safehealthcarefore
verywoman.org/aim-program/

Carroll, A. (2017). What we mean when we say evidence-
based medicine. New York Times. Available online from
https://www.nytimes.com/2017/12/27/upshot/what-
we-mean-when-we-say-evidence-based-medicine.
html.

Lost mothers: Maternal mortality rates in the U.S. (2018).
ProPublica and National Public Radio. Available online
from https://www.npr.org/series/543928389/lost-
mothers.

Tavernise, S. (2016). Maternal mortality rate in U.S. rises,
defying global trend, study finds. New York Times.
Available online from https://www.nytimes.com/2016/
09/22/health/maternal-mortality.html.

The Editorial Board. (2016). Global Burden of Disease Study
2015 provides GPS for global health 2030. The Lancet.
Available online from https://doi.org/10.1016/S0140-
6736(16)31743-3.

The Editorial Board. (2018). High maternal death rate
shames America among developed nations. USA Today.
Available online from https://www.usatoday.com/
story/opinion/2018/07/31/high-maternal-death-rate-
shames-america-developed-nations-editorials-
debates/866752002/.

Waldman, A. (2018). New York City launches initiative to
eliminate racial disparities in maternal death. Propubl-
ica. Available online from https://www.propublica.org/
article/new-york-city-launches-initiative-to-elimi
nate-racial-disparities-in-maternal-death.

Young, A. (2018). Hospitals know how to protect mothers.
They just aren’t doing it. USA Today. Available online
from https://www.usatoday.com/in-depth/news/inves
tigations/deadly-deliveries/2018/07/26/maternal-mor
tality-rates-preeclampsia-postpartum-hemorrhage-
safety/546889002/.

Karen S. Cox, PhD, RN, FACHE, FAAN
Nursing Advocacy and Leadership,

Children’s Mercy Hospital, Kansas City, MO

Corresponding author: Karen S. Cox, Children’s Mercy
Hospital, 2401 Gillham Road, Kansas City, MO 64108.

E-mail address: KarenCox@chamberlain.edu

Available online August 24, 2018

0029-6554/$ – see front matter

� 2018 Published by Elsevier Inc.
https://doi.org/10.1016/j.outlook.2018.08.001

https://safehealthcareforeverywoman.org/aim-program/

https://safehealthcareforeverywoman.org/aim-program/

https://www.npr.org/series/543928389/lost-mothers

https://www.npr.org/series/543928389/lost-mothers

https://doi.org/10.1016/S0140-6736(16)31743-3

https://doi.org/10.1016/S0140-6736(16)31743-3

https://www.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/866752002/

https://www.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/866752002/

https://www.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/866752002/

https://www.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/866752002/

https://www.propublica.org/article/new-york-city-launches-initiative-to-eliminate-racial-disparities-in-maternal-death

https://www.propublica.org/article/new-york-city-launches-initiative-to-eliminate-racial-disparities-in-maternal-death

https://www.propublica.org/article/new-york-city-launches-initiative-to-eliminate-racial-disparities-in-maternal-death

https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/

https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/

https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/

https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/

mailto:KarenCox@chamberlain.edu

https://doi.org/10.1016/j.outlook.2018.08.001

• Global maternal mortality rate declines-Except in America

References

Bull World Health Organ 2015;93:135 | doi: http://dx.doi.org/10.2471/BLT.14.148627

Editorials

135

Although considered mainly as prob-
lems of the developing world, maternal
mortality and morbidity remain a chal-
lenge in the United States of America
(USA).1 Between 1990 and 2013, the
maternal mortality ratio for the USA
more than doubled from an estimated
12 to 28 maternal deaths per 100 000
births1 and the country has now a higher
ratio than those reported for most
high-income countries and the Islamic
Republic of Iran, Libya and Turkey.2
About half of all maternal deaths in the
USA are preventable.2

Each year an estimated 12001 wom-
en in the USA suffer complications dur-
ing pregnancy or childbirth that prove
fatal and 60 0003 suffer complications
that are near-fatal – even though costs
of maternity care in the USA in 2012 ex-
ceeded 60 billion United States dollars.4

Three factors are probably contrib-
uting to the upward trend in maternal
mortality and morbidity in the USA.
First, there is inconsistent obstetric
practice. Hospitals across the USA lack
a standard approach to managing obstet-
ric emergencies and the complications
of pregnancy and childbirth are often
identified too late. Nationally endorsed
plans to manage obstetric emergencies
and updated training and guidance on
implementing these plans is a serious
and ongoing need.5

A second factor is the increasing
number of women who present at an-
tenatal clinics with chronic conditions,
such as hypertension, diabetes and
obesity, which contribute to pregnancy-
related complications. Many of these
women could benefit from the closer
coordination of antenatal and primary
care – including case management and
other community-based services that
help them access care and overcome
cost and other obstacles. In the USA,

women who lack health insurance are
three to four times more likely to die of
pregnancy-related complications than
their insured counterparts.6

Another factor is the general lack
of good data – and related analysis – on
maternal health outcomes. Only half
the USA’s states have maternal mortal-
ity review boards and the data that are
collected are not systematically used to
guide changes that could reduce mater-
nal mortality and morbidity. There is no
national forum for the states to share
either their best practices for reviewing
maternal deaths or the relevant lessons
that they may have learned.

There is a growing effort by physicians,
nurses and community organizations to
address these three factors. Hospitals are
beginning to implement standard ap-
proaches to managing obstetric emergen-
cies so that, wherever a woman gives birth,
she receives appropriate evidence-based
care. Community initiatives are coordi-
nating care for high-risk women to ensure
good health and management of chronic
conditions during and beyond pregnancy.
More states are establishing or strengthen-
ing maternal mortality review boards.

Recent changes to national poli-
cies should also help improve maternal
health outcomes. In 2010 the Afford-
able Care Act included antenatal and
maternal care as essential health benefits
that insurance plans must cover. By ex-
tending insurance coverage to pregnant
women with low incomes, many states
have lowered the economic hurdles that
limit access to antenatal care for millions
of women. As the health community
solidifies the post-2015 agenda to end
preventable maternal mortality, the USA
needs to be brought into the global dia-
logue on maternal health. Although ma-
ternal mortality is relatively rare in the
USA, one preventable maternal death is

one too many. All states need to mobilize
health providers, policy-makers and
communities to make maternal health
a priority. With increased awareness of
maternal mortality and life-threatening
events – and concrete actions to ensure
that pregnant women get the quality care
they need – many fatal and near-fatal
complications could be prevented. ■

Acknowledgements
I thank Heather L Sings (Merck), Maria
Schneider (Rabin Martin) and Dana
Huber (Rabin Martin).

Competing interests: PA is the executive
director of Merck for Mothers and owns
Merck stock.

References
1. Trends in maternal mortality: 1990 to 2013.

Estimates by WHO, UNICEF, UNFPA, The World
Bank and the United Nations Population
Division. Geneva: World Health Organization;
2014. Available from: http://www.who.int/
reproductivehealth/publications/monitoring/
maternal-mortality-2013/en/ [cited 2014 Jul 18].

2. Main EK, Menard MK. Maternal mortality:
time for national action. Obstet Gynecol.
2013 Oct;122(4):735–6. doi: http://dx.doi.
org/10.1097/AOG.0b013e3182a7dc8c PMID:
24084528

3. Creanga AA, Berg CJ, Ko JY, Farr SL, Tong
VT, Bruce FC, et al. Maternal mortality and
morbidity in the United States: where are
we now? J Womens Health (Larchmt). 2014
Jan;23(1):3–9. doi: http://dx.doi.org/10.1089/
jwh.2013.4617 PMID: 24383493

4. Welcome to HCUPnet [Internet]. Rockville:
United States Agency for Healthcare Research
and Quality; 2015. Available from: http://
hcupnet.ahrq.gov/ [cited 2015 Jan 13].

5. D’Alton ME, Main EK, Menard MK, Levy BS. The
National Partnership for Maternal Safety. Obstet
Gynecol. 2014 May;123(5):973–7. doi: http://
dx.doi.org/10.1097/AOG.0000000000000219
PMID: 24785848

6. Chang J, Elam-Evans LD, Berg CJ, Herndon J,
Flowers L, Seed KA, et al. Pregnancy-related
mortality surveillance – United States,
1991–1999. MMWR Surveill Summ. 2003 Feb
21;52(2):1–8. PMID: 12825542

Maternal mortality and morbidity in the United States of America
Priya Agrawala

a Merck for Mothers, Merck & Co. Inc., 1 Merck Drive, Mail Stop WS2A-56, Whitehouse Station, New Jersey, 08889, United States of America.
Correspondence to Priya Agrawal (email: priya.agrawal@merck.com).

http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/

http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/

http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/

http://dx.doi.org/10.1097/AOG.0b013e3182a7dc8c

http://dx.doi.org/10.1097/AOG.0b013e3182a7dc8c

http://www.ncbi.nlm.nih.gov/pubmed/24084528

http://dx.doi.org/10.1089/jwh.2013.4617

http://dx.doi.org/10.1089/jwh.2013.4617

http://www.ncbi.nlm.nih.gov/pubmed/24383493

http://hcupnet.ahrq.gov/

http://hcupnet.ahrq.gov/

http://dx.doi.org/10.1097/AOG.0000000000000219

http://dx.doi.org/10.1097/AOG.0000000000000219

http://www.ncbi.nlm.nih.gov/pubmed/24785848

http://www.ncbi.nlm.nih.gov/pubmed/12825542