“NO JUDGMENT, JUST CARE.” These words cover the walls of a bus stop near my house. It is an ad for Planned Parenthood—the organization that, depending on one’s perspective, is known as America’s largest, best-funded abortion provider, and/or as a champion of women’s health. For Planned Parenthood, the term “women’s health” is synonymous with access to abortion and contraception. Yet their sole focus of “women’s health” on methods that seek to prevent motherhood has played a part in the United States’s comparatively dismal state of maternal health among the developed countries of the world.
An incomplete picture of “women’s health”
Last year, Planned Parenthood ousted president Dr. Leana Wen after just eight months at the organization’s helm. The exact circumstances that led to Wen’s departure (or removal) from Planned Parenthood are murky, but rumors swirled that Wen’s desire to focus more intensely on non-abortion care—such as maternal health—produced “philosophical differences” with the organization’s board chairs.
Dr. Wen’s short presidency is an example of a concerning phenomenon: when abortion and pregnancy prevention are prioritized as the most pressing topics of the day, a more holistic view of women’s health suffers, including maternal health.
When women’s health groups focus on abortion and contraception access first, it suggests that preventing or postponing motherhood are the top goals for women regarding their health today. But the majority of women in the United States say they desire to be (and will eventually become) mothers. Of course, there are some women who will not become mothers, some by circumstance and others by choice. But given the fact that most women will eventually bear children at some point, it seems that a conception of “women’s health” predominantly focused on preventing motherhood misses an extremely significant aspect of the life and health of the average woman. It is one of many potential reasons why the United States has the highest maternal mortality rate (MMR) among the developed nations of the world.
Pregnancy and childbirth in the United States
Around 4 million babies are born in the United States each year, and the CDC estimates that about 700 women die each year from pregnancy or childbirth-related complications. While these numbers indicate that death from childbirth is still a blessedly rare occurrence in the United States, the maternal mortality rate appears to be rising. But the MMR alone presents an incomplete picture with regards to maternal health: investigative reporting in 2017 by NPR and ProPublica found that for each American woman who dies in childbirth, an additional 70 come close to dying (suffering from what is known as severe maternal morbidity). Therefore, while death in pregnancy or childbirth might be rare, nearly dying during those times is much less so.
According to the World Health Organization, the major complications that account for nearly 75 percent of all maternal deaths worldwide are severe bleeding, post-birth infections, high blood pressure during pregnancy (or conditions otherwise known as preeclampsia and eclampsia), complications from delivery, and unsafe abortion. The WHO also notes that many of these complications or conditions are preventable or treatable.
The reasons why our MMR is on the rise are likely multifactorial. On the whole, Americans are increasingly unhealthy, suffering from obesity and associated risks like diabetes and hypertension, and American women are increasingly delaying childbirth until an older age than prior generations. All of these conditions increase the likelihood of complications in pregnancy, delivery, and during the postpartum period.
When mothers’ concerns go ignored
In interviews with NPR and ProPublica, many of the mothers who almost died from pregnancy, childbirth, or related complications expressed that they felt like their health concerns were not taken seriously, or were completely dismissed until things became blatantly dire. For women who did die, their family members reported feeling the same way.
In the course of writing this article, I put out a call for personal stories on social media about pregnancy, childbirth, or postpartum complications that could have been avoided if doctors took their patients’ concerns more seriously, and the responses came flooding in. There are too many to include them all here, and of course, all of the women who answered my call are fortunately still alive, but for some, death came too close for comfort. One woman shared with me how she almost lost her life from an ectopic pregnancy that could have been caught earlier if her “extreme pain and bleeding” had been taken more seriously. Another shared how after a miscarriage led to complications, she had to “beg and plead for appointments, antibiotics, and attention,” and ultimately was hospitalized for an infection that had worsened due to lack of care.
Many women have experienced the incredibly frustrating experience of being turned away at the hospital while in labor; this can be even more frustrating for women who have had babies before and know when they are in labor. This happened to Haley Stewart, who was sent away from the hospital with assurances of, “No, you’re not in labor,” as she moaned through painful contractions during the end of her fourth pregnancy at age 32. This led to an incredibly fast birth (with almost no time to get into a hospital bed) a mere three hours later. Recounting the birth story on her blog, Haley says, “I do feel angry that my instincts were dismissed and that I was told not to listen to my body.”
Amy Garlick was 27 at the time of her first pregnancy, and also felt her health concerns were disregarded to the point of serious risk. Incredibly sick during the first trimester of her pregnancy and plagued by severe panic attacks, Garlick’s doctor told her more than once to stop “being a baby” when she shared her symptoms. It took until her 12-week appointment when she weighed in at under 100 pounds, for her doctor to start taking her concerns seriously. It turned out that Garlick had Hyperemesis Gravidarum (HG), a serious condition that can require hospitalization if it causes severe enough dehydration and weight loss.
Melissa Kobialka, 32, experienced postpartum depression (PPD) and postpartum anxiety (PPA) after the birth of her first child at age 27 that resulted in “suicidal ideation and full blown panic attacks if I heard a crying baby (any baby, even someone else’s child or a doll that made crying sounds).” Shockingly, Kobialka was not even screened for PPD at her six-week postpartum visit. Instead, she was screened at her daughter’s two-month pediatric appointment, but the pediatrician “blew off” the positive results of Kobialka’s PPD survey. It wasn’t until seven months postpartum, when Kobialka says she “started to wish I was dead,” that she finally received help for her PPD.
Black women have even worse maternal health outcomes than white women
A study from the American Journal of Public Health concluded that black mothers are more likely to die from conditions such as “preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage” than white mothers who have the same conditions. This terrible disparity holds true even across income and education levels: the MMR for black women with at least a college degree is 5 times as high as it is for white women with a similar education. Status and experience in public health won’t save a black woman from pregnancy morbidity or mortality, either: whether she is a famous athlete (Serena Williams, who very nearly died in childbirth), an epidemiologist (Shalon Irving, who died three weeks after giving birth via planned C-section), or a former American Hospital Association staffer (Arika Trim, who recently died one week after giving birth via emergency C-section). According to the NPR/ProPublica MMR investigation, the disparity in maternal health outcomes between white and black women is “the main reason the U.S. maternal mortality rate is so much higher than that of other affluent countries.”
The reasons for the disparity in maternal health outcomes between white and black women are complex and multi-faceted. Obesity and hypertension are more prevalent in black women, and both can adversely affect pregnancy outcomes. On the whole, black women are also less likely to have access to early prenatal care, the lack of which is associated with worse maternal and fetal outcomes. Again, however, having a higher income and/or higher education level is not protective for black women or their babies against the increased risk of maternal or fetal death. This has led many in public health to theorize that an insidious form of racism may be at play in black women’s interactions with the medical system, putting them at higher risk of death when their concerns are dismissed as “not a priority.” Bias in medicine (and a vile legacy of historical mistreatment of Black Americans in health care and medical research) has perhaps fostered a culture of mistrust between black patients and their health-care providers, especially in situations where women cannot be treated by a provider with whom they have had an opportunity to establish a trusting relationship.
Babies vs. mothers: a false choice
Whether the mother is white or black, some say that the United States’ focus on saving babies during and after childbirth is largely to blame for the state of maternal health. There may be some truth to this claim (as long as the babies are wanted and viable, of course). The NPR/ProPublica investigation found that “federal and state funding show only 6 percent of block grants for ‘maternal and child health’ actually go to the health of mothers.”
Consider also the current disparity in follow-up care after childbirth for moms versus their babies. The prenatal period is full of dozens of checkups, but after childbirth, most mothers are afforded only one quick check-up at four to six weeks postpartum which will be covered by insurance. For women who have had any sort of complications in pregnancy or childbirth, this can literally be too little, too late; the CDC estimates that one-third of pregnancy-related deaths occur one week to one year after delivery. This is also prime time for postpartum mental health issues to appear, from postpartum depression, to postpartum anxiety, to postpartum psychosis, which if gone undiagnosed and untreated, can lead to devastating outcomes for mothers and their babies. New babies, meanwhile, will have several thorough checkups within their first six months of life. The contrast in care sends a clear message: “Mom’s health doesn’t matter.”
Contrast, too, the increasing numbers of women dying or facing severe maternal morbidity, even as survival rates for premature babies are increasing, and the age of viability keeps decreasing. Armed with these statistics, those who claim that the lives of babies are valued more highly than the lives of their mothers become harder to refute.
How can we decrease the maternal mortality rate?
What are we to do about the increasing MMR in the United States? First, it is clear that we must shift our focus to recognize the truth that a healthy mother makes for a healthy baby, and that both are worthy of the same level of dignity and care. Too often, mothers’ health concerns go ignored, and they need to be taken seriously by healthcare providers before it is too late. No child should have to lose his mother on his birthday, and no mother should have to lose her life on what should be a most joyful and meaningful day.
Practically speaking, it is clear from the NPR/ProPublica reporting that doctors and nurses need better training in recognizing and treating the leading, treatable causes of maternal mortality and morbidity, such as hemorrhage and preeclampsia. States like California have made significant strides in this direction. The recent standardization of maternal mortality reporting data across all 50 states, Washington D.C., and U.S. territories will also, one hopes, prove to be a useful tool in better identifying the leading causes of maternal mortality and in developing data-driven protocols for how to better recognize, prevent, mitigate, or treat these causes. The United States also needs to make a concerted effort in improving postpartum care. A single appointment at four- to six-weeks postpartum is insufficient to safeguard the physical or mental health of new mothers. Especially for women who have experienced any complications in pregnancy or delivery, additional care (preferably in the form of home visits) is needed, as is education of the mother and her partner/caregiver for warning signs of any serious complications that require immediate attention.
It is also clear that the disparity in MMR across racial differences deserves far more attention than it has received. Health-care providers need a better awareness of the conditions that disproportionately plague black mothers, and how to recognize and treat them earlier. More initiatives like the Black Child Legacy Campaign, which pairs black women with doulas to assist and advocate for them during labor (based on research that shows better outcomes for mothers and their babies when the mother has continuous support during labor), are needed on a wider scale, especially in areas where racial disparities are highest. Increased focus on identifying and mitigating possible implicit biases in health-care providers is also of vital importance, as is a commitment on the part of providers to forming trusting doctor-patient relationships.
Better care for women who aren't seeking pregnancy termination
There is some good being done to increase awareness of both the maternal mortality rate and the racial disparities in MMR in the United States, but there is a long way to go. Further, the focus on abortion access has somewhat stunted women’s health conversations when it comes to pregnancy. The sad irony is that maternal health is suffering as abortion and pregnancy prevention takes up all the oxygen in the women’s health conversation.
Recall how the World Health Organization listed “unsafe abortion” as one of the leading causes of maternal deaths worldwide. Yet the WHO also doubles down on abortion as a way to prevent maternal deaths: “To avoid maternal deaths, it is also vital to prevent unwanted pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care.” Abortion providers constantly assure us that legal abortion is an extremely safe procedure—in fact, Planned Parenthood says it “is one of the safest medical procedures you can get.” Abortion advocates stress that unsafe abortions will kill women, but in the same breath, many fight against legislation that would hold abortion clinics to medical standards prioritizing patient care. When the Supreme Court recently struck down a Louisiana law requiring that abortionists have admitting privileges at a local hospital in the event of abortion complications, the ruling was heralded as a victory for women’s health. Ensuring widespread access to abortion was prioritized over ensuring that women could get immediate, emergency care in the event of a complication.
Consider the laxity of abortion restrictions on the federal level in the United States: America tops the very short list of the world’s most liberal countries when it comes to abortion access. In fact, the United States is only one of five countries in the entire world that has no gestational age limit (that is, how far along one’s pregnancy is) for obtaining an abortion at the level of federal law. Notably, abortion complications increase as gestational age increases. The fact that the United States has simultaneously the worst maternal mortality rate in the developed world, yet is one of the most liberal when it comes to abortion in the entire world, throws a wrench into the narrative that safe abortion is vital to avoiding maternal deaths.
Of course, some states have instituted their own abortion restrictions in recent years, while others have become even more liberal. Take New York and its recently signed Reproductive Health Act, which notably allows for late-term abortions up until birth. New York consistently tops the list of states with the most abortions performed per thousand women, and that number is disproportionately made up of black women; in fact almost half of black pregnancies in New York City are ended through abortion rather than through delivery (notably, NYC also happens to be the location of Planned Parenthood’s headquarters). And yet despite the access to (and utilization of) abortion services by black women in NYC, they are still twelve times more likely to die in pregnancy or childbirth than white women.
The New York City example showcases that the WHO’s recommendation that “to avoid maternal deaths, it is also vital to prevent unwanted pregnancies” is like placing a dirty Band-Aid over the open wound of our maternal mortality crisis. Is abortion truly the best we have to offer women so that they don’t die in childbirth? It is sad if this is the implication—but it is also untrue.
Pregnancy prevention at all cost
From a young age, American girls are put on hormonal contraceptives and conditioned to treat their fertility as something to be controlled, covered up, and little understood. Pharmaceutical birth control has been used as a symptom cover-up for common reproductive issues (like endometriosis and PCOS) for so long, that it has disincentivized doctors and researchers from investigating root causes for these disorders and developing effective treatments for them.
In America, instead of seeking answers as to why a young woman is having intensely painful, irregular periods, cystic acne, and debilitating PMS, we place her on a birth control method that will simply mask her symptoms—at least, for as long as she stays on it. When she gets off it, her symptoms may be worse. If later in life she’s trying to get pregnant, she may face infertility due to an underlying condition that could have potentially been treated years earlier.
If we are to expand to a more comprehensive view of women’s health, beyond pregnancy prevention and toward greater reproductive health, we should equip girls from a young age to understand their fertility. Widespread contraceptive access has not convincingly reduced the numbers of women seeking abortion for unplanned pregnancies, since about half of all abortions are obtained by women who were using contraceptives at the time they conceived.
Hope for comprehensive women’s health
These days, some of the most substantive advances in women’s health toward solutions for reproductive disorders have come from the corners of medicine specializing in what’s called “fertility awareness.” There is a growing field of restorative reproductive medicine that uses health information collected by women charting their cycles with fertility awareness methods, such as the Creighton Model, Fertility Education & Medical Management (FEMM), Marquette Method, and Sympto-Thermal Method. Doctors specializing in restorative reproductive medicine are able to use information from a woman’s monthly charts and any accompanying symptoms to pinpoint and treat reproductive health disorders like PMS, PCOS, and endometriosis, including disorders that can cause infertility. In addition, since fertility awareness methods teach a woman how to identify the signs of her fertility, a woman using fertility awareness can work with her body to plan for or avoid pregnancy without side effects (and, depending on the method, with rates as effective as the leading methods of contraception).
Advances in fertility awareness and restorative medicine offer hope that the field of women’s health can incorporate a more holistic view of women’s health and doesn’t have to pit pregnancy avoidance against maternal health. This vision of women’s health puts each woman back in the driver’s seat of understanding her unique body and fertility, equipping her with greater self-knowledge and agency to be a more active participant in her reproductive and overall health care.
Given the sad fact that too many pregnant and postpartum women cannot trust the medical field with their lives in the moments that count the most, we need a paradigm shift away from one-size-fits-all prescriptions and toward more personalized care to treat the unique woman in the doctor’s office. The best path toward greater transparency and accountability for poor care is a more informed patient base. Toward that end, the greater self-knowledge and agency that comes with fertility awareness may be exactly what the field of women’s health needs most.