Cutting-edge medical advances and innovative technologies have made headlines and continue to flourish in the new millennium. However, these medical achievements stand in stark contrast to the paradoxical increase in US maternal mortality, which is among the highest of all developed nations.1 Why are our mothers dying? The question and, more importantly, the answers are complex. Maternal mortality is a multidimensional phenomenon encompassing: barriers to health care access; racial and ethnic disparities; concurrent escalating maternal comorbidities including obesity, diabetes and hypertension; inadequate perinatal science and translational perinatal medicine; and variable reporting statistics which only recently enhanced ascertainment of cases. With this issue, Contemporary OB/GYN begins a year-long commitment to raising awareness, detailing etiologies and providing clinically relevant algorithms for the management of life-threatening maternal complications in an effort to mitigate this tragedy.
Maternal mortality ratio (MMR) is defined as pregnancy-related deaths per 100,000 live births. Globally, the MMR was 282 (95% uncertainty interval (UI) 264-300) in 1990 and decreased to 196 (173-224) in 2015, falling by 30%. In contrast, the United States MMR rose from 16.9 (16.2-17.8) in 1990 to 26.4 (24.6-28.4) in 2015, climbing more than 56%.1 Among 31 Organization for Economic Cooperation and Development countries reporting maternal mortality data, the United States ranked second from the bottom.2 In contrast, during this same time period, the MMR remained relatively low in Canada, increasing slightly from 6.0 (5.2-6.9) in 1990 to 7.3 (6.2-8.7) in 2015. This discrepancy between neighboring countries seems incomprehensible, particularly considering that Canada has a lower per capita income. With over 4 million American women giving birth annually, this is not a statistical aberration, it is a medical catastrophe. Our mothers deserve so much more.
Although the statistics are sobering, the addition of “pregnancy question formats” to death certificate data introduced in 2003 account for some of the apparent increase. To counteract underreporting of maternal deaths in the National Vital Statistics system, a pregnancy question with checkboxes was introduced in 2003 but has had differential state update. The goal of the question was to ascertain whether women were pregnant at the time of death or within 1 year of pregnancy. MacDorman et al. have estimated that as much as 79.9% of the total increase in maternal mortality since the new millennium may be due to improvement in ascertainment.2 However, adjustment for ascertainment bias should not diminish our national shame in having one of the highest maternal mortality rates in the industrialized world.