Although maternal and child death rates have declined in many countries in recent years, the U.S. is among eight nations in which these rates have increased over the past decade, according to a report published May 2 in the medical journal The Lancet.
Karen Tabb Dina, a professor in the School of Social Work at the University of Illinois, is a member of the Global Burden of Disease Expert Collaborators, the group of researchers who developed the report. Tabb Dina's research focuses on racial and ethnic health disparities, and includes collaborative projects with maternal health clinics to combat postpartum depression and suicide.
Tabb Dina spoke recently with News Bureau social work editor Sharita Forrest about the problem of maternal mortality in the U.S.
What is the Global Burden of Disease Study and what did the group find in its study of maternal and child death rates?
The Global Burden of Disease Study is a collaborative of more than 1,000 researchers worldwide that aims to improve health policy, bring attention to diseases and conditions, and guide new target-setting exercises for health improvement. The Institute for Health Metrics and Evaluation at the University of Washington coordinates the project.
I also belong to a subgroup of the GBD called the All-Cause Mortality Section, which produced the May 2 report in The Lancet.
Child death rates dropped by 48 percent globally between 1990-2013. However, 6.3 million children still died before their fifth birthday in 2013.
In 2000, the United Nations established Millennium Development Goals, which called for reducing maternal death rates by 75 percent, and child death rates by two-thirds of their 1990 levels by 2015.
Since the U.N. set the MDGs, we found that only 45 countries, including 27 in the developing world, are on track to meet the MDGs' child mortality targets.
And only 16 countries, mostly in Central and Eastern Europe, are likely to achieve the maternal death rate targets.
The U.S. and Canada are two of the countries that have seen increases in maternal mortality, which is alarming. (In the U.S. the number of maternal deaths per 100,000 live births increased from 527 in 1990 to 796 in 2013).
Some countries are making progress, especially Brazil, China, India, Russia and South Africa. So we are seeing progress internationally and moving toward reaching those goals of reducing maternal mortality - but rates in North America are increasing.
What lessons, programs or ideas could the U.S. take from those countries that are improving their maternal mortality rates?
We've seen improvements in infant and maternal mortality in the global South - Africa, Central and Latin America, and most of Asia - through outreach, such as prenatal education and nutrition programs, which are cost effective and life saving for moms and infants. A lot of these programs could be replicated here in the U.S. There's lots of room for improvement, but I'm hopeful.
The paper indicated that maternal deaths might occur up to a year postpartum. Are those deaths attributable to increased incidence of chronic diseases, such as high blood pressure and diabetes, to problems that occur during delivery/pregnancy or other causes?
The leading cause of maternal death globally is medical complications associated with childbirth and the period post-delivery. About one-quarter of maternal deaths occur during childbirth or within the first 24 hours of delivery. Another one-quarter occurs during pregnancy, and the remaining deaths up to one year after delivery.
In the U.S., we've seen that homicide, suicide and injury are the leading causes of death during pregnancy and that first year after delivery. Complications from chronic illnesses can show up later in the year as well, but we still attribute that to maternal mortality.
With previously uninsured women now having access to health care services under Obamacare, is the U.S.'s performance on these measures likely to improve?
One of the foci of the Patient Protection and Affordable Care Act is strengthening the infrastructure that will improve maternal and child health. That includes increased screening for psychosocial and social determinants, such as domestic violence and perinatal depression, and a focus on prevention that's been lacking.
There's also a layer of oversight that we haven't had previously - mandates to reduce hospital admissions and reduce costs - and there are smaller provisions of the Act, such as emphases on breastfeeding and prenatal education, which are setting things in place that can lead to healthy pregnancies and births.
Another provision of the PPACA, called the Melanie Blocker Stokes Act - or the Mothers' Act - calls for increased educational efforts on behalf of providers to promote awareness about suicide during pregnancy and the postpartum period.
Illinois is one of eight states that mandates perinatal depression screening. Illinois has had its mandate in place since 2008. So we've already started to do a lot of the groundwork here in Illinois. Thankfully, all of our local clinics are screening for perinatal depression and suicide.
I have a lot of hope for the perinatal depression screening. Some of my research has looked at screening moms for suicidal ideation in-clinic, so that we can catch it before moms go home with their babies.
In my research with Carle Clinic and the Champaign-Urbana Public Health District, our initial analyses of the data suggest a direct association between maternal depression and low birth weights. We have a database registry to review depression screens from all pregnant women in our local clinics, and we're looking at the role of depression in combination with diabetes and hypertension.
In Brazil, right now I'm working on a study about suicidal ideation and interpersonal violence, both of which are independently associated with maternal mortality. We interviewed moms during pregnancy and delivery, and we're finding that women who report thoughts of death or harm are experiencing increased incidence of interpersonal violence - such as verbal, physical and sexual abuse.