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How health cuts are killing women

The Guardian/UK, 7/6/11

As Republicans push for bigger budget cuts, slashed public health programmes mean maternal mortality is already ticking up

The medical records archive at a community health centre in Bakersfield, California; thanks to the state's budget crisis, all state funding for maternal and child health programmes has been cut. Pregnancy-related mortality is rising rapidly in California. Photograph: Phil McCarten/Reuters

While Republicans and Democrats are engaged in apparently abstract debt reduction talks, it's worth noting that a cascade of federal, state and local spending cuts has already taken its toll on the health of pregnant women, mothers and babies. Between 2003 and 2007, the average maternal mortality rate – defined by deaths that occur within 42 days of childbirth – has risen to 13 deaths per 100,000 live births, approximately double the low of 6.6 deaths per 100,000 live births recorded in 1987. Today, the United States ranks 41st in the world for maternal mortality, one of the worst records among developed countries. "Near misses", complications so severe that a woman nearly dies, have increased between 1998 and 2005 to become common – at one woman every 15 minutes.

These disturbing trends are even worse for African American women and poorer women. Nationally, African American women are three to four times more likely to die of pregnancy-related death than white women. States in which poverty rates exceeded 18% had a 77% higher rate of maternal mortality than states with lower rates of poverty.

And yet, over the last seven years, federal spending for maternal and child health programmes has been reduced by 10%. That women can still bleed to death after childbirth in 21st-century America does not seem to bother lawmakers too much. (In New York City, in 2004, haemorrhaging was the leading cause of maternal death – approximately one third of all cases.)

Maternal health services – including home visitation programmes for pregnant women, new mothers and their babies, infant health programmes, adolescent life and family programmes and community health centres – play an important role in ensuring women receive the care they need during and after pregnancy. These community health centres, for instance, can be lifesavers for low-income women with no easy access to medical practices located in more affluent areas. In 2011, the federal budget for these centres has been cut by 660m.

Federal spending cuts have a trickledown effect. Take California, for example, which has been in the grip of a budget crisis since 2008, longer than most states, and has completely eliminated state general funds for maternal and child health. County councils have followed suit. In San Joaquin county, staff cuts have led to a sharp decrease in the provision of maternal and child health services: where, in past years, they were able to follow and provide care to 1,300 pregnant women, that number dropped to 400 in 2010. As public health nurses concentrate on the most acute cases, many women are falling between the cracks of an already stretched system.

The timing of these cuts could not be worse. More women now have risky pregnancies due to a surge in chronic diseases and adverse socio-economic conditions. Meanwhile, states are scaling back Medicaid enrolment efforts and/or reimbursement rates as additional federal funding under the Recovery Act expires at the end of June. This will, no doubt, have a disproportionate effect on low-income pregnant women who already struggle to find doctors who accept Medicaid clients.

Paradoxically, even as governors are slashing funding for maternal health programmes, there is growing awareness of the problem of poor maternal health. With one of the best maternal mortality review systems in the country, California is a trendsetter. The state department of public health provides a comprehensive, long-term picture of maternal mortality that examines "pregnancy-related" deaths among women who died of pregnancy-related causes within a year of giving birth, rather than the standard 42-day postnatal period. The report released in April 2011  found that the pregnancy-related mortality rate rose from 10.3 per 100,000 births during the years 2000-2002, to 16.4 during the years 2006-2008. The Californian model has inspired the Maternal Accountability Act (HR 894), which requires states to establish state maternal mortality review committees on pregnancy-related deaths. Unfortunately, the legislation has no chance of passing in the current political climate.

Maternal deaths at these levels are a national disgrace. Amnesty International, in its report, asserts that high maternal mortality reflects a continuous violation of women's human rights. Under the Global Health Initiative, the Obama administration has intensified the US's commitment to improve maternal health in developing countries. Given the rising death rate for American women, it's time for the president to step in forcefully to provide similar efforts at home, too. Standards of maternal healthcare should not be allowed to deteriorate further under Obama's watch.

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