When Devika Maulik was pregnant with her first child, her friends wondered why she wasn’t more excited. They said she almost seemed emotionally detached from the pregnancy.
“I think I was just so aware of what could go wrong,” said Maulik, an assistant professor at the University of Missouri-Kansas City and an obstetrician-gynecologist at Children’s Mercy Hospital and Truman Medical Center. “Even with all the improvements in care that have happened over the course of the 20th century. ... Pregnancy is a time that your body is growing a human being. It’s going to be put to the test and things can go wrong.”
For Maulik, who specializes in high-risk pregnancies, deaths due to childbirth are not a relic of America’s pioneer days. They’re a real and present danger.
The United States has the highest maternal mortality rate of all developed nations and Missouri has one of the highest rates in the nation.
The United Health Foundation’s 2016 Health of Women and Children Report pegged the national average at about 19.9 deaths per 100,000 live births, while Missouri’s maternal mortality rate was 28.5 deaths per 100,000 live births, which ranked 42nd nationally. Kansas clocked in at 19.6 and states like California (5.9) and Massachusetts (5.8) were well under double digits.
Missouri’s rate is about on par with Belize, and worse than poorer countries like Moldova (23) and Costa Rica (25), according to the CIA’s World Factbook.
“It’s not acceptable,” said Randall Williams, the director of the Missouri Department of Health and Senior Services.
Williams, an OB-GYN himself, was appointed by Gov. Eric Greitens this year. He came from North Carolina, where he was part of a task force that examined every pregnancy-related death that occurred in the state. Williams said he expects bills to create a similar task force in Missouri will be introduced in the legislative session that begins next month and maternal mortality will be a hot topic for lawmakers.
Williams said he doesn’t want to “disproportionately scare people, because the vast majority of moms obviously do fine.”
But there’s room for improvement in Missouri.
Williams said the majority of maternal deaths are preventable, especially those due to hemorrhage, or bleeding out.
The leading causes of maternal death in Missouri are all cardiac-related, with embolisms caused by blood clots topping the list. The state’s high rates of smoking and obesity during pregnancy put women at higher risk for those complications. They also make them more likely to have diabetes or high blood pressure, which Maulik said are the most common risk factors she deals with in her patients.
All of those risks are compounded when pregnant women don’t see a doctor regularly. A report released by Williams’ agency in May found that 17.5 percent of Missouri women received no prenatal care in the first trimester of pregnancy.
That’s partly an issue of access. Williams said 67 Missouri counties don’t have a single OB/GYN. He’s decided to spend one Saturday a month working in a clinic in Springfield, in addition to running the health department.
“We need all hands on deck,” Williams said.
Cost is also a factor.
Maulik said women should ideally start seeing a physician when they’re considering trying to get pregnant, so doctors can look for underlying medical conditions and advise them to take supplements like folic acid.
But the state report found that 26 percent of Missouri women were uninsured in the months before they got pregnant.
Most of those women qualify for Medicaid once they’re pregnant, but for those who aren’t covered, Maulik said government-subsidized places like Truman might be their only option for miles.
“A safety net hospital like this I think is actually really critical to these moms because sometimes these mothers don’t get care,” Maulik said. “Sometimes they haven’t seen a physician in years until they’re pregnant.”
By then, they might already have several risk factors.
The difference is more stark when it comes to tobacco use. About 15 percent of Missouri women smoked during pregnancy in 2015 and that number had been steady for about six years. Nationally, the rate is about 8.4 percent.
“I’ve worked on both coasts and when I came here I was actually shocked to see how many smoking pregnant mothers we do have,” Maulik said. “They have an idea that it’s not good for the pregnancy, but it is so hard to quit and even as a physician there are really limited options if they’re not self-motivated to do it.”
Then there are women who manage to quit, but live in households where they are still exposed to secondhand smoke.
Maulik said that’s an illustration of one of the main challenges doctors face in keeping pregnant women healthy. They need the support of the woman’s family, and even the community at large.
“If I think about it, every single woman I have taken care of has had to deal with the fact that their pregnancy may not be fully supported by their family or their employer,” Maulik said. “These things do matter in terms of the care they get and some of it is even beyond a physician’s control, or nurse’s control, or hospital’s control.”