The death rate that mars Mother’s Day
Mothers must be honored in the same way that fathers must be honored. Mothers must be revered in the same way that fathers must be revered. That is the lesson to be learned from the way two Torah commandments are worded.
Both Exodus 20:12 and its repetition in Deuteronomy 5:16 command us to “Honor your father and your mother,” while Leviticus 19:3 commands us to “revere your mother and your father.” By putting mother first in the Leviticus verse, the Torah is telling us that mothers and fathers are equal in God’s eyes, and thus should be equal in our eyes.
That message, however, seems to be lost here in America. We set aside a national day to celebrate mothers, this Sunday being that day this year, but we either ignore their prenatal, natal and postnatal needs, or we give those needs short shrift.
The term maternal death, as both the Centers for Disease Control and the World Health Organization use it, includes deaths during pregnancy, at birth, or within the first 42 days after giving birth. According to a January 2019 CDC report, there were 658 maternal deaths here in 2018. Knowing that, you would think that we would do whatever is necessary to keep as many women as possible from dying because of a pregnancy or in the aftermath of delivery, but that is not the case. The numbers keep climbing — 754 maternal deaths in 2019, 861 deaths in 2020, and 1,205 in 2021.
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There are 195 nations in the world, and 191 of them report maternal death rates. There are 134 nations among them with lower rates than the United States. We rank 14th worst out of 191 nations in high maternal mortality rates. (By comparison, Israel ranks 128th on that list.)
What turns a shameful statistic into a disgraceful one is that somewhere around 60 percent of these deaths in the United States are preventable, yet we do little to prevent them.
As if that is not disgraceful enough, the picture is probably even worse than the CDC statistics show because there are gaping holes in the methodology used. Women who are 44 and older are excluded, although women can give birth until age 50 or 51, and although the older a woman is, according to that very same CDC study, the greater is her risk of death. The data show that beginning at age 35, the risk of a pregnancy-related death rises with every year that goes by.
The CDC also excludes women who died later than 42 days after giving birth, although as many as 24 percent of pregnancy-related deaths in the United States, or nearly one out of every four, occur from 43 days to a full year after delivery.
Women with postpartum depression who die by suicide or drug overdoses also are excluded, even though expert after expert says such deaths must be considered birth-related.
Racial disparity is another disgrace. Black women, the annual CDC reports show, have way higher rates of death than other groups.
Maternal death knows no social status, by the way. Women of every race and ethnicity, education, and income level, in every part of the country, are among those who die. A list of maternal deaths since 2011 includes the poor and the homeless, but it also includes teachers, insurance brokers, journalists, administrators, and even doctors and nurses.
There are many reasons for this higher maternal mortality rate. We knew those reasons before 2018, we knew them in 2018, and we still know them, but we have not done much to correct them.
The insurance-driven medical system in this country is in great part to blame. Mothers are sent home from the hospital much too quickly. Too many doctors are opting for C-sections over natural births, too often leading to more life-threatening complications, especially in older women. Our woefully inadequate health care system makes it harder for new mothers — especially those without sufficient insurance coverage — to get proper prenatal and postnatal care through the 12 months after birth.
One reason is the shortage of qualified OB-GYNs and midwives here. This country has the lowest overall supply of both — there are only 12 OB-GYNs and midwives per 1,000 live births, and that is nowhere close to enough. Canada is not much better, with just 15 providers per 1,000 live births. All other countries have between two and six times more providers.
Increasing the number of qualified midwives would help alleviate this shortage. Various studies have shown that midwives in other countries often provide better care than OB-GYNs because their care is more personal, and they offer follow-up care for the entire year after birth.
As a November 2020 study by the Commonwealth Fund explained, midwives “can help address the social and personal needs of mother, baby, and family. OB-GYNs, meanwhile, are physicians trained to identify and intervene in abnormal conditions that come up before, during, and after pregnancy. They typically provide care in hospital-based settings.”
The New York City-based fund has as its mission “to promote a high-performing, equitable health care system [in the United States] that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including people of color, people with low income, and those who are uninsured.”
Follow-up care is crucial, but the United States “lacks comprehensive postpartum supports,” according to the fund’s study. In fact, “Although a large share of its maternal deaths occurs post-birth, the U.S. is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period.”
According to the American College of Nurse Midwives, the “U.S. maternity workforce is upside down relative to patient needs.”
State laws, which have the complete support of the American Medical Association, are mainly responsible for the dearth of midwives. There are many legal obstacles imposed on the practice of midwifery throughout the United States. These include outdated state licensing laws that limit the scope of what a midwife is permitted to do, rules that require midwives to be supervised by physicians, who by and large do not want anything to do with midwives, and denying midwives the power to prescribe for their patients.
Then there is Medicaid. It pays for about 47 percent of births, but in too many states, it covers mothers for only 60 days after they give birth, even though the number of maternal deaths that occur goes all the way up to a full year. According to the latest figures we have, there were 343 maternal deaths after day 42, the CDC’s cutoff day, and 217 of these maternal deaths occurred after day 60, the Medicaid cutoff.
Extending maternal coverage to a full year is essential, say the experts, and they have been saying it for quite a while, but the political will to do so is lacking. Republicans in the House, for example, in a bill passed in late March, actually voted to cut Medicaid substantially.
Liberals are not much better than conservatives when it comes to maternal health care. They make big issues out of maternity leave and equal pay for equal work, but too many of them say too little about extending maternal health care. They did bring it up in 2020, but only because the Democratic presidential primary race that year included several women who forced the issue onto the agenda.
We are supposed to be “one nation, under God,” but God seems to have no influence when it comes to setting policy, whether at the government level or in the medical profession. To both, it is not the Almighty but the Almighty Buck that rules.
As I noted at the beginning of this column, the Torah goes out of its way to make sure we understand that mothers are on the same level as fathers. It also goes out of its way through its narratives, as well as its laws, to make sure we understand that all women are the equals of men in all things and must be treated as such.
As Genesis 1:27 is understood by many of our Sages of Blessed Memory, the “human” who God created on the sixth day was half man and half woman, capable of procreating on its own, and is referred to only as ha-adam, the human. (“Adam” is not a name; it is just a word meaning human.) The first human to be created as we understand humans was a woman (see Genesis 2:22) because the word for woman (ishah) appears in the Torah before the word for man (ish) appears.
She also was the first human in the Torah to be given a name: Chavah (Eve), meaning “the mother of all the living,” as the Torah says. (See Genesis 3:20.)
The most selfless people in Genesis are the women — Hagar, Sarah, Rebekah, Rachel, Leah, Bilhah, and Zilpah. Long before God ever speaks to Isaac, God speaks to Rebekah.
If we truly want to celebrate mothers in America, we need to raise our voices as high as they can go, so that our politicians can hear those voices, even if the health and insurance industries remain deaf to them.
Shammai Engelmayer is a rabbi-emeritus of Congregation Beth Israel of the Palisades and an adult education teacher in Bergen County. He is the author of eight books and the winner of 10 awards for his commentaries. His website is www.shammai.org.