Megan Hollis, a medical director with the nonprofit Community of Hope, gives a prenatal checkup. While maternal deaths have declined globally since 2000, they have risen in the U.S., in part because many women enter pregnancy in poor health and don’t receive adequate prenatal care. Caroline Preston / Al Jazeera America

“The U.S. takes such pride at being at the front of so many medical breakthroughs, but it continues to tolerate systemic failures and a haphazard approach to maternal health care,” says Rachel Ward, the senior director of research for Amnesty International U.S. and a co-author of a 2009 report, “ Deadly Delivery: The Maternal Health Care Crisis in the USA .”

Buruca and Aguirre are there for their second-trimester ultrasounds, after each sought medical aid early in their pregnancies. They have received monthly checkups, nutritional advice and other support designed to ensure their health as well as their baby’s. But many of the women at Mary’s Center serves are late to care, meaning they don’t receive prenatal services until well into their second or even third trimester. Many expectant mothers are unaware of their health care options, distrustful of the system or unwilling or unable to keep appointments. Although most low-income women in the district, including undocumented immigrants, are eligible to apply for Medicaid when they become pregnant, bureaucratic and paperwork delays sometimes mean they don’t get coverage until their sixth or seventh month. High levels of poverty , homelessness and substance abuse add to the challenges.

Now 26, she lives down the street from Mary’s Center, in the Adams Morgan neighborhood in northwestern Washington, and started going to the facility for care after walking by its blue and white sign. Like Buruca, she is hoping for a girl, though she has picked out only a boy’s name (Hernán) because she doesn’t want to jinx her chances. “If the baby’s healthy,” she says through an interpreter, “I’ll be happy.”

In a chair a few feet away, Delmy Magaly Aguirre reports that, after weeks of constant nausea and vomiting, she’s feeling better as she enters her fifth month of pregnancy. A petite woman with long black hair pulled back in a high braid, she left her hometown in Honduras after the sixth grade. She found a job cleaning houses but quit after having her first child, a boy, at age 20.

WASHINGTON — It’s a little before 11 a.m. at the sonography clinic at Mary’s Center, a nonprofit health group that serves low-income patients across Washington. Janet Buruca, a 22-year-old mother of two boys, is filling out paperwork for the government nutrition program WIC as she waits to enter the small, windowless room to her right. There, the sonographer will press a device called a transducer against Buruca’s belly, screen for fetal abnormalities and register her baby’s length, weight and sex.

The sonography clinic at Mary’s Center, a nonprofit health organization in Washington, D.C. Many of its patients are late to care, meaning they don’t receive prenatal services until their second or third trimester. Caroline Preston / Al Jazeera America

‘Many of our sickest patients may not realize until quite late in their pregnancy that there are problems or complications, because they haven’t been attending routine care.’

The report, along with other research, suggests the problem is manifold. Many women in the U.S. enter pregnancy in ill health, suffering from diabetes, hypertension and other conditions that can complicate childbirth. A shortage of obstetricians, a lack of hospital protocols around postpartum care and high rates of cesareans (roughly a third of births, twice the rate recommended by the World Health Organization) may also play a role, according to some medical experts. The Centers for Disease Control and Prevention estimates that approximately half of maternal deaths, from conditions such as hemorrhage and pre-eclampsia, could be prevented through early diagnosis.

“Many of our sickest patients may not realize until quite late in their pregnancy that there are problems or complications, because they haven’t been attending routine care,” says Melissa Fries, who chairs the department of women’s and infants’ services at MedStar Washington Hospital Center, a facility in northwestern D.C. that serves many high-risk patients.

That hospital, the city’s largest, recorded two maternal deaths in the past year, she says. In one case, a healthy woman died of an amniotic fluid embolism, a rare condition in which the fluid surrounding the fetus enters the mother’s blood stream and triggers an allergiclike reaction. The second case involved a young, HIV-positive woman who was suffering from several infections and then developed sepsis. She ultimately died when an infection reached her brain. Pregnancy wasn’t a direct cause of her death, Fries says, but it may have been a contributing factor.

A former Air Force doctor, Fries is one of a number of medical professionals working with the D.C. government to establish a maternal health review board to study the problem. In its 2009 report, Amnesty found that 29 states and D.C. lacked such an oversight mechanism. That’s despite evidence that reviews can help reduce fatalities. After creating a review board in 2006, California saw its maternal deaths drop from 17 per 100,000 live births that year to 7.3 in 2013, according to Christine Morton, a Stanford University research sociologist and a member of the group. She attributes the decrease in part to the introduction of statewide protocols for how hospitals respond to postpartum hemorrhages.

In Washington it has been hard to focus political will on maternal deaths, doctors there say, in part because the numbers are small compared with some other types of fatalities. With a population of roughly 658,000, D.C. sees only a handful of maternal deaths each year; by contrast, there were 62 infant deaths in the city in 2013, according to NCHS estimates. And the city’s Department of Health says the maternal mortality rates among D.C. residents are roughly half those provided by the NCHS — just two per year, on average. The NCHS data capture women who receive care in the city but don’t live there, the city government says. Washington, the CDC’s Pregnancy Mortality Surveillance System and state governments sometimes do additional analyses of death certificates to cull cases in which pregnancy may not have been a direct cause of mortality; that can result in lower figures.

Still, city officials acknowledge a problem. “In our eyes, one death is one too many,” the city government said in a statement. “We are committed to addressing maternal mortality more formally in the coming year so that our residents have more information surrounding the risks.” The Health Department and the mayor’s office declined to comment on specific plans, but doctors involved in discussions about a review board say they expect the city council to introduce legislation next year to allow its establishment.