Elizabeth “Liz” Logelin was a young, fit woman with a promising career in operations management at Disney. On March 24, 2008, after a complicated pregnancy that saw her bedridden for nearly two months (three weeks of which were in the hospital), she delivered her daughter Madeline (“Maddy”) through an emergency cesarean section. Two and a half months early, Maddy was healthy, if tiny. Twenty seven hours after the delivery, Liz was finally cleared to hold her firstborn. Her husband Matt Logelin already was, he teased her, several diaper changes ahead of her. She got up from the bed, ready to make her way to the nursery, and stopped in front of the mirror. “My hair looks like shit,” she said, of her long tresses. She laughed, Matt laughed, the nurses laughed. He thought her hair looked great.

She walked towards the wheelchair that was going to take her to the nursery, and suddenly didn’t feel well. “I feel lightheaded,” she complained. Moments later, at age 30, Liz was dead.

The cause was a pulmonary embolism—a blood clot that travelled from her leg to her lungs, and killed her instantaneously.

Though she had a family history of blood clots, suggesting a genetic predisposition, and her risk was increased by the prolonged bed rest and the subsequent c-section surgery, to Matt’s knowledge Liz wasn’t given anticoagulant medications, or advised to exercise to help stimulate her blood flow. Everyone’s attention, hers included, was turned elsewhere, to baby Maddy—so precious, so perfect.

Photo courtesy of Matt Logelin Matt Logelin with his daughter Maddy, 11 months, in Joshua Tree, California.

There’s an assumption that death from childbirth is just not something that happens—not in America, or at the very least not in Matt and Liz’s America. “We were very healthy people living in Southern California, with great jobs; [Liz] was very healthy—she didn’t smoke, she barely drank,” Matt says. “We thought we were untouchable,” he adds ruefully.

But dying of childbirth, Matt would learn in the worst possible way, did happen in America. Even to women as young and healthy as Liz, with access to good medical care, and the wherewithal to understand and follow up on their doctor’s advice.

“We were very healthy people living in Southern California, with great jobs […] We thought we were untouchable.”

On that March day, she joined one of the US’s most shameful statistics. With an estimated 26.4 deaths for every 100,000 live births in 2015, America has the highest maternal mortality rate of all industrialized countries—by several times over. In Canada, the rate is 7.3; in Western Europe, the average is 7.2, with many countries including Italy, Norway, Sweden, and Austria showing rates around 4. More women die of childbirth-related causes in the US than they do in Iran (20.8), Lebanon (15.3), Turkey (15.8), Puerto Rico (15.1), China (17.7), and many more.

While most of the world has drastically reduced maternal mortality in the past three decades, the US is one of just a handful of countries where the problem worsened, and significantly.

Between 700 and 1,200 women die from complications related to pregnancy or childbirth every year in the US. Fifty times that number—about 50,000 in all—narrowly escape death, while another 100,000 women a year fall gravely ill during or following a pregnancy.

The dire state of US data collection on maternal health and mortality is also distressing. Until the early 1990s, death certificates did not note if a woman was pregnant or had recently given birth when she died. It took until 2017 for all US states to add that check box to their death certificates. Calculating the number of near-deaths and severe illnesses related to pregnancy is still guesswork. There is no standard or official method of tracking, and cases are not routinely documented. In other words, data collection about maternal health and mortality is a complete mess. Even gathering reliable data for this story was difficult. Quartz was forced to turn to state data where there was a lack of national data, and to supplement gaps of any data with anecdotal evidence. If the US does not know it faces a crisis, how can it reverse the tide, and prevent the needless death of the next Liz Logelin?

Quartz probes the sorry state of US maternal data in a separate story.

The lack of proper documentation of maternal health is about more than data collection though, and speaks volumes about what little thought or consideration has been given to expectant and new mothers in the US. It’s hard to avoid the inference that they’re not considered important enough to merit focused attention. It’s certainly representative of a bigger problem, that women in the US are not getting the medical attention they need. It’s as though the US is rendering its mothers invisible.

“It’s the biggest catastrophe that we have in medicine to have young mothers die of preventable causes,” says Elliot Main, the medical director of the California Maternal Quality Care Collaborative (CMQCC).

“It’s the biggest catastrophe that we have in medicine to have young mothers die of preventable causes.”

Determining exactly why so many American mothers are dying of, or suffering through, pregnancy is a gargantuan public-health puzzle. Through the course of reporting this story, it quickly became apparent that there is no single reason, but instead a complex brew of factors that, together, point to deep-rooted, systemic problems that run through the entire social and health care system of the country. Gender, class, race—and across all, a fragmented, mainly private health system—conspire to work against maternal health. In many ways, it’s a litmus test of the health of health care in the US.

Older, fatter, sicker: The fault of the mothers

America didn’t always fare so poorly in maternal health. Like most other developing countries, in the decades following the end of World War II, maternal mortality rates dropped across the US—until the late 1980s, when the trend began to reverse.

Historic data from the Centers for Disease Control and Prevention (CDC) show that right around the turn of the millennium, the US diverged from most countries’ focus on policies to curb maternal mortality in a drive to comply with a United Nations commitment to cut deaths by three quarters globally by 2015. Though the global target was missed, maternal mortality fell dramatically around the world—30% according to more conservative estimates, 45% per the official UN report—between 1990 and 2015. In the US, maternal mortality rose nearly 60% over the same period.

Given the inadequacy of the data collected in the US over those years, it’s very possible that the country was undercounting its maternal mortality rates all along, and that the increase wasn’t an increase at all, but simply reflected better data. Regardless, says David Goodman, senior scientist for the CDC’s Maternal and Child Health Epidemiology Program, “At best [maternal mortality] is going flat, but it’s still higher than it should be.”

It’s very possible that the country was undercounting its maternal mortality rates all along.

Other, related trends were evident in the US over that 1990-2015 period, in particular steep increases in the rates of obesity and diabetes. Couple that with a growing trend of women deciding to delay motherhood until they were older, and you very quickly arrive at a refrain that is often used to explain why America is failing to keep its number of maternal deaths at acceptable levels: that new mothers are “older, fatter, and sicker.”

“The increasing number of women who enter pregnancy with higher rates of obesity, hypertension, diabetes, abnormal placentation…are typically the first and only factors considered,” points out Christine Morton, a researcher at the CMQCC, in a commentary paper.

In other words, she notes, it’s presented as the women’s fault.

In a culture that places such emphasis on the value of self-determination and personal responsibility, it’s perhaps not surprising that expectant or new mothers would be judged deficient in their apparently poor life choices. But that ignores the fact that increased rates of obesity and related chronic health conditions are global, not just American, and that in other countries, they do not amount to a death sentence. Obesity among white mothers worldwide nearly doubled between 1980 and the early 2010s. Maternal deaths nearly halved (pdf, p.5-6).

Suellen Miller, a professor of gynecology and director of the Safe Motherhood Project at the University of California-San Francisco (UCSF), told Quartz that “all over the world, there is an obstetric demographic shift to older women, to more obese women, to women with more chronic conditions, and in many places to women who smoke.“ And yet, outside of the US, many women are safely delivering babies despite conditions that, some years ago, would have made that impossible. In certain parts of the world—Scandinavia and Western Europe, in particular—a focus on more dedicated care, before, during, and after birth leads to dramatically different results.

It’s not enough to say “that women are entering pregnancy ‘older, fatter and sicker,’ although that may be part of the story,” Morton insists. Instead, we need to understand why American women are fatter and sicker in the first place, and why manageable conditions end in women dying.

Priority matters

Whether they are pregnant or not, women are second-class citizens when it comes to health care. They wait longer to be seen by doctors than male counterparts, their pain is routinely minimized (by gynecologists, no less), and though they are less likely to seek medical attention than men, their symptoms are more frequently dismissed as superficial—for instance being attributed, mistakenly, to psychological rather than physiological causes. Serious health conditions, from heart attack to cancer, are often downplayed in female patients.

When it comes to pregnant women, this manifests itself in a focus on the child, at the cost of a focus on the mother, as highlighted in a recent investigation by NPR and ProPublica into the issue. Health-care professionals spend their time and energy on the baby. This was the experience of the Logelin family—in the end, it was a case of the woman not being fully seen or heard by the US medical system.

Photo courtesy of Matt Logelin Newborn Maddy Logelin.

Jen Albert, a communications professional from Philadelphia who nearly died after developing polyhydramnios (excess of amniotic fluid) and being induced, says her experience taught her that “no one expects that someone could die in childbirth.” The only potential risks that are taken seriously, she says, are the child’s, while “the mother is only a vehicle to bring the baby.”

Evidence of the US’s medical (and social) priorities can be seen everywhere, including in the disproportionate amount of care a woman receives while pregnant compared to after she has delivered. American women typically have three to five ultrasounds of their fetus, for instance, compared to the two or three British (and most other European) women have. After birth, it’s a different story. Many other countries (including the UK) provide support from nurses and doulas after a woman has left the hospital, while that’s rarer in the US. Meanwhile, the US is the only rich country that doesn’t mandate maternity leave.

Women feeling unheard were among the findings of a 2013 maternity care policy report, “Listening to Mothers” (pdf). Researchers, led by Eugene Declercq, a professor of community health science at Boston University, surveyed 2,400 women who had recently given birth in the US. The results suggested that most women didn’t always feel fully supported through their pregnancy. The majority of women reported holding back from asking questions of their providers because they felt rushed (30%) or they wanted a different kind of care than the one chosen by their doctors (22%), with 23% women saying they held back due to fear of being considered “difficult.”

An especially striking example can be found in the way mental health issues—the most common pregnancy-related complication in the US, affecting over 14% of pregnant women—are handled.

In 2016, the US Preventive Services Task Force, an independent panel of experts established in 1984 to decide which preventive measures should be adopted by doctors in the US, recommended that all pregnant and postpartum women be screened for depression. This marked a big step forward given that suicide is the second leading cause of death among postpartum mothers. But a pregnant or postpartum woman who finds herself in need of mental health support still has to navigate a complex process of getting treatment, including waiting lists and screenings, said Joy Burkhard, who leads 2020 Mom, an organization focused on improving maternal mental health care in the US.

Once the baby is born, new mothers in the US generally have to wait six weeks for their first post-delivery obstetrician-gynecologist (OB-GYN) appointment, so even if their doctor is trained to recognize symptoms of depression (which isn’t common) those first symptoms of depression that can follow delivery will be missed entirely. This contributes to a vast underdiagnosis of postpartum depression (only 50% cases are recognized in the US) and undertreatment of the condition (15% receive treatment). Suicide accounts for 20% of postpartum deaths.

Too many women report their calls for help being ignored.

Too many women report their calls for help being ignored. “I visited 29 care providers, begging for help. I was given so many reasons why I couldn’t be helped,” remembers Maureen Fura, whose documentary The Dark Side of the Full Moon deals with postpartum depression and the difficulties of getting treatment for it. “I was told that my problem was ‘too big’ for my graduate school’s three free sessions of therapy care, that I had to wait three months to be seen, that my insurance was too good, that my insurance wasn’t good enough.”

It’s hard to fathom why, though pregnancy, delivery, and post-delivery are important medical episodes in the arc of a woman’s life, her health during those experiences seems to often fall into a blind spot. According to the CDC, as many as 17% of the pregnancy-related deaths caused by blood clots—like Liz Logelin’s—could be prevented with simple measures such as compression stockings, or anti-coagulants post-surgery. Such precautions are typically employed after other kinds of surgery, yet often aren’t after c-sections. It was only in 2011 that the American College of Obstetricians and Gynecologists (ACOG) postpartum guidelines were updated to recommend anticoagulant therapies following a c-section.

Birthing while black

Even within a health system that cares poorly for new mothers, the Logelins were somewhat right to think of maternal mortality as something that happened to other people. It typically does.

Black mothers, for example, are three times more likely to die or suffer serious illness from pregnancy-related causes than white women, with at least 40 deaths per 100,000 live births on average, compared to 14 for white mothers. Native-American mothers are nearly twice as likely to die as their white peers.

Black women giving birth in New Jersey, where mortality rates are highest for them, are more likely to die of childbirth—at a rate of 79.8 per 100,000 live births—than women living in some developing regions of the world.

Many other states, such as New York (57), Texas (56.5), Oklahoma (49), produce equally shocking maternal mortality rates among black women. Overall, 33% of white women’s pregnancy-related deaths were preventable, according to ACOG. For African-American women, at least 46% of deaths could have been avoided.

Any analysis of race’s impact on the rates of maternal death necessarily overlaps with poverty. Black Americans are nearly three times more likely than whites to live below the poverty line, and suffer from the overall health consequences that come with being poor, affecting everything from life expectancy to chronic diseases. But that is just one facet of what’s going on. America’s Hispanic population, for instance, has rates of poverty comparable to blacks, yet it doesn’t experience a similar level of pregnancy-related tragedies. Moreover, major pregnancy complications occur at similar rates for black and white women, yet death and morbidity rates are higher among black women. Education doesn’t seem to close the gap, either: Black college graduates experience maternal mortality rates that are three times as high as their white counterparts. In fact they have worse birth outcomes than white high-school dropouts.

“Think about this, we’re talking about African-American doctors, lawyers, business executives, and they still have a higher infant mortality rate than…white women who never went to high school in the first place,” says Michael Lu, a neonatal specialist. Lu believes that pregnant black women face the stress of a lifetime of exposure to racism, exacerbated by the experience of nine months of pregnancy.

“African-American doctors, lawyers, business executives […] have a higher infant mortality rate than… white women who never went to high school in the first place.”

Research backs him up. Institutional racism has been linked to high-blood pressure; black women’s bodies pay the consequences of “unique stressors around racism, sexism, violence of any kind, or economic burden,” says Fleda Mask Jackson, a professor of public health who led a 2001 study on why African-American women, regardless of their socio-economic background, are more likely to have premature babies. She found that the mother’s internalized stress is likely to lead to poor birth outcomes for the baby, and believes it’s not unreasonable to infer that those stressors have consequences for the mothers too.

Overall, black women in the US have above-average rates of obesity, type 2 diabetes, hypertension, and experience higher rates of other chronic conditions too. Joia Crear-Perry, an OB-GYN and founder of the National Birth Equity Collaborative, believes that the historical and social causes of maternal mortality, especially among black women, must be taken into account. We have, she says, “a whole language around making it the individual’s responsibility without taking any ownership, as a system, of what [society] has done and continues to do.”

In other words, the “older, fatter, sicker” refrain will often be applied to black mothers—as a way to hold them individually responsible for problems that date back deep into America’s history. Take obesity, for instance, or high blood pressure. Both are often a byproduct of a poor diet, points out Nikia Lawson, an African-American doula and advocate for maternal health based in Fort Worth, Texas. You can trace a line between that poor diet and the historical, social, and economic experience of blacks in the US.

Photo courtesy the Tatia Oden French Memorial Foundation Tatia Oden French during her pregnancy.

But black mothers die even when they are young, and fit, and educated. Tatia Oden French wasn’t poor or unhealthy when she entered the Summit Medical Center in Oakland, California, at the end of December 2001, for a routine check after she had passed the due date for the delivery of her first child, Zorah. Quite the opposite, in fact. A fit, 32-year-old woman with a doctorate in psychology from the University of California-Berkeley, Oden French had an uneventful pregnancy and intended to have a natural birth. But 10 days past her due date, even though neither she nor the baby showed any signs of distress, the personnel at the hospital insisted on inducing labor.

Maddy Oden, her mother, remembers her daughter arguing with the staff that she did not want to be induced, but “finally the nurse said ‘well, you don’t want to go home with a dead baby, do you?’” This succeeded in gaining her daughter’s assent.

“When I asked what [the drug] was,” Oden told Quartz, “they said it’s perfectly fine, we use it all the time.” She said it was only later, after both Tatia and baby Zorah had died during an emergency c-section, that the family was told that the drug, misoprostol, could cause severe side effects, including amniotic fluid embolism, a potentially lethal complication of childbirth that occurs when amniotic fluid enters the bloodstream.

Oden, who is now a doula and an activist against the use of misoprostol to induce labor, believes her daughter’s desire for a natural birth was overlooked at least partly because of her race: “Unless you’re rich and white, you usually don’t get an explanation of the risks, the alternatives, and the benefits of whatever they are asking you to do,” says Oden, who herself is white. (Summit Medical Center declined to comment.)

“Unless you’re rich and white, you usually don’t get an explanation.”

Oden’s deep lack of trust of doctors echoes a sentiment that’s common among the US’s black population. Elizabeth Dawes Gay, a consultant and writer who chairs the steering committee of the advocacy organization, Black Mamas Matter, explains that African Americans come “from a history filled with abuse and neglect,” and it’s only “relatively recent generations that interact with the health care [system].”

Their distrust is justified. There is a well-documented race bias affecting the medical profession, and it’s made worse by the lack of black medical personnel, in general medicine as well as in the maternity ward: Only 6% of physicians, 4% of OB-GYNs, and less than 4% of midwives are black, versus a general black population of over 12%.

A matter of access

While the higher mortality rates of black mothers in the US cut across class and economic background, a mother’s ability to pay for care is nevertheless an important factor in determining the outcome, regardless of her race. A direct correlation can be drawn between not being able to afford care and pregnancy-related deaths and morbidity. Texas, for instance, is the state with the highest number of uninsured people, and the state with the most maternal deaths.

Declercq is currently leading an effort to quantify childbirth practices and outcomes in the US. She says 13% of women who give birth are uninsured, forcing them to pay the cost of childbirth out of their own pockets. Another nearly 50% of deliveries are covered by Medicaid, the federally funded program that pays for prenatal care, delivery, and postnatal care for women who live at 133% or less of the poverty line.

Medicaid for parents, however, typically mandates a lower income qualification than the program’s pregnancy coverage, which leaves many mothers without coverage beyond 60 days post-delivery. But they are still vulnerable well past that timeframe. “Maternal health doesn’t just begin [and end] at pregnancy,” says Nadia Hussein, an advocate with MomsRising, noting that health care before, in between and after pregnancies is equally important, especially for the 20% of women dependent on Medicaid who suffer from chronic conditions like depression, hypertension, and type 2 diabetes.

While there are no data available covering that 60-day span, the maternal mortality and morbidity task force of Texas found that the majority of maternity-related deaths occurred after the 42nd day post-delivery, and within the first year (pdf, p. 6-7).

“Maternal health doesn’t just begin [and end] at pregnancy.”

Even for those who can pay the medical bills, there are other ways in which their access to health care is curtailed. For example, of the 3,144 counties that make up the US, more than a third—1,263—don’t have an OB-GYN. By 2020, it is estimated the country will be 8,000 to 9,000 OB-GYNs short, largely because the number of OB-GYNs has remained steady since the 1980s, while the population has continued to grow. Financial pressures are, once again, a major reason why. OB-GYNs pay the second-highest malpractice insurance rates after neurosurgeons, reflecting their exposure to a high risk of claims against them. (78% of ACOG fellows have been sued at least once in their career.)

Malpractice insurance premiums can range from $30,000 a year to north of $100,000, depending on whether the state has enforced a cap on claims. This dissuades young doctors from choosing obstetrics as a specialization, and forces many of those who do practice to limit the number of Medicaid patients (pdf, p.63) they see, as the reimbursement rates paid to the doctors are too low to cover the cost of running the business. The OB-GYN scarcity is particularly striking in rural areas: less than half the women living there have access to a hospital offering prenatal services within a 30-minute drive.

Having enough qualified personnel can be a problem in hospitals, too, which often operate under a financially-dictated “productivity mandate.” According to guidelines issued by the Association of Women’s Health, Obstetric and Neonatal Nurses, the ratio of nurses to patients in a maternity ward should be one to one for women with complications or women receiving oxytocin in labor, and one to two for uncomplicated women, but it’s not uncommon to see nurses attending several patients at once. Even when things go well, new mothers often report struggling to get consistent attention from the nurses, and having only minimal contact with the doctor. “The doctor caught the child, put it on my chest, told me what I needed to do, and went on to deliver the next baby,” remembers Tobler of her first birth, which took place in a hospital.

Less than half the women living in rural areas have access to a hospital offering prenatal services within a 30-minute drive.

Crear-Perry describes the hospital birthing practice as a mix of “efficiency and fear of litigation.” There are, she says, certain delivering techniques, for instance how to turn a baby who’s in an inconvenient position for birth, that are no longer taught to OB-GYNs. They are instead trained to turn to surgical intervention whenever the situation isn’t straightforward, or if delivery isn’t happening within a certain timeframe.

Too much is not enough

The twin impulses of efficiency and litigation-avoidance result in rushed visits and reduced access on the one hand, and an excess of medical intervention on the other. John Jennings, former president of the ACOG, calls it “the unmet needs of some and the overmet needs of others.”

These overmet needs result in what is known in the maternity field as a “cascade of interventions” for many women, even those who would have preferred a natural delivery.

Excessive interventions carry serious additional risks, but they have a deep history in the US. Delivering in the hospital with pain medication became the preferred option of wealthy Americans in the early 1900s, and by the late 1930s the practice of extracting a child from a near-unconscious woman during a “twilight sleep” was widespread, and remained so until the natural Lamaze movement became more popular in the late 1950s/early 1960s.

“US care is over-medicalized,” says UCSF’s Miller, and though she acknowledges that it’s hard to quantify the impact on the health-care system, she thinks it’s significant. “One of the things [the medical community] is trying to do is swing back to [intervention] ‘only when necessary’” she explains, and indeed ACOG’s guidelines have been encouraging medical personnel to be more patient, and let labor run its natural course.

“One of the things [the medical community] is trying to do is swing back to [intervention] only when necessary”

That is easier said than done. C-sections, after all, are far more convenient for a hospital. They are easier to schedule, quicker, and make a lot more money; a US hospital can, on average, bill 50% more for a c-section than a vaginal delivery.

Surgical deliveries, however, also come with a higher risk of complications—from blood loss during the procedure to a condition called placenta accreta, in which the placenta attaches itself too deeply into the uterus, potentially leading to severe hemorrhage. Kristen Terlizzi, a healthy, fit woman from California, knows that well. At 33, pregnant with her second child, she gave birth via a c-section. She lost almost her entire body’s worth of blood in a postpartum hemorrhage due to placenta accreta, and very nearly died.

According to ACOG records, in the 1970s, placenta accreta occurred in one out of every 4,027 pregnancies; between 1982 and 2002, one in 533 pregnant women developed placenta accreta. Not coincidentally, the incidence of c-sections ballooned over that same period, from 4.5% in 1965 to 32% in 2015. C-sections increase the risk of developing placenta accreta, and each c-section multiplies (table 1) the likelihood of developing placenta accreta in a subsequent pregnancy.

Despite that risk, once a woman has had a c-section in the US, it’s unlikely she will have a vaginal birth for her subsequent deliveries. So-called “vaginal birth after cesarean” (VBAC) is safe in up to 80% of cases, yet is chosen by only 10% of women (and doctors) in the US, compared to 40% to 45% in Europe, says Declercq. Typically, the decision to avoid VBAC is based on a desire to lower the risk of uterus rupture—a dangerous condition which requires emergency surgery. But that risk is relatively rare (less than 1% of cases), and c-sections, like all major surgeries, carry their own risks.

Jennie Joseph, a British-trained nurse midwife who has been practicing in the US for the past 26 years and runs Commonsense Childbirth, a birth center which offers midwifery prenatal care in Orlando, Florida, sums it all up effectively: “It’s racism, it’s classism, it’s sexism: All of these things are at play and […] the intersection with capitalism and power,” she told Quartz. “[Women] are dying of a system that’s broken.”

No country for new mothers

If the US was like other rich countries, a health crisis such as this would be met with a flurry of initiatives, spearheaded and mandated at a federal level, to find out why mothers are dying, and to figure out ways to reverse it. But the US isn’t like other rich countries. With its uniquely fragmented health system, straddling states and federal government in a complex web of public and private, for-profit and nonprofit, it is nearly impossible to effectively tackle complex issues.

That is not to say the US has no avenues for greater coordination and response. For years, 27 state review groups known as maternal mortality review committees (MMRCs)—some which have sprung from public-health initiatives, others via state OB-GYN societies—have tried to look at available data to assess the causes of maternal death, and if and how they were preventable. “[MMRCs] have existed in the US for a century independently from one another,” says Goodman. Five years ago, the CDC embarked on an effort to coordinate this ad-hoc system of state-by-state analysis of maternal mortality, providing guidance to help individual review committees standardize their findings to make them comparable across states. However, the CDC still isn’t involved directly in the reviews and, so far, the committees continue to operate independently from one another, says Goodman.

It’s a leadership void that in the past few years has been filled in part by a private-sector actor. Pharmaceutical giant Merck has been providing support to a wide range of programs geared towards improving the state of maternal health through its 10-year-initiative Merck for Mothers, launched in 2011.

Though the program was built for developing countries with maternal mortality outcomes far worse than the US, Naveen Rao, the doctor who leads it, says Merck for Mothers was expanded to include the US in response to the poor state of childbirth outcomes in the country.

“The whole idea that in our backyard here is a problem [like this] when we have NGOs that do this work in Africa” was baffling, Rao told Quartz. “Of all the health issues affecting the US, [maternal mortality] is the most unacceptable,” he says.

“Of all the health issues affecting the US [maternal mortality] is the most unacceptable.”

Merck for Mothers has embarked on a flurry of initiatives, partnering with seven organizations in 16 states, and financing projects ranging from better data-collection initiatives to standardized care practices and community efforts to expand health care access.

One project supported by Merck is Review to Action, an initiative to pull together the findings of MMRCs, with the goal of comparing the findings between states. Other efforts focus on deploying simple, standardized post-delivery practices to help identify and prevent some of the avoidable tragedies that afflict high-risk patients.

Main and his team at CMQCC have spearheaded one such effort. They collaborated with a number of hospitals in California to develop three “safety bundles,” toolkits that provide a checklist-based set of interventions to address some of the more common complications that occur during delivery. One helps personnel deal with obstetric hemorrhage—from assessing a patient’s risk to evaluating the seriousness of the blood loss, along with an inventory of medications, blood units, and tools required for an intervention. Other toolkits developed by CMQCC include ones to address preeclampsia, and a third to promote vaginal delivery over a c-section.

These toolkits have been adopted by over 250 hospital and birthing facilities around the state, and are largely responsible for California’s success in cutting maternal mortality rates by 55% between 2006 and 2013 (pdf, p. 4).

Despite the clear success of the toolkits, deploying them in hospitals nationwide has been, at best, a patchwork affair. ACOG has worked with over 100 hospitals on safety bundles for hemorrhage, pulmonary embolism, and severe hypertension. A similar project, run by the Association of Women’s Health, Obstetric and Neonatal Nurses, is working with 55 hospitals in New Jersey, Georgia, and Washington, DC.

That rollout exemplifies much of what is broken in America’s health care system. There are solutions—some of them are even straightforward. But if adopting solutions to discrete, clearly defined problems is this complicated, how is the US going to to deal with the seemingly intractable, deeply-entrenched societal ills of sexism and racism that are embedded in the care its mothers receive?

There are solutions—some of them are even straightforward.

Current federal and state governments’ efforts to improve the health care provided to new and expectant mothers are disjointed and sporadic, and they lack any overarching goal or vision. It’s an enormous problem to tackle for sure, but it is also one where the scope for improvement is as great as the gap between maternal mortality rates in the US and other countries of comparable wealth.

Two things are clear: The first is that the US health system needs to render its women, its mothers, fully visible, a process that starts with collecting and publishing more and better data. The second is it needs to see the whole woman, the whole mother—white or black, poor or wealthy, fit or unhealthy—so that the next Liz Logelin and the next Tatia Oden French and all the other new moms get to hold their babies, and to raise them.