A new report reveals that, on average, pregnant women and newborns in Philadelphia fare worse than in the rest of the state and country.
Led by Professor William McCool of the University of Pennsylvania and published in the journal Midwifery, the study is an evidence-based progress report on the city’s follow-through of the United Nation’s eight Millennium Development Goals (MDGs), established in 2000. The study collected data between 1997 and 2011.
“Our manuscript was submitted as evidence that the United States was not only not approaching the MDGs with regards to women’s and newborns’ health, but was actually getting further away from those goals,” McCool told RH Reality Check.
One of the main goals of the MDGs is to reduce maternal mortality in the United States by 75 percent between 1990 and 2015. But one year away from that deadline, the data shows that maternal deaths in the United States have actually increased over the last two decades—despite operating the costliest health-care system (in terms of health per capita) of all developed nations in the world, according to the report.
The report shows that between 1997 and 2004, the maternal mortality rate in Philadelphia is 23.8 per 100,000 live births (compared to the U.S. average of 15.2 over the same period). The difference is starker between city and state, with Pennsylvania’s average at 9.01 per 100,000 live births.
Philadelphia’s dire performance can be attributed to the collision of widespread, profound poverty and a sharp reduction in the number of hospitals providing maternity care.
Philadelphia, where 28.4 percent of all residents live in poverty, also has the highest rate of deep poverty, defined as having an income below half the poverty line.
Meanwhile, the health-care system has made childbirth unprofitable for hospitals. As a result, prenatal care and delivery options have been steadily shrinking in Philadelphia for the last 15 years. In that time, approximately two-thirds of city hospitals that offered maternity care have closed their doors, citing inadequate insurance reimbursement, rising malpractice insurance premiums, and burdensome staffing requirements.
Between 1997 and 2011, the number of obstetric units in Philadelphia has decreased from 19 to six. The remaining units include Temple University, Thomas Jefferson University, Pennsylvania Hospital, Hahnemann University Hospital, Einstein Medical Center, and the Hospital of the University of Pennsylvania. The authors of the report explain these hospitals are able to offer obstetric care because they are also teaching centers that need to conduct childbirths for training purposes.
McCool notes that preterm birth rates in Philadelphia “were as much as 40 percent higher than Pennsylvania rates and 32 percent higher” than the national average. The result is a system in which a number of hospitals now rely on income earned from serving sick and premature babies in neo-natal intensive care units to turn a profit on maternity services, creating a vicious cycle in which poverty and lack of health care lead to high rates of pre-term births and create perverse financial incentives for a system that continuously fails to address the root causes of poor maternal and newborn health.
As with nationwide and state trends, maternal and infant mortality rates in Philadelphia vary, in some cases significantly, by race. The Midwifery article found that Black mothers were 2.7 times more likely to die than were white mothers in Philadelphia.
“I think it has to do with the cumulative impact of racism and stress and poor nutrition,” said JoAnne Fischer, executive director of Maternity Care Coalition in Philadelphia.
McCool agrees that diet-related issues are significant and lead to obesity, diabetes, and high blood pressure. But, he says, violence—physical and otherwise—is also a significant factor in the socioeconomic and racial disparities of maternal outcomes.
“What goes under-reported is the amount of emotional stress that women face because of either emotional violence, or physical violence, or even the stress of being a minority in a society like ours,” McCool said. “These are all socio-political issues that we don’t address head on with pregnant women.”
Like their mothers, Black babies born in Philadelphia have a consistently higher risk of death than any other group. According to the report, “non-Hispanic Black infants are at a 2-3 times greater risk of dying in the first year than any other racial/ethnic group in the city.”
The racial disparity in accessing maternity care reflects both financial and geographic obstacles. Philadelphia, after all, is one of the most racially segregated cities in the country. Research from 2010 reveals that even “the average black household with an income over $60,000 lived in a neighborhood with a higher poverty rate than did the average white household earning less than $20,000.”
So, although the whittling of delivery options have led the remaining six hospitals to coordinate care in what’s been called an unlikely alliance, the fact remains that the six remaining maternity hospitals are clustered in or near downtown Philadelphia, or Center City as it is known—not one of the neighborhoods suffering from poverty. This clustering leaves entire regions of the city with no maternity wards. For example, there are no such wards in South or Northeast Philadelphia.
Many of McCool’s patients, some who live in homeless shelters, rely on public transportation. He says they often take two or three buses or train connections to get to his office. Because traveling takes time, it can cost patients who have to arrange childcare more money to get to an appointment. Navigating public transportation with small children in bad weather can make it nearly impossible to keep an appointment.
“You ask them, they’ll say, ‘I just didn’t have anyone to watch my kids, and [couldn't] cart them on [public transportation],’ or ‘It was raining,’” he said. “Anecdotally, they actually make some healthy choices that [don’t] fit in with what the system thinks is healthy.”
Another problem with the shortage of delivery options is that pregnant women who rely on public transportation are at high risk for what McCool calls a “discontinuity of service” when they go into labor.
If they go into sudden labor and don’t have the time to take multiple buses, or go into labor in the middle of the night and call 9-1-1, pregnant patients will often wind up at a hospital they’ve never been to before. In Philadelphia, 9-1-1 is handled by the fire department. “If you’re pregnant, they’ll take you to the nearest hospital that does delivery,” said McCool, “which may not be where they got prenatal care.”
One of the consequences of this de facto patchwork system is that hospitals are reporting—anecdotally, as this information isn’t formally collected—a spike in what they call “near misses.” A near miss is a situation wherein emergency intervention saves a woman who nearly died from a complication, such as executing a life-saving cesarean section for a woman who had little or no prenatal care.
While a rise in “near misses” showcases emergency room savvy, it also underscores the fault lines of the health system in which unhealthy women who have unhealthy pregnancies and few or no other interactions with health care beyond these near-death experiences.
With so many complicated factors leading to the problem—the report doesn’t dig into health insurance—there are no easy answers. But the authors of the report point to evidence that midwifery services and community-based health-care options improve the health of pregnant women.
The closure of the 13 maternity wards since the 1990s included the shuttering of at least five midwifery services associated with the hospitals, according to the report.
The authors also note that improvement can only begin when political leaders begin to look at evidence rather than rhetoric. These leaders must realize, “despite claims to the contrary,” that “they may not have ‘the best healthcare delivery system in the world.”