It’s been described as one of the greatest public health achievements of the 20th century: the incredible rate at which maternal mortality has dropped. Less than a century ago, one in every 100 women giving birth in the US died of related complications. Today, that figure globally stands at just 216 deaths per 100,000 live births.

To be sure, the rate is still unacceptably high. Most cases of maternal mortality can be prevented, and the developing world faces a disproportionate burden. In places like South Sudan, the situation is so bad that until recently, a girl was more likely to die in childbirth than she was to become literate.

But that shouldn’t detract from the enormous progress that has been made: between 1990 and 2015, maternal mortality fell by an incredible 44%.

 Maternal deaths per 100,00 live births

Only half the story

Look beyond the headline numbers, though, and a more nuanced picture emerges – particularly when it comes to the United States.

That’s because, despite spending some 17.1% of its GDP on healthcare – far more than any other developed nation – the US is one of only a handful of countries where maternal mortality rates have actually risen. Between the late 1980s and 2011, pregnancy-related deaths rose from 7.2 to 17.8 per 100,000 live births, according to the Center for Disease Control and Prevention.

Today, women in the US are more than three times as likely to die from a pregnancy-related complication as women in the UK, Japan or Germany, and twice as likely as women in Canada. In fact, the US has the highest maternal mortality rate in the developed world.

 Maternal mortality ratio for developed countries

More worryingly, it appears that the US is even trailing behind some developing countries. According to a 2014 Lancet study, America’s maternal mortality rate is more than double that of Saudi Arabia, and a woman giving birth in the US is more likely to die than her counterpart in China.

Understanding what lies behind the figures

“It’s hard to do anything about a problem if you don’t have the problem fully defined,” Cynthia Shellhaas of Ohio State University Wexner Medical Center told the Washington Post recently. Unfortunately, this particular problem is far from defined.

Some experts think that the increase might be because authorities are simply getting better at reporting: it’s not that more women are dying, it’s just that we now have a more accurate measure. “Administrative issues in the past may have camouflaged a problem that is only now coming to light,” Dina Fine Maron writes for Scientific America.

Others say it could be that women are choosing to wait longer to have children, which puts them at higher risk than before. But while American women are putting off having babies, they still start having families well before the OECD average of 27.8. Over in the UK, women on average wait until they’re 30 before having their first child, and yet maternal mortality rates there are falling.

On a more positive note, one of the authors of the 2014 Lancet study argues that it could actually be down to improvements in healthcare: women with cardiovascular or neurological diseases who in the past would not have made it to adulthood are now living long enough to give birth.

 Causes for pregnancy-related deaths in the US

For experts like Neil Shah, writing in the Huffington Post, it’s this lack of understanding that’s the real problem: “Failing our mothers is bad enough, but not knowing how to do better is worse.”

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