The United Nations has put improving maternal health and child mortality among its eight Millennium Development Goals. Healthy People 2020, a U.S. government-based initiative, has set more specific standards.
The CIA - yes, the Central Intelligence Agency - ranks the United States as 51st best for infant mortality (behind Cuba and the Czech Republic), McCool said, and 48th best for maternal death (behind Bulgaria and Iran).
Philadelphia's even worse numbers may be driven by its high rate of poverty and the fact that there were 19 city maternity units in 1997 and only 6 in 2011, McCool said. "I think Philadelphia just does not have as much emphasis on health care delivery as other states or cities do," he added.
Nonetheless, several key health indicators have remained fairly stable. McCool said, though, that there are anecdotal reports of an increase in "near misses" for pregnant women and babies. Because the remaining hospitals are high-tech, academic centers, patients may be surviving but having a much rougher time than necessary.
Arnold Cohen, an obstetrician at Einstein Medical Center, said he did not think his hospital had seen an increase in near misses. He said the remaining maternity units have cooperated to standardize care and share medical information. "In many ways, the quality of care that people are getting is better because it's more standardized," he said.
He said all of the hospitals have been working to reduce premature births.
McCool said his report, which was published in the journal Midwifery, did not include post-2009 data because the city stopped collecting it for a while for budgetary reasons.
Overall, McCool said, the country has not made improving the health of pregnant women and children a priority. Other countries have a bigger incentive because aid is sometimes tied to health goals.
According to the Centers for Disease Control and Prevention, about 650 women die of pregnancy-related causes each year, and 25,000 infants die.
Maternal mortality in the U.S. increased from 12 deaths per 100,000 live births in 1990 to 21 in 2010. In the latest year in McCool's report - 2004 - the rate was 9.01 per 100,000 in Pennsylvania, 15.2 in the United States, and 23.8 in Philadelphia.
While the Healthy People 2020 goal for infant mortality is six deaths per 1,000 live births, Philadelphia hovered between 10 and 12 from 1998 through 2009. The rate for African Americans in Philadelphia in 2009 was about 15.
Philadelphia's numbers were also higher than the state's or nation's for premature and low-birth-weight babies.