Maternal Mortality: Rare but Too Common

Maternal mortality can be viewed as a rare event. The rate in the United States is roughly 20 maternal deaths per 100,000 births. Put another way, there are about 700 deaths among the approximately 4 million people who give birth each year

But seen through a different lens, there are far too many maternal deaths. Experts have found that 60% are preventable, and the U.S. has the dubious distinction of having highest maternal mortality rate among comparable developed countries.

By some estimates, American women today are 50% percent more likely to die because of pregnancy-related health issues than their mothers were, notes Courtney Furrow-White, M.P.M., RN, program director of performance improvement collaboratives at Vizient, a healthcare services company based in Irving, Texas. Focusing exclusively on maternal mortality also misses the larger picture beecause for every death, hundreds of women experience health difficulties related to pregnancy and birth that can cause serious consequences.

The U.S. healthcare system is poorly equipped to deal with maternal mortality and pregnance-related health issues for many reasons. Postpartum care is patchy, partly because insurance coverage is. The relative rarity of maternal mortality can translate into lack of readiness. “Because maternal death numbers are relatively small, hospitals sometimes lack the preparation to deal with rare or catastrophic complications,” says Furrow-White. “Hospitals have historically put more effort into managing medical emergencies that happen every day and not those that might occur every couple of years depending on a hospital’s size and location.”

The issue of maternal mortality has come to light in recently partly because unreliable U.S. maternal mortality data had kept the problem under the radar. In 2003, the CDC added a checkbox to death certificates, which was to be marked if the deceased was pregnant or postpartum, says Furrow-White. It wasn’t until 2017 that all states implemented the protocol.

Many factors cause pregnancy and childbirth to remain unusually risky in the U.S. Based on recent CDC data, the leading causes of pregnancy-related deaths are cardiovascular conditions, infection, and hemorrhage. However, it’s increasingly recognized that the cause varies depending on when the death occurs — during pregnancy, during childbirth or afterward, notes Stephanie Leonard, Ph.D., an epidemiologist at Stanford University School of Medicine.

Leonard’s Stanford colleagues found that comorbidities such as hypertension, asthma, heart disease and other chronic conditions have increased among people having children over the past 15 years. Those conditions are associated with the growing rate of maternal morbidity — outcomes during pregnancy, birth and the postpartum period that are short of mortality but have health consequences.

Maternal mortality is often misunderstood as death during childbirth, but maternal mortality includes periods before and after labor. The inadequacy of postpartum care is a major contributor to maternal mortality, notes Yenupini Joyce Adams, Ph.D., RNC-MNN, visiting assistant professor of global health at Notre Dame’s Keough School of Global Affairs. CDC data show that 37% of maternal deaths occur one to 42 days after birth and an additional 23% occur 43 days to one year after birth. “The postpartum period is the time of highest risk for maternal deaths, and mortality risks extend to one year after birth,” says Adams. “Most maternal deaths are from preventable obstetric complications, especially during the postpartum period. There is an urgent need to focus more on access to, and quality of, postpartum care.”

Despite the overall advances in healthcare technology and that the U.S. spends more on healthcare than any other country, there are still disparities in maternal care in the U.S. “Oftentimes, maternity care in the U.S. fails women by not being accessible, safe, equitable, evidence-based or affordable,” Furrow-White says. “Social determinants of health play a major part on the impact of people’s health and well-being.” Factors such as wealth, education, access to health insurance, food security and housing (to name just a few) affect people’s health and therefore birth outcomes.

High rates among Black women

The maternal mortality rate for Black women is higher than the rates for any other demographic group; it is a difference that goes back a century, Adams notes. In 2019, the last year for which statistics are readily available, the maternal mortality rate for non-Hispanic Black women was 44 deaths per 100,000 live births, 2.5 times the rate for non-Hispanic White women (17.9 deaths per 100,000 live births), and 3.5 times the rate for Hispanic women. Studies of maternal mortality have shown that Black-White disparities increase with age: The gap is narrowest among women younger than 20 years and highest among those aged 30 to 34 years. Education is not a mitigating factor: Among women with a college education, the pregnancy-related mortality ratio (a statistic similar to maternal mortality) is 5.2 times higher among Black women than among White women.

Several factors contribute to racial disparities in maternal deaths, including differences in access to care and prevalence of chronic diseases, Adams says. Risk factors such as obesity and gestational diabetes are prevalent in Black women. In addition, Black women are also more likely to be readmitted after birth and to suffer life-threatening postpartum complications. Moreover, community determinants such as transportation options and inadequate housing have been shown to contribute to maternal mortality.

Obstetric complications such as hemorrhage, hypertensive disorders, sepsis, cardiac disease, venous thromboembolism, and pulmonary embolism are the leading causes of maternal deaths in the U.S. Among Black women, however, cardiomyopathy, thrombotic pulmonary embolism and hypertensive disorders of pregnancy are major contributors to maternal deaths. While hemorrhage and infections occur more frequently in the immediate postpartum period six weeks after a pregnancy is over, conditions such as cardiomyopathy can occur much later after birth (45% within 43 to 365 days postpartum). “Therefore, access to quality postpartum care for up to one year after birth is especially important for Black women,” says Adams.

Researchers at the Rutgers Robert Wood Johnson Medical in New Brunswick, New Jersey, reported findings in the journal Hypertension showing that Black women having children are between three to four times more likely to die from hypertension-related causes than their white counterparts. Their research into maternal deaths from 1979 to 2018 shows that deaths associated with preeclampsia and eclampsia have dipped, while those associated with chronic hypertension have gone up. In this context, chronic hypertension is defined as hypertension before pregnancy or during the first 20 weeks. Obese women and those giving birth when they are in their late 40s also had an elevated risk of maternal death that was associated with hypertension.

Several studies show that maternal deaths among Black women extend beyond preexisting educational and socioeconomic inequities that contribute to poorer access to care, Adams points out. Institutional racism across many levels of America’s healthcare system and implicit bias among healthcare providers also factori into the higher maternal mortality among Black women.

Fixing the problem

Maternal mortality has not gone unnoticed. Many healthcare organizations and other entities are working on the problem, notes Rikki D. Baldwin, D.O., FACOG, an obstetrician and gynecologist at Memorial Hermann Health System in Houston. The American College of Obstetricians and Gynecologists (ACOG) has been working with the U.S. government and leaders in women’s healthcare to address high maternal mortality rates. The organization spearheaded the creation the Alliance for Innovation on Maternal Health (AIM), a national, data-driven maternal safety and quality improvement initiative based on interdisciplinary

consensus-based practices to improve maternal safety and outcomes. There have also been efforts to optimize postpartum care and to standardize the levels of maternal care.

States are encouraged to use ACOG-approved AIM safety bundles as the core building blocks to improvement. Key principles common to the safety bundles are standardization to improve readiness, recognition, response and reporting. “The bundles aim to ensure organizations have the knowledge, skills, supplies and appropriate care linkages to recognize existing or developing problems; intervene to mitigate potential harm in an evidence-based, effective and timely manner; and use data collection and analysis for continuous learning and improvement,” says Furrow-White of Vizient.

The American Medical Association (AMA) recently adopted a new policy to promote equity in maternal healthcare and expand insurance access. The policy includes advocating for expanding Medicaid and Children’s Health Insurance Program (CHIP) programs to extend past the current 60-day postpartum period. According to the AMA, 1 in 3 women in the U.S. experiences discontinuous insurance coverage before, during or after pregnancy.

HHS has plans to expand access and coverage for maternal health services by proposing a “birthing-friendly” designation to hospitals that meet certain criteria. Additionally, CMS is encouraging states to participate in the American Rescue Plan’s 12-month postpartum coverage to pregnant women enrolled in Medicaid or CHIP. These programs cover more than 42% of U.S. births, nearly half of which are Black, Hispanic or American Indian/Alaskan Native.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.