“Maternal Mortality in the US”

Why would anyone think that pregnancy or having a baby is now a dire subject? What usually would carry promise and excitement has a cloud over it. News accounts suggest we should be asking questions and giving new Idaho legislative decisions a lot more gravitas. Now, as women and their partners and families discuss what the new laws in their home state mean for them, they might consider moving elsewhere. 

We hope our examination of maternal health complications helps illuminate the intricacy of what Maternal Mortality is, and what the underlying data actually means. We also address the added ramifications when state officials insert themselves in the exam room, which further complicates this already difficult subject. Maternal healthcare concerns discussed with a medical provider aren’t so clear anymore. Let’s look at why.

Oh, those darn statistics.

We remember all too well the horrific numbers and variability in causes of deaths from COVID-19. Each state’s department of health had its own way of collecting data about COVID cases, including ages or age ranges, sex, hospitalizations, vaccinations, deaths, etc. This left national agencies of health and researchers in a quandary on how best to compare and contrast diversely documented information, and then report it back to the public.

Similarly, collecting Maternal Mortality statistics is not always as straightforward as one may think. Recording practices vary from state to state, and with who is filling in the information. A medical provider who completes a death certificate may do so quite differently than other staff. As a result, a key piece of information can easily be lost in the mix of data, such as: “was this death related to the person’s status of being pregnant?” 

Here’s an example when a question is written poorly or recorded wrongly on a death certificate, and data becomes vague and alters interpretations of it. A checkbox was added to a death certificate asking “was the person pregnant within the last year”; the resulting study indicated that maternal mortality rates increased. Sometimes this box would be checked in error for an older person. Subsequently, having added a checkbox for age still didn’t fix this death certificate question, or how the data was reported for official death records. 

Another example of a problem with death certificates is when the cause of death is noted as “high blood pressure.” The diagnosis of high blood pressure would need to be associated with a person's status of pregnancy or recent pregnancy for Maternal Mortality reporting purposes. It’s far more difficult to collect data about a person’s death — whether it was maternal-caused or pregnancy-associated — if the appropriate pregnancy box is not checked.

Race and socio-economic status play a role in maternal mortality.

Many would be surprised to know that a black woman with a PhD has a higher rate of death during pregnancy than a white woman who is in high school. Black pregnant women, in particular, suffer the worst maternal health disparities and have the highest rate of maternal death. This is largely due to racial and socio-economic inequities, including, access to quality health care, nutritious food, safe housing and home or neighborhood environment, employment opportunities, financial security, and more. How does a society start to level this uneven playing field and address the systemic, structural, and social determinants of health?

Consistency and precision matter in defining the cause of death during pregnancy.

Compounding disparities in diagnoses is data collection terminology, such as: “year of pregnancy being measured”. There is a specific definition of time that statisticians use to collect information about maternal mortality. However, the American College of Obstetricians and Gynecologists (ACOG) collects data differently than the Centers of Disease Control and Prevention (CDC). For example, a report indicated deaths of pregnant persons “in the hospital” have decreased – suggesting improved care during hospitalization. However, continued rising death rates of pregnant people and new mothers point to the vulnerable times when maternal deaths occur outside the labor and delivery unit. In order to achieve a more accurate measurement of maternal mortality, we need to identify these unique situations that led to death during a woman’s pregnancy, and address the causes, regardless of when in the “year of pregnancy” the death occurred.

The U.S. maternal mortality rate is more than ten times that of other developed countries.

Regardless of the numbers, the significant fact here is that the U.S. – the country that spends the most on healthcare  (18% GDP) of all developed countries – has the highest maternal mortality of ALL developed countries. In 2020, the average maternal mortality of all high-income countries was 12/100,000, whereas in the U.S. it was almost 24/100,000 and is climbing. Compare these numbers to some European countries that have rates of 0-3/100,000. In contrast, the U.S. had its lowest rate of maternal mortality from 1980 through 1990. Clearly, we can do better!

The most common contributors to maternal mortality in the U.S. include several conditions. Some may be surprised to learn that mental health is the leading cause. Other reasons are hemorrhage, cardiac issues, infection, blood clots, high blood pressure related to pregnancy, amniotic fluid embolism, injury, cerebrovascular accidents, cancer, endocrine/metabolic disorders, and pulmonary conditions. 

It’s important to know that almost all maternal deaths are preventable with adequate screening, and prenatal and postpartum care. There are several other interventions that also reduce maternal deaths such as avoiding unintended pregnancies, extended postpartum care, and increasing strong social support systems for our pregnant women. However, there is far more information to be gleaned from the data and to be studied.  Does the U.S. have the commitment and the money to find out?