Every new data point or report seems to confirm it: The US is in the midst of a deepening maternal mortality crisis. Of more than 32 maternal deaths per 100,000 live births, the risk of dying during pregnancy or in the year after giving birth is average 10 times higher in the US than comparable wealthy and democratic countries, and more than 20 times higher for black and indigenous people.
A recent JAMA study provides new insight into the magnitude of the problem and shows that US maternal mortality rates more than doubled in the two decades from 1999 to 2019.
The study is notable not only for its findings, but also because it highlights a problem that continues to hamper maternal health research: the inconsistent data collection of maternal deaths.
Although the analysis provides a reliable estimate of trends over the past two decades, the study is limited to data obtained through birth and death certificates. But without a state-by-state overview of individual deaths and their causes, the US still lacks a comprehensive picture of the epidemic and its causes, rendering the country less effective in developing strategies to prevent maternal deaths.
A better way to measure maternal mortality
Until recently, little attention has been paid to documenting the health of America’s new mothers. For example, prior to 2003, standard U.S. death certificates did not include the so-called “pregnancy checkbox” that indicates whether the person was pregnant at the time of death. Maternal mortality tripled while states have adopted the updated death certificate. Still, it was not until 2017 that the last state (West Virginia) made the change, making it difficult to conduct historical comparisons between states and accurately track trends.
The JAMA study, co-led by the Institute of Health Metrics and Evaluation at the University of Washington and Mass General Brigham, was able to overcome that challenge and achieve a reliable estimate of maternal mortality even for the years leading up to the introduction of pregnancy. check box.
The researchers defined maternal deaths as those in people who were either pregnant at the time of their death or were pregnant within the past year, identifying them through the checkbox on the death certificate or through a diagnosis code. Subsequently, the study corrected for incorrect reporting by follow a method which reclassified a small proportion of deaths that occurred during those years and had initially been attributed to an unlikely cause of death (such as senility), but should have been coded as maternal deaths.
This allowed researchers to rule out the possibility that the recent increase in maternal mortality was mainly due to better measures.
“We saw increasing trends before most states adopted a pregnancy checkbox and we saw increasing trends after adoption in all states, strongly suggesting to us that these trends are real and not just a reflection of reporting biases,” said Greg Roth, a professor of medicine at the University of Washington, who is one of the study’s authors.
The study also identified key trends by race and geography. Not only were maternal death rates higher for black women to begin with, they have more than doubled in the past two decades, reaching an average of 67.6 per 100,000 live births in 2019. Maternal death rates for Native Americans and Alaskans have tripled.
The study identified geographic patterns in maternal mortality and found that the Northeastern states, often believed to offer better maternal care, were in fact the deadliest for new black mothers, with an estimated 89.5 deaths per 100,000 live births in 2019.
“It is interesting to me that there is much more geographic variation in certain subgroups than in others. Because especially when you look at the whites, there’s a reach, but it’s not a huge reach,” said Audrey Lyndon, a professor of health equity at New York University who was not involved in the study. “But when you look at the black people, it’s a huge reach.” This, she said, points to more systemic issues shaping disparities in maternal mortality than medical disparities. “For me it’s structural,” she says.
What counts as maternal death?
Despite the researchers’ progress in measuring maternal mortality more accurately, the number of new mothers who die during pregnancy or in the year after giving birth is likely to be underestimated. In particular, as the researchers say, the analysis does not include violent and suicide-related deaths, nor does it take into account overdose deaths. Death certificate coding rules do not allow any of these categories to be counted as pregnancy-related deaths – despite the fact that mental health problems are the most common complication of pregnancy and suicide, homicide and overdoses are. the main cause of pregnancy-related deaths.
This is partly a matter of definition. Data from death certificates follow so-called pregnancy-related deaths, or deaths from causes related to pregnancy, or aggravated by it. These are mainly obstetric causes. Suicide, overdose or murder are instead defined as pregnancy-associated deaths.
Some researchers believe that the latter categories should also be included in maternal mortality counts. “I have argued that we should pay more attention to pregnancy-associated [deaths] because even if it wasn’t caused by the pregnancy, this is most likely a premature death,” said Eugene Declercq, a professor of health sciences at Boston University School of Public Health, who was not involved in the study.
In addition, some pregnancy-related deaths may be directly related to the condition. An opioid overdose may be related to the person being pregnant had to quit cold turkey during pregnancy and relapse afterwards; a suicide can be attributed to postpartum depression; a murder can be the result of an argument with a roommate about the pregnancy.
Maeve Wallace, a reproductive and perinatal epidemiologist at Tulane University, says, “Maternal mortality rates alone would not fully capture the magnitude of death among pregnant and postpartum people given what we know about how homicide and suicide also occur in this population. involved in the study.
Only an assessment of every possible maternal death could explain all the nuances. That is actually a viable undertaking.
When measuring maternal mortality becomes a political issue
Although maternal mortality rates are high in the US, the number of actual deaths is relatively small: a few hundred cases per year in all states. This limited pool means that state-based maternal mortality review committees (MMRCs) can evaluate any case in which a pregnant or recently pregnant individual dies and determine whether the cause of death was properly reported, determine whether the death was preventable, and propose interventions that reduce deaths in the may decrease in the future.
Violent deaths are typically not included prior to the committee’s review because it was not the pregnancy, or any resulting complication, that directly caused a person’s death, said Declercq, who sits on Massachusetts’ MMRC. But if there is enough information to reconstruct the chain of events leading up to the violent death, the committee can determine whether the death should be included in the updated count maternal mortality published in his annual report.
“Maternal mortality review committees run by states […] are able to view much more data, including hospital records and other information to correctly assess a death as a maternal death, and more importantly, understand what the drivers were so that they can recommend and implement interventions appropriately that will make a difference,” Roth said.
Still, not all states have MMRCs, and those that do do not always routinely report their findings. Between 2017 and 2019, 49 statesas well as Washington, DC, New York City, Philadelphia, and Puerto Rico had MMRCs, but only 36 of them reported their findings. “Increasingly, the reporting of those findings has become a political issue, and efforts have been made to suppress their findings,” Roth said.
For example, lawmakers in Idaho dissolved the state’s MMRC on June 30. The commission had noted a dramatic rise in maternal mortality in the state, from 18.7 deaths per 100,000 live births in 2018 to 41.8 in 2020 and 40.1 in 2021. The commission had also determined that 98% of those deaths were preventable was and made recommendations on how to improve maternal outcomes, including by increasing substance abuse treatment and expanding postpartum Medicaid coverage in the state to one year. (Postpartum Medicaid coverage in Idaho is currently set at the federal minimum of 60 days.).
The far-right group Idaho Freedom Foundation is successful lobbied for the commission’s terminationexpressing concerns that future deaths may be understated, especially as the state abortion ban is expected to increase maternal mortality.
The reason MMRCs can become a political problem, experts say, lies in recommendations that often involve improvement social determinants of health through interventions such as housing and nutrition programs and improved access to health and reproductive care. In addition, states with restrictive abortion policies are associated with many higher risk of maternal deathand states that introduced abortion bans in the wake of the Dobbs decision may be hesitant to share data showing deteriorating maternal health.
Aside from the complications of accurately measuring maternal mortality, the increasing severity of the crisis is hard to miss, Lyndon said. “We are an extremely prosperous country,” she said. “We spend an incredible amount of money on medical care, and we fail mothers and families.”