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By Annalisa Merelli
Dec. 20, 2024
General Assignment Reporter
Too many new moms are dying in the U.S.
Exactly how many, however, is harder to establish.
After years of neglect, the issue of maternal mortality is finally getting attention in policy and politics, as well as in the media, with headlines drawing attention to figures that show the maternal mortality rate has, at least according to some measurements, doubled in the past two decades.
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But some recent papers and media stories have questioned whether the crisis is more one of perception, raising concerns about whether overcounting and poor data have led to fear-mongering. An essay published in The Atlantic, criticizing the “doom and gloom” attitude about the state of maternal health in the U.S., argued: “Things aren’t getting worse for women; we’re just getting better at tracking what’s going on.”
It’s true that the data varies: Various sources estimate that the rate of maternal mortality per 100,000 live births in 2020 was 23.8 (per the Centers for Disease Control and Prevention’s National Vital Statistics System); 24.9 (according to the CDC’s Prevention’s Pregnancy Mortality Surveillance System); and 18.4 (according to the 38 states reporting to the CDC’s Maternal Mortality Review Committee). Some data sources classify deaths as maternal mortality only up to 42 days postpartum, while others categorize them as such up to a year after the person has given birth. Variations in death certificates over time make accurate historical comparisons impossible. And the absolute numbers of maternal deaths are small enough (typically under a thousand per year, and 861 in 2020) that even one or two miscategorized deaths make a difference.
Yet even without definitive data, there are undeniable facts. Maternal mortality in the U.S. is several times higher than in comparable countries. Racial inequity plays a huge role in maternal health outcomes. And Black women in particular face three to four times the risk of dying of pregnancy-related causes than their white counterparts, irrespective of their income or educational status.
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The upshot: Improving maternal data collection and analysis is important. But experts who study the issue say that shouldn’t overshadow the fundamental work of understanding why maternal mortality deaths are happening and how they can be prevented.
“We can’t let ourselves get distracted by discrepancies around data and distract ourselves from how poorly we perform in the United States, and also the extent to which there are disparities across different, racial groups, payer groups, language groups,” said Amanda Williams, clinical innovation advisor at the California Maternal Quality Care Collaborative, an organization co-founded in 2005 by the state of California and Stanford University to improve maternal health.
“By any standard, we really have a problem,” said Eugene Declerq, a professor of community health sciences at the Boston University School of Public Health and a leading maternal mortality data expert. “And you can’t solve it by ignoring it.”
While data is important, experts say, so is the qualitative side of maternal mortality — that is, not just whether or not a new mother died, but how, and why, and what led to such an outcome.
This side of the issue is perhaps best captured by the work of state maternal mortality review committees, which serve as medical and social investigation teams, taking every case reported as a potential maternal death in a state — even in very large states, deaths are rarely more than 100 per year — and studying whether it could be considered a maternal death, and if it could have been avoided.
The key question is whether the person would have died had she not gotten pregnant in the previous year. “And trying to determine that in a death that happens five months after the baby was born is really, really challenging,” said Declercq, who sits on the Massachusetts review committee. “Then we also have to wrestle with, ‘was it preventable?’ And you often end up with this dilemma: it would be preventable if we had a functional social system that helped take care of her back when she was 17 and first started having a problem with drugs.”
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Such questions apply to many other potential causes of death. A woman who is killed by her domestic partner: Was her being pregnant, or a new mother, a factor? A new mother falls asleep at the wheel after work: Would parental leave have prevented her death?
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Maternal health advocates believe that one reason it took so long for these deaths to be acknowledged as a serious health issue is that maternal mortality sits at the intersection of many systemic ills: racism, economic inequality, poor access to health care, misogyny.
Addressing maternal mortality “was never about one thing — it’s about a revolution,” said Joia Crear-Perry, the founder and president of the National Birth Equity Collaborative, one of the country’s leading maternal health advocacy and policy organizations.
Focusing on data accuracy in order to argue that maternal mortality concerns have been overblown can even be understood as backlash to the movement focused on caring for mothers, according to Michelle Drew, a midwife, maternal health advocate, and the director of Ubuntu, a collective of health care and community workers serving Black families in Delaware.
Black women have been at the forefront of the movement to recognize and address the maternal mortality crisis, Drew points out, and the nature of the issue makes it inherently political. “Every [case] points back to some type of bias,” she said.
The history of maternity care in the U.S. is inextricably linked to white supremacy issues, Drew said. For instance, at the turn of the 20th century, white doctors used racist stereotypes to question the competence of Black midwives, with the intent of profiting from childbirth.
Those who aren’t convinced that there is a crisis now wouldn’t be compelled by stronger data either, said Crear-Perry: “I don’t know what number is going to make [them] care about it.”
There is no way to successfully improve the state of maternal health in the U.S. without embracing bigger reform, which is what ends up making the issue controversial, according to Crear-Perry and Declercq.
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This is particularly evident when making international comparisons. “The difference in those other countries is very often that they have universal health insurance, they have paid leave, they have all these other things that make life more livable for a pregnant woman and her family,” said Declercq. “That’s right in the policymakers’ wheelhouse, and then that’s uncomfortable because that’s real expenditures.”
Some of the advocacy for better maternal health in the past few years has already delivered important policy progress, Williams noted. “Expansion of Medicaid, paid family leave, increased funding in maternal health, better funding for pregnancy mortality review committees — these are steps that are being taken that are meaningful moves in the right direction,” she said.
An overfocus on quantifying maternal deaths also risks overshadowing another important issue: The much larger number of women who nearly die, or get severely ill, during and shortly after pregnancy.
Data on this problem is even more elusive. Estimates suggest there are between 50 and 100 near misses for every maternal death, and about 60,000 cases annually of severe maternal morbidity cases — unexpected labor and delivery outcomes with serious short- or long-term consequences.
Focusing on near misses offers better insight into what could be done differently, medically and beyond, to save mothers’ lives. A vast majority of maternal deaths, or more than 80% of cases, are preventable.
“I’ve been an OB-GYN for over 20 years, and I can count on one hand the number of maternal deaths that I have been even tangentially associated with,” said Williams. “But when it comes to severe maternal morbidity … that’s something that’s happening once or twice a month. It’s 1% to 2% of births.”
Conditions Williams sees in her patients include eclampsia, seizures, and sepsis, all of which could result in death if they occurred, say, in a hospital with fewer resources, or where the staff was less skilled. Every near miss, said Williams, offers an opportunity to understand how a death was prevented — and what goes wrong when the mother can’t be saved.
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In many cases, “if the patient had someone to call, or knew the warning signs, or did not feel stigmatized about getting care for her drug treatment, or if she lived in a town that was closer to a major hospital, she would not have lost her life,” said Williams. “These are all things that are solvable if we have the political will to do so.”
Annalisa Merelli
General Assignment Reporter
Annalisa (Nalis) Merelli is a general assignment reporter at STAT. Her interests are ever-expanding, but she is especially drawn to the coverage of reproductive and maternal health, and their intersection with health equity.
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