Maternal Health Reaches a Crisis Point in the United States
August 1, 2023
By Melinda Young
EXECUTIVE SUMMARY
Increasingly, American women are dying during or shortly after pregnancy due to a variety of systemic problems, including racism, comorbid conditions, and lack of access to quality care.
- Between 2018 and 2021, the maternal mortality rate doubled, partly due to the COVID-19 pandemic.
- Black women are nearly three times more likely to die from pregnancy and childbirth than white women.
- Of all the industrialized nations in the world, the United States’ maternal mortality rate is the highest.
The number of women dying from pregnancy-related causes in the United States has risen dramatically since 2018. Those numbers may continue to rise sharply as the nation creates more maternity deserts, obstetric staffing shortages, and obstacles to standard maternity care in states that enforce abortion bans and restrictions that affect women experiencing pregnancy crises.1-4
The maternal mortality rate nearly doubled between 2018 and 2021, partly due to the COVID-19 pandemic. Black women died at a rate 2.6 times higher than white women in 2021.1 Also, women aged 40 years or older recorded the highest death rate of 138.5 per 100,000 live births in 2021.1,2
“The United States has the worst maternal health outcomes out of any industrialized nation,” says Inas-Khalidah Mahdi, MPH, DrPh (candidate), vice president of Equity-Centered Capacity Building at Reproductive Health Impact (RH Impact) in New Orleans. “Those rates of maternal morbidity are not improving. We’re seeing increasing rates in 2020 and 2021.”
The highest maternal morbidity and mortality rates are among Black women and indigenous people. But white women also experience worse outcomes when compared with peers in industrialized countries.
Black Women Are at High Risk
“Sixty percent of maternal deaths are preventable, so why aren’t we preventing those deaths?” Mahdi asks. “The answer is simple and slightly complex: It’s the lingering impact of reproductive oppression, lack of high-quality maternal care, and lingering systemic racism and discrimination in treatment of pregnant people.”
One tragic example is the recent death of Olympic gold medalist Tori Bowie, age 32, who died from childbirth complications in May 2023. Bowie, who is Black and was eight months pregnant, died during childbirth at home in Florida. Her baby did not survive. Autopsy findings suggested Bowie suffered eclampsia.5
“We know from lived experiences that Black women report having their concerns dismissed consistently,” Mahdi says. “Their whole humanity is not being recognized, and their concerns are not being heard or respected. You don’t get to the 37th week of pregnancy without someone seeing there is something wrong here.”
Perceived racism in pregnancy care also can prevent some women from seeking prenatal services, particularly in states where poor and minority women can be jailed if their pregnancy ends badly.
Policing pregnancy has led to injustices, including the case of Chelsea Becker, a woman struggling with a substance use disorder, who was imprisoned for 16 months after a 2019 stillbirth in a California hospital. A county prosecutor charged her with murder of a human fetus, saying she had acted with malice because there was meth in her system. A judge dismissed the charges because no California law allowed that type of prosecution.6
These cases of women jailed because of their pregnancies also could deter marginalized people from seeking mainstream pregnancy care. But in recent years — and especially since the U.S. Supreme Court overturned Roe v. Wade — a few states have passed laws that criminalize imperfect pregnancy outcomes. For instance, Georgia’s HB 481 bill banning abortion after six weeks would charge women with murder if they induce a miscarriage through their own conduct or perform an abortion outside a medical setting.7
Healthcare professionals and case management teams can provide coordinated care that addresses pregnant patients’ social determinants of health and helps at-risk patients receive all the services they need to ensure a healthy pregnancy, labor, and delivery. For example, case managers could link pregnant patients to specialists to help manage their chronic illnesses, mental health challenges, and substance use disorders. “We need wraparound services, so no woman falls between the cracks,” Mahdi says.
Case managers could help pregnant patients with mental health diagnoses access treatment and navigate barriers to finding help, says Stephanie Hall, PhD, MPH, a post-doctoral research fellow in the department of psychiatry at the University of Michigan.
“Ideally, the case manager would focus on follow-up and be well-versed in culturally sensitive care, as well as social determinants of health,” Hall says. “Those are big factors that clinical care physicians are not equipped to deal with on the clinical side.”
From a legislative perspective, states need to ensure women’s access to abortion care, as this is standard care for pregnant women experiencing a medical crisis, Mahdi says. They also need to pass laws that allow for midwives to be the point person for women who desire that model of care during pregnancy.
“Right now, everything is focused on hospital-based delivery,” Mahdi explains. “Black midwives have been delivering babies from the beginning of time with comparably better outcomes than hospital systems.”
Since most women will continue to give birth in a hospital, it is important to consolidate and share all best practices and reform the health system so providers respond better to patients’ needs. “We need significant investment in the midwifery model of care, and we need more doulas in the health system and more Black healthcare workers who are reimbursed at equitable rates,” Mahdi says. “We have to stop the one-way approach. Women are dying because of the system.”
Obstetric care would benefit from collaboration between midwives and OB/GYNs, doulas, and clinicians. “We need all of those people together to build a complex healthcare system that meets the needs of all people,” Mahdi says. “Right now, we meet the needs of very few people.”
Solving the maternal health crisis will take a major societal, political, and individual shift in priorities and attitudes about pregnant patients. At the individual level, healthcare providers and health systems could incorporate case management principles and practices to help reach at-risk patients and to prevent maternal illnesses and deaths.
The COVID-19 pandemic likely exacerbated problems women experienced during pregnancy. Unvaccinated pregnant women were at high risk of developing severe disease if infected with SARS-CoV-2. Also, social isolation may have prevented some pregnant women from visiting physicians regularly during the pandemic.4
Given several disturbing health trends, there is a strong possibility maternal morbidity and mortality rates will continue to rise — even as the pandemic has ebbed. For example, pregnant patients increasingly face common health risks, including diabetes, hypertension, mental health disorders, and cardiovascular diseases. Being Black in America is a risk factor as well.8-11 Cesarean deliveries, which have become more popular, also create more risk.12
Abortion Bans Create Greater Risk
There is emerging evidence suggesting states that have passed anti-abortion legislation have created more health risks for pregnant patients, who are being turned away from life-saving procedures by EDs and hospitals. These risks are outlined in a lawsuit filed against Texas by the Center for Reproductive Rights. Eight women said they did not receive standard abortion care when they experienced pregnancy crises that threatened their lives.13
For example, plaintiff Amanda Zurawski, age 35, suffered preterm rupture of membranes at about 18 weeks. Zurawski was kept in the ED overnight and was sent home instead of receiving the standard treatment of abortion care to prevent sepsis and further injury. Within a few days, Zurawski’s temperature spiked, and she developed sepsis. Once she was “sick enough that inducing labor would clearly not violate Texas’ abortion bans,” she was given the care she needed to prevent illness.10
Health systems, case managers, and healthcare providers can take several steps to save lives and decrease risk among pregnant patients. One of the first steps is to screen patients for risk factors, including mental health issues. Stay alert to social determinants of health that could affect the care they receive.
“We know that mental health and substance use disorders are the leading causes of preventable maternal mortality,” Hall says. “The best thing the healthcare system can do to prevent maternal [morbidity and mortality] is to screen, identify, diagnose, and treat. A large body of literature has demonstrated that mental health disorders are underdiagnosed and undertreated.”
A possible contributor to the abysmal maternal morbidity and mortality rates in the United States is the way the American healthcare system is siloed. Pregnancy care is largely left to specialists and not seen as every provider’s responsibility. This makes it less likely a pregnant patient is screened for mental health problems, for instance.
“Maternal mental health falls at a nexus between obstetric and psychiatric care,” Hall says. “We need to make sure our clinical processes are structured to leverage interaction of our healthcare system because these problems fall between different specialties, and it’s easy for people to fall through the cracks.” It is important to treat the healthcare system as a system, rather than siloed specialties, she adds.
In Hall’s research, pregnant patients with perinatal mood and anxiety disorders who were satisfied with their prenatal care were more likely to seek mental healthcare.10
“I don’t think it’s a coincidence in this study that satisfaction with prenatal care was one of the biggest drivers of psychotherapy,” Hall says. “High-quality prenatal care facilitates mental healthcare.”
REFERENCES
- Harris E. US maternal mortality continues to worsen. JAMA 2023;329:1248.
- Hoyert DL. Maternal mortality rates in the United States, 2021. Centers for Disease Control and Prevention. Last reviewed March 16, 2023. https://www.cdc.gov/nchs/data/...
- Thomas L. U.S. maternal mortality rates rose during COVID-19 pandemic. News Medical Life Sciences. March 23, 2023. https://www.news-medical.net/n...
- Thoma ME, Declercq ER. Changes in pregnancy-related mortality associated with the coronavirus disease 2019 (COVID-19) pandemic in the United States. Obstet Gynecol 2023;141:911-917.
- Chappell B. Tori Bowie, an elite Olympic athlete, died of complications from childbirth. NPR Health. June 13, 2023. https://health.wusf.usf.edu/np...
- Levin S. She was jailed for losing a pregnancy. Her nightmare could become more common. The Guardian. June 4, 2022. https://www.theguardian.com/us...
- Panetta G. Women could get up to 30 years in prison for having a miscarriage under Georgia’s harsh new abortion law. Insider. May 10, 2019. https://www.businessinsider.co...
- Meng ML, Fuller M, Federspiel JJ, et al. Maternal morbidity according to mode of delivery among pregnant patients with pulmonary hypertension. Anesth Analg 2023;May 16. doi: 10.1213/ANE.0000000000006523. [Online ahead of print].
- Sangtani A, Owens L, Broome DT, et al. The impact of new and renewed restrictive state abortion laws on pregnancy-capable people with diabetes. Curr Diab Rep 2023;May 22. doi: 10.1007/s11892-023-01512-4. [Online ahead of print].
- Hall SV, Zivin K, Piatt GA, et al. Factors associated with mental health treatment among Michigan Medicaid enrollees with perinatal mood and anxiety disorders, 2012-2015. Gen Hosp Psychiatry 2023;83:164-171.
- American Heart Association News. Why are black women at such high risk of dying from pregnancy complications? Feb. 20, 2019. https://www.heart.org/en/news/...
- Austin J, Wirtz A, Garrett M, et al. Associations of cesarean sections with comorbidities within the Pregnancy Risk Assessment Monitoring System. J Perinat Med 2023;May 22. doi: 10.1515/jpm-2023-0005. [Online ahead of print].
- Plaintiff’s original petition for declaratory judgment and application for permanent injunction. Submitted to 353rd District Court. March 6, 2023. https://reproductiverights.org...
The number of women dying from pregnancy-related causes in the United States has risen dramatically since 2018. Those numbers may continue to rise sharply as the nation creates more maternity deserts, obstetric staffing shortages, and obstacles to standard maternity care in states that enforce abortion bans and restrictions that affect women experiencing pregnancy crises.
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