The Buzz This Week
The United States has one of the highest maternal mortality rates (MMRs) among high-income countries, at 33 maternal deaths per 100,000 live births—more than 10 times the rates in countries such as Japan, Spain, Israel, Austria, and Australia. MMRs are defined as maternal deaths that take place during pregnancy up until 42 days (6 weeks) postpartum. Racial disparities are stark, with 2021 MMRs for non-Hispanic Black women more than 2.5 times higher than those for non-Hispanic white women.
The shocking death of Black Olympic medalist Tori Bowie, age 32—found deceased in her bed at 8 months pregnant—captured the world’s attention and reignited the discussion around the Black maternal mortality crisis. Bowie’s agent Kimberly Holland said that Bowie felt her doctors were not listening to her concerns and that she “didn’t trust hospitals.” According to an autopsy report, Bowie’s death may have resulted from eclampsia, which can cause seizures and respiratory distress. Eclampsia is usually detected during routine prenatal care in a condition known as preeclampsia, which is usually identified by sudden high blood pressure and protein in the urine. Black women are 60% more likely to develop the condition compared to white women. Because a higher percentage of Black women experience delayed access to prenatal care and receive less adequate prenatal care, this condition and other pregnancy complications may be missed.
The Journal of the American Medical Association (JAMA) found in an analysis of pre- and post-COVID data that maternal mortality increased 33% after March 2020, corresponding to the onset of COVID-19. The authors write, “change in maternal deaths during the pandemic may involve conditions directly related to COVID-19 (respiratory or viral infection) or conditions exacerbated by COVID-19 or other health care disruptions (diabetes or cardiovascular disease).”
However, even before the pandemic, rates had been increasing for decades. Another analysis published in JAMA last week looked at available mortality rates from 1999 to 2019, and found an overall 260% increase in the U.S. MMR in that 20-year period. For some racial and ethnic groups, and in certain states, the rates were much higher and the increases even greater. For example, Alaska Natives and American Indians in the West region of the U.S. saw nearly a 400% increase, and states in the South had higher MMR rates than other regions across all racial and ethnic groups. The authors note, however, that maternal mortality data is not collected consistently across all groups and states, hindering efforts to understand longitudinal U.S. maternal mortality trends. This is largely due to “inconsistent use of terminology, differences between states in how maternal death has been defined, and states’ differential timing of the addition of a U.S. standard pregnancy question (the ‘pregnancy checkbox’) to their death certificates.” Because of this, the study employed a complex set of statistical models to extrapolate existing data to areas and groups where data was unavailable, inconsistent, or deemed unreliable.
Why It Matters
The Centers for Disease Control and Prevention (CDC) has stated that 80% of maternal deaths are preventable. While U.S. rates are at a crisis level—in particular for Black mothers and other minority groups—federal and state agencies, healthcare institutions, and community groups have been working for decades on prevention and intervention programs. A previous edition of Top Reads discussed existing and proposed interventions, including ensuring adequate insurance coverage and access to prenatal and post-natal care, expanding access to doulas and midwives, and establishing maternal mortality review committees.
However, the recent JAMA article suggests that these and other efforts have not been effective, at least not in sum. In addition, the recent Dobbs ruling and subsequent actions taken by many states to ban abortion services is likely to elevate maternal mortality risk. The Commonwealth Fund published a briefing in December 2022 stating that MMRs are 62% higher in states with abortion bans. In addition, systemic racism in healthcare is contributing to higher maternal mortality rates in Black women and other minority groups. An 11-year analysis of over 9 million deliveries in U.S. hospitals, presented at the 2022 American Society of Anesthesiology meeting, found that Black women had a more than 50% higher risk of dying in the hospital during childbirth than white women, regardless of their income level, type of insurance, or other social determinants of health.
It is time for new, more creative, farther-reaching approaches to combat the maternal mortality crisis in the U.S. While some prevention and intervention programs may have a positive impact, they clearly are not reaching enough women to reverse the upward trend in MMRs. Healthcare organizations and medical education institutions need stronger, more dedicated efforts to reduce systemic racism in healthcare. Finally, a coordinated effort (supported by federal, state, or insurance-driven mandates) needs to be put into place to track maternal deaths more effectively and consistently so progress as well as areas of continued crisis can be better tracked over time.
RELATED LINKS
JAMA:
Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States
Kaiser Family Foundation:Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them
Editorial advisor: Roger Ray, MD, Chief Physician Executive.
