April 05, 2023

Increased maternal mortality: we need to act

Maternal Mortality in the US is not declining. Why? Why are we as a people not upset about it?

It is hard to believe that the maternal mortality in the US, our beloved country, is still going up. Even harder to believe is that we the people are not outraged about this fact. When I was a nursing student in 1958, I was taught that infant mortality and especially maternal mortality rates were a bell weather indicator of the health of a nation. Throughout my entire career as an obstetrician-gynecologist and a physician-scientist researching women’s reproductive health I focused on the question of how to decrease the numbers of women dying from pregnancy related causes. Many reasons for maternal deaths are known. We understand very clearly that there has been an increase in maternal age and that women in their thirties are at risk for pregnancy complications. We know that one-half of adults in the US have hypertension. We know that cardiovascular problems are a leading cause of maternal death, we know how to treat hypertensive disorders of pregnancy and prevent eclampsia and understand a great deal about its pathophysiology at a detailed molecular level. We know how to prevent preeclampsia from advancing to where it is a serious threat to the life of the mother as well as the infant. We know that obesity had increased in the US and that about 42% of adults at obese and that 11% have diabetes. We know that obesity and diabetes are risk factors for complications of pregnancy. We know how to treat infections, especially infections acquired because of premature rupture of the fetal membranes and we know how to treat obstetrical hemorrhage due to uterine atony, obstetrical trauma, or lack of blood clotting factors. We know that good healthy food and a healthy environment is necessary for a successful pregnancy and yet we have a serious problem in our country with food deserts and polluted environments. We know that education is important to the health of childbearing individuals and yet be provide little in the way of the necessary education about how to have a healthy pregnancy and birth. We know so much about all of this at many levels: the molecular biology and physiology, pathophysiology, preventive public health measures, modern therapeutic approaches for treatment of pregnancy complications, the need for more providers including more providers of diverse backgrounds of race, ethnicity, and economic status. Study after study has demonstrated that midwives and doulas are important essential members of the care team. We have the knowledge to change the high maternal morality rate in the US. We do not have the will. Why? Why are we not outraged by this blatantly poor statistic.

In 2021 the latest data we have demonstrated that there was a 40% increase in maternal mortality from 2020. In that year one thousand, two hundred and five maternal deaths occurred in the US. One thousand, two hundred and five infants have no mothers. This is a rate of 23.8/100,000 live births. In the Netherlands that year there were fewer maternal deaths. Their maternal mortality rate was 1.2/100,000. Maternal mortality rates as we have stated in the past are the number of maternal deaths per 100,000 live births and are defined by the World Health Organization as death while pregnant or up to 42 days after the end of a pregnancy regardless of the length of gestation. Three states in 2021 had the highest rates: Arkansas, Kentucky, and Alabama. The states with the lowest rates in the US were Massachusetts, Colorado, Illinois, and California. As we have stated previously, non-Hispanic black maternal mortality is unspeakably high. It is three times higher than the white maternal mortality. The white maternal mortality in our country is higher than that of other developed countries. Thus, we are not doing well at all. We really are getting a F.

One study reported that the US maternal mortality rate increase 33.3% after March 2020 after Covid-19 pandemic commenced and this might account for the increase especially among Hispanic and non-Hispanic blacks. The study felt that this increase might be related to Covid-19 directly to conditions that exacerbated the disease as diabetes and cardiovascular disease. They also mentioned that there were a large percentage of maternal deaths where the pregnant individual was positive for Covid but that there was a nonspecific indication of cause of death. The authors state that this problem reflects a maternal death coding profile issue. As a profession we need to continue to study Covid impacts on maternal death. At the Campion Fund-NIEHS meeting on the basic science of gestation and parturition on of the speakers discussed his studies of the molecular biology of covid -19 infections in pregnancy. In terms of the international data, one study reported on maternal mortality in nine developed countries during a pandemic year. In six of the nine, the rate went up suggesting that perhaps covid -19 was the reason. In three countries the maternal mortality rate went down: Australia, Japan, and the Netherlands. In the Netherlands during the pandemic there was an increase in home births, and increase in vaginal births and a decrease in C-Sections (both planned and emergency). These facts may have helped to lower the maternal deaths there. But it is still to be noted that during the global pandemic in three countries, maternal mortality decreased. Whether or not the pandemic contributed to the increase in maternal deaths is still open to further study.

There is no doubt though about the factors that create an environment to reduce maternal mortality rates. These are: 1. Policies that allow all women to have access to free or affordable primary care, before, during and after pregnancy. 2. The maternal health care workforce consists mainly of midwives for physiologic births with physicians for high-risk situations, all paid for by insurance. 3. Comprehensive postpartum support. In the US about 8 million women of reproductive age are uninsured. It is important to note that universal health insurance is not the same as nationalized health. In Japan and Germany, their entire populations have insurance, covered by many insurance companies and mechanisms. It is possible to have universal coverage by many companies rather than one national health program- so call “socialized medicine”. In addition, Japan has long had a system of local community support for pregnant women and for children.

During 2023 and 2024 the Campion Fund is focusing on pregnancy and birth. We aim to raise awareness of the issues surrounding healthy childbearing at all levels. We have already conducted a scientific meeting on the basic science of gestation and parturition and are proud to note it encouraged collaborations between scientist as we still have a great deal to learn and to translate into clinical medicine. We are in the process of crystalizing a concept for a meeting to discuss strategies to eliminate serious pregnancy complications and the prevention of maternal mortality. This will be a meeting to discuss prevention encompassing molecular development and reproductive biology to public health measures in the community as well as the increase of a diverse well-prepared health care team of many types of practitioners. We need to get beyond asking why? We need to act.                                                                                              

Further reading:

Thoma ME, Declercq ER. All-Cause Maternal Mortality in the US Before vs During the COVID-19 Pandemic. JAMA Netw Open. 2022 Jun 1;5(6):e2219133. doi: 10.1001/jamanetworkopen.2022.19133. PMID: 35763300; PMCID: PMC9240902.





Leppert, PC. An Analysis of the Reasons for Japan's Low Infant Mortality Rate. Journal of Nurse-Midwifery 38:6, 353-357, 1993.