Maternal Mortality and morbidity

Author: Quynhvy Ta, DO PGY3
Reviewed by: Jordana Haber, MD, MACM 
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For decades in the U.S. and around the world, maternal mortality rates decreased, due to medical advancements in conjunction with public health efforts. Women gained increasingly healthier living conditions, improved maternity services, greater access to surgical procedures and antibiotics. Then, about 30 years ago, the US maternal mortality ratio began to rise. Between 1990 and 2016, the U.S. was the only high-income country in which material death increased, more than doubling over that time span. In 1987 the rate was 7 per 100k live births. Today it is an astounding 24 per 100k. Not only is the U.S. a stark outlier among our peers but giving birth in the U.S. is paradoxically becoming more dangerous as maternal health is improving around the rest of the world. Pregnancy related mortality and morbidity rates are unacceptably high in this highly developed country. Most of these deaths and health sequela related to childbirth, most disturbingly, are preventable. 
 
The maternal mortality ratio is defined as a death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, notably not from accidental or incidental causes. This is the number used by the WHO, a rate of deaths per 100k live births, and the number most cited as an index to examine historical trends. This is a very conservative estimate of what’s really happening, since at least 24% of maternal deaths occur in the postpartum period after 42 days. Pregnancy-related mortality encompasses up to one year postpartum. During pregnancy, hemorrhage and cardiovascular conditions are the leading causes of death. At birth, infection is the leading cause. And in the postpartum period, typically after the traditional 6–8-week post pregnancy visit, cardiomyopathy, and mental health conditions, including substance use and suicide, are identified as leading causes. 
 
Severe maternal morbidity is defined as the unexpected outcomes of the process of labor and delivery that result in short- or long-term consequences to a woman's health, most common indicators in the U.S. being blood transfusion, DIC, hysterectomy, acute renal failure, and ARDS. ACOG and the CDC recommend the following two criteria to screen for severe maternal morbidity: transfusion of four or more units of blood, and admission of a pregnant or postpartum woman to an ICU. Akin to the cases of maternal mortality, the outcomes that are encompassed by maternal morbidity could have largely been avoided with timely and appropriate care. 
 
The US currently ranks 55th in the world behind all other developed nations in maternal mortality. Russia is currently ranked 52nd. The maternal mortality rate in the US is 23.8 per 100k live births, a stark contrast to the 3 per 100k in New Zealand, Norway, and the Netherlands. This rate is more than doubled, 55 per 100k, for Black women. It should be noted that these numbers do not account for undocumented pregnant women. Severe maternal morbidity affects approximately 60 thousand women annually- and this is a conservative estimate.
 
According to a report from maternal mortality review committees across 14 states, two thirds of pregnancy related deaths were preventable. Both patient and health systems factors were noted to profoundly contribute to these abysmal numbers. Reproductive factors including younger age, higher parity, and unwanted pregnancy are associated with higher mortality. On a health system level, there is a lack of standardized approaches to emergency obstetric care. Depending on the primary provider, there exists great variability in the approach to the management of severe hypertension, VTE, obstetric hemorrhages. There is a marked lack of health services, including lack of access, providers, preventative services, and notably postpartum care, when most maternal deaths occur. The disparate access to quality, accessible and culturally appropriate health care is undoubtedly a driving factor in the gaping racial disparities in maternal health outcomes. Unequal access to providers, education, structural racism and sexism, avoidance of healthcare facilities due to a history of racism, and a lack of empathy from healthcare providers are just a handful of the socioeconomic injustices that exacerbate this crisis. 
 
There are some notable distinctions of the U.S., compared to other high-income countries, that should be mentioned. We are the only high-income country that does not guarantee paid leave time from work (while several provide more than a year.) We have the lowest overall supply of midwives and OB/GYNs, 15 to every 1000 births which is less than half of all other high-income countries. We are also the only country not to guarantee access to provider home visits in the postpartum period. Women with Medicaid coverage, as compared to those with private health insurance, are more likely to report no postpartum visit, having to return to work within 2 months of birth, less postpartum support at home, not having decision autonomy during labor and delivery, and being treated unfairly and with disrespect by providers. 
 
The Black white maternal mortality disparity is the largest amongst health disparities. Social determinants of health including disparities in income, housing, and education associated with poorer health and chronic conditions put Black women at greater risk. They are at greater risk of dying from pregnancy related hemorrhage, hypertensive disorders, and cardiomyopathy. Racism in healthcare, at an individual level, compounds this issue, with studies demonstrating that Black women are less likely to have access to treatment and receive good quality care even with insurance coverage.  Though there is no statistically significant greater prevalence of pre-eclampsia or placental abruption among Black women, they are three times more likely to die from these conditions, independent of age, parity or education.  At the intersection of sexism and racism, women of color are not listened to or respected by their health care providers, often receiving delayed diagnosis or care. A Black mother with a college education is 60% more likely to die from a white or Hispanic woman with less than a high school education. 
 
Access to safe abortion care is an essential component of maternal health care. Per the CDC, carrying a pregnancy to term is thirty three times deadlier than having an abortion, the latter with a 0.6 maternal mortality rate per 100 thousand. Women most likely to seek abortion care, i.e., women of color, those with poor access to care and those with chronic conditions, are those most likely to encounter serious complication during pregnancy. According to a University of Colorado study in 2021, banning abortion nationwide would lead to a 21% increase in number of pregnancy related deaths overall and a 33% increase among black women. 

Improving maternal health requires identifying and addressing barriers that limit access to quality maternal health services at systemic and individual levels. We most prevent unwanted pregnancies, providing all women including adolescents access to contraception, safe abortion services and quality post abortion care. We must improve women’s health services before, during, and after pregnancy. We need to increase not only first trimester entry into prenatal care, but to maintain postpartum care. The diversity of causes of maternal mortality and morbidity that occur at different stages of pregnancy until one year postpartum must be addressed through integrated care delivery models such as tele-health, midwives and doulas. There needs to be a greater availability of maternal health services, particularly in underserved areas. Paid parental leave, that is actually taken by parents and accepted culturally, should be guaranteed. We must ensure nondiscrimination in access to health care by supporting vulnerable segments of our population, particularly Black women who need more access to comprehensive public health programs that address pre-conceptual health and chronic conditions, implicit racial bias among healthcare professionals, and improving the quality of care at the hospitals predominantly servicing these women at the community level. And we must standardize care through implementing evidence-based practices by developing safety bundles addressing obstetric emergencies such as obstetric hemorrhage, severe, HTN, venous thromboembolism.
 
Maternal mortality and morbidity are largely preventable. It is unacceptable that these rates have markedly increased over the last two decades despite the marked medical advancements made in that same time span. It is our duty as health care providers to incorporate this knowledge into our own practice and relationships with patients in our current landscape, in which political galvanization seems to be eroding trust in medical expertise. We must not only practice health care, but advocate for the fundamental right to health.
 
 
References:

1. Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65.
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