The Issue
April 11th is International Day for Maternal Health and Rights. Last month, the United States Centers for Disease Control and Prevention (CDC) released a report with the staggering statistic that the maternal mortality rate reached 32.9 deaths per 100,000 live births in 2021; 1,205 women died of maternal causes. Maternal mortality in the United States grew by 40% in 2021.
Maternal mortality is defined by the World Health Organization as the death of a mother during pregnancy or within 42 days of the end of a pregnancy. A pregnancy-related death is defined by the Centers for Disease Control and Prevention as “the death of a woman while pregnant or within one year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management.” The causes of death as noted in the CDC report can include suicide, excessive bleeding, and heart issues like high blood pressure, among others.
There are at least two alarming underlying facets of the 2021 maternal mortality statistic. First, prior to 2021 the United States already had the unflattering distinction of being the country with the highest rate of maternal mortality among developed nations. The US maternal mortality rate is more than triple the rate of other developed countries.
Second, and even more alarming is that the mortality rate in the US for Black women is worse than it is for white women. The death rate for Black mothers was 69.9 per 100,000 live births—a figure that is more than double the rate for white mothers. These disparities in health outcomes by race persist regardless of education and income.
Especially notable is that the rate of maternal death from preeclampsia and eclampsia for Black women is nearly 5 times that of white women. Preeclampsia is a blood pressure disorder occurring in approximately 4 percent of pregnancies. The reasons for racial disparities in outcomes can include lack of access to care, underlying health conditions, implicit bias in the delivery of care, and underlying misconceptions about people from different racial groups or socioeconomic factors.
Maternal mortality in the United States grew by 40% in 2021.
Reason for Hope
It is difficult to find any good news among these statistics, but there is hope for the future. Because 60 to 80 percent of maternal deaths are considered “preventable,” there are practical interventions and solutions available.
Some of the state-level efforts to address maternal mortality over the past decade have grown out of the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) program. This MIECHV program resulted in states like Maryland and Michigan passing legislation to support home visitation programs for mothers. More recently, and after a thorough review by the Commission on Civil Rights in 2021, the federal government issued additional policy proposals that seek to reduce maternal deaths. For example, in April 2022, the federal Centers for Medicare and Medicaid Services (CMS) proposed a designation to encourage “birthing-friendly hospitals.” To earn this designation, hospitals have to participate in a statewide or national collaborative program where medical teams and public health leaders work together to improve care quality for birthing parents and babies. In June of 2022, the Biden administration issued a Maternal Health Blueprint with policy proposals such as those outlined below, which are aimed at reducing maternal mortality.
Solutions to Decrease Maternal Mortality
Luckily, there are solutions that have been used that can help reduce maternal mortality. Whether federal, state, or private initiatives, strategies to reduce maternal mortality can be grouped into five categories:
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Improve health insurance coverage and access
Among the solutions that have been noted in previous research is improved access to care, including better insurance coverage. According to the CDC, approximately 24 percent of deaths occur during pregnancy, 34 percent occur on the day of delivery or within a week after delivery, 19 percent occur between 7-42 days postpartum, and 24 percent occur in the later postpartum period (43-365 days postpartum). Since most maternal deaths occur within 1 year of birth, there have been recent policy proposals, including one from the Biden administration, that encourage states to guarantee Medicaid coverage for women for a full year after childbirth. Many states are already expanding Medicaid coverage to pregnant women from the minimum of 60 days to a full year after giving birth. But providing coverage doesn’t always ensure that mothers have access to that care. Transportation and the availability of providers and services, as well as culturally competent and community-based care are also important.
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Quicker and regular postpartum check-ups and preventive care
Research on the causes of maternal mortality also points to the need for changes in care practices such as quicker and more consistent follow-up care after giving birth. It used to be common that new moms were not seen by a doctor after being discharged from a hospital until 6 to 8 weeks later. That is too long. Research also shows that 40 to 50 percent of new moms are not receiving routine care after giving birth. As pointed out previously, postpartum maternal deaths are most common during the first few months after birth so getting check-ups sooner and ensuring consistent monitoring of a mother’s physical and mental well-being makes sense.
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Better prenatal, perinatal, and postnatal care
Studies have shown that methods for caring for moms in other countries result in lower maternal mortality rates. These methods could be expanded in the US. They include more widespread use of midwives and doulas and universal maternity leave. To make access to care easier for moms, home visits are being used by more and more states. In addition to the examples in Maryland and Michigan that were cited earlier, in 2019 and 2021, Oregon (SB 526) and New Jersey (SB 690), respectively, enacted home visiting programs. These new laws implemented and maintained universal statewide programs to provide visiting nurse services at home to all families with newborns that choose to utilize them in order “to support healthy child development, strengthen families and provide parenting skills.” In states like New York, there are initiatives that expand perinatal care networks and clinical guidelines about perinatal care standards. And a number of hospital providers are now using hub-and-spoke type models of care, where a larger hospital collaborates with smaller rural hospitals to transfer more acute cases to the “hub” and make maternal services more available in rural areas of the country.
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Training and clinical practice that acknowledges racial differences and minimizes implicit bias
As referenced above, race is an important factor in maternal outcomes. According to a multi-disciplinary scientific workgroup convened by the March of Dimes organization, the stress associated with being a Black woman is “a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.” Growing evidence points to not only race but racism as a factor in disparities in maternal outcomes. Research shows that a Black mother with a college education is still nearly twice as likely to die of a pregnancy-related cause as a white counterpart with a high school education. California is an example of one state that has focused efforts on reducing race-based inequities in care delivery. The state has produced a number of training and technical assistance documents to help providers reduce maternal mortality and birth inequities.
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Use of new and creative solutions such as virtual monitoring and home care
One of the fastest growing areas of digital start-up companies in healthcare are those that deal with women’s health. In the first quarter of 2021, the “FemTech” industry had nearly a billion dollars in investments according to CB Insights, an entity that tracks venture capital investments. The focus of these companies can range from virtual monitoring of blood pressure, to connecting expectant mothers with care resources in their communities, to predicting the likelihood of delivery complications. For example, one company provides remote maternity care. The rapid growth of these companies and their applications for care delivery could go a long way to providing better resources for expectant and new parents.
Despite the fact that the US has a poor track record on maternal mortality, there is significant opportunity for improvement and a host of promising strategies that are starting to be more widely implemented. As Albert Einstein said, “in the midst of every crisis lies great opportunity.” If ever there was a crisis, maternal mortality—especially for Black women in the US—is certainly one of them. It is past time to make sure more pregnant patients get the care they need.
ABOUT THE AUTHOR
Courtney Burke is senior fellow for health policy at the Rockefeller Institute of Government