"The groundwork of all happiness is health." - Leigh Hunt

Maternal mortality continues to be high, but perhaps higher than expected

March 13, 2024 – Maternal mortality rates within the United States are lower than previous estimates – but still higher than other developed countries, in line with a study published Today.

Researchers said inaccurate records had caused undue concern that the number of girls dying while pregnant or shortly after birth was increasing. The maternal mortality rate is stable, they report, and deaths from complications have declined.

“Birth-related complications as a reason for death have decreased over time. That's to be expected because we have now improvements in medical care,” said KS Joseph, MD, PhD, an obstetrician and gynecologist at the British Columbia Children's and Women's Hospital and Health Center in Vancouver, and co-author of the new study.

This good news comes with sobering asterisks. The maternal mortality rate in this country is still highest in the developed worldAAnd black women in the United States are far more likely to die during or after pregnancy than women of other racial or ethnic groups.

“Whenever we have inequities, it always comes down to two things: implicit bias and systemic racism,” Dr. Veronica Gillispie-Bell, division chief of obstetrics and gynecology at Ochsner Health in Kenner, LA.

Gillispie-Bell said systemic racism leads to economic insecurity and poor access to health care, which can lead to increased maternal mortality among Black women. And implicit bias can cause Black women to be treated differently and potentially distressingly by doctors without even being aware of it, she added.

Different counting method, different results

In 2003, officials at the National Center for Health Statistics recommended adding a “pregnancy check box” to U.S. death certificates to address what was then considered an undercount of deaths due to a pregnancy complication. This check box indicates whether deceased women were pregnant at the time of death, within 42 days of death, within 43 days to one year before death, were not pregnant, or if the information was unknown.

Just because someone was pregnant at the time of their death doesn't mean the pregnancy was to blame. But as Joseph and colleagues reported, the guidelines counted any death of a woman listed as pregnant on the certificate as a “maternal death.” From 2003 to 2017, this classification applied regardless of the person's age at death; Since 2018, this only applies to women who died of childbearing age (ages 15-44).

NCHS made the change to reduce the number of deaths that were incorrectly attributed to pregnancy, Joseph said.

The checkbox method reportedly led to a 144% increase in maternal mortality among women ages 15 to 44 between 1999 and 2002 (9.65 per 100,000 live births) and 2018 and 2021 (23.6 per 100,000 live births).

Joseph and colleagues also looked for death certificates that listed an explicit cause of death as well as the fact of pregnancy. For these deaths to be associated with pregnancy, they had to be related to an obstetric complication during the pregnancy or to an underlying disease or condition that aggravated the pregnancy.

Using this refinement, researchers found 10.2 maternal deaths per 100,000 births from 1999 to 2002 and 10.4 maternal deaths per 100,000 births from 2018 to 2021. Deaths associated solely with pregnancy or childbirth decreased. Indirect causes of maternal death such as cardiomyopathy (any disease affecting the heart muscle), high blood pressure, or attachment of a placenta to the uterine wall increased.

For black women, the alternative method found 25.7 deaths per 100,000 births from 1999 to 2002 and 23.8 deaths per 100,000 births from 2018 to 2021. Both numbers are twice the overall rates, and black women also suffered more from conditions such as High blood pressure and cardiomyopathy, according to the researchers.

Gillispie-Bell is the medical director of Louisiana's Pregnancy-Associated Mortality Review Board, which searches mortality records to obtain accurate maternal mortality statistics for the state.

And that process also shows disparities in maternal mortality between black women and other U.S. women, Gillispie-Bell said.

One strategy to close this gap, which both Joseph and Gillispie-Bell advocated, is to intensively treat all signs of hypertension and cardiomyopathy in pregnant black women as they arise. Gillispie-Bell also suggested doctors take this Implicit association test to search out out in the event that they are unintentionally introducing bias into their interactions with Black women so that they can change their behavior when vital.

“Our brains use shortcuts to process information,” Gillispie-Bell said. “This is how prejudices arise. There’s no reason to feel guilty.”