Pregnancy-associated fatalities in the U.S. are still escalating

In the U.S., over 80 percent of fatalities related to pregnancy are avoidable. Yet, for numerous years, the country has experienced the highest maternal mortality figures among affluent nations. This trend persisted between 2018 and 2022, with significant variations based on state, race, and ethnicity, a recent study reveals.

A cohort of investigators at the National Institutes of Health, in association with Associate Professor Rose Molina from Harvard Medical School, utilized information from the Centers for Disease Control and Prevention to analyze pregnancy-related fatalities during that four-year duration.

The most substantial rate increase was recorded in 2021, likely indicating the impact of the COVID-19 pandemic that began in 2020. Although rates subsequently decreased, they remained elevated in 2022 (32.6 deaths per 100,000 live births) compared to 2018 (25.3 deaths per 100,000 live births).

The findings were in line with previous studies that have highlighted considerable disparities among racial demographics. American Indian and Alaska Native women experienced the highest mortality rate (106.3 deaths per 100,000 live births), which is nearly four times higher than the rate for white women (27.6 deaths per 100,000 live births), followed by non-Hispanic Black women (76.9 deaths per 100,000 live births).

Rates among states also exhibited significant variation, ranging from 18.5 to 59.7 deaths per 100,000 live births.

In this edited dialogue, Molina, an obstetrician-gynecologist, elaborates on the findings and the necessary future actions.

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What accounts for the significantly higher rate of pregnancy-related fatalities in the U.S. compared to other affluent nations?

There are numerous factors: our fragmented healthcare system, unjust policies, areas deficient in maternity care, along with ongoing biases and discrimination among racial and ethnic groups. This reflects how the healthcare framework is structured. Additionally, there are trends indicating that individuals of reproductive age are encountering more chronic health issues, including cardiovascular ailments, at younger ages than previously.

The findings revealed noteworthy racial disparities in maternal mortality rates. Was this unexpected?

While I am disheartened that the racial inequities have persisted, the fact is that this has been repeatedly demonstrated in academic research. There have been various innovations aimed at mitigating disparities among racial groups within health systems. However, on a population scale, as a nation, we have not yet witnessed substantial progress.

Our study indicates various policy mechanisms that must be addressed, as the existing state-level variations are excessive. One of our most significant discoveries is that we could have averted 2,679 pregnancy-related fatalities in this timeframe had the national rate aligned with California’s. If California can achieve this, how can we encourage other states to reach similar outcomes?

The primary cause of death identified in your study was cardiovascular disease, which was responsible for just over 20 percent of the fatalities. Has this always been the case?

Over the years in the U.S., there has been a shift from hemorrhage being the major cause of pregnancy-related fatalities to cardiovascular disease taking precedence. Cardiovascular disease includes various disorders: hypertension, pre-eclampsia, eclampsia, as well as peripartum cardiomyopathy, cardiac arrest, and stroke.

One reason for this transition could be the rising number of individuals with chronic hypertension. We found that the most significant increase in pregnancy-related fatalities occurred among the middle-age demographic (ages 25 to 39), rather than the oldest demographic. Thus, a potential concern is that chronic conditions like hypertension are increasingly affecting younger individuals. Historically, hypertension has been more prevalent among those aged 40 and above. However, we are now observing a rise in hypertension at younger ages.

In fact, pregnancy-related fatalities increased across all age demographics between 2018 and 2022. How significant is this increase?

It’s just four years, and the examined timeframe included the early stages of the COVID pandemic. Nonetheless, the evidence is substantial enough to warrant increased attention toward this rise. Even in 2022, the rates surpassed those of 2018. Moreover, rates were already climbing in 2019, prior to the onset of the pandemic.

Additionally, you discovered that “late maternal fatalities”— those that occur between 42 days and one year postpartum—accounted for nearly one-third of the total. Yet the World Health Organization does not include late maternal deaths in its definition of pregnancy-related mortality. Why is it vital to consider this timeframe?

Globally, any death during pregnancy or within 42 days post-birth is classified as maternal mortality. In the U.S., we are progressing towards acknowledging the full year after birth, since the 42-day postpartum limit is somewhat arbitrary.

There’s an increasing acknowledgment that the postpartum period does not simply conclude abruptly at six weeks, even if that is how many of our healthcare systems are structured, but rather the postpartum…

Recovery should be regarded as a continuum. The significant number of delayed maternal fatalities highlights the necessity for us to establish more effective healthcare systems during those later months, rather than solely concentrating on the initial six to twelve weeks.

This research provides a more comprehensive view of the issue compared to previous counts. Could you elaborate on that?

One of the primary obstacles in monitoring maternal fatalities in the United States is the absence of a national system for consistently tracking these incidents until 2018, which is when the complete implementation of the pregnancy checkbox on death certificates was executed across all 50 states.

This implies that currently, when an individual passes away, the death certificate includes a checkbox for pregnancy, allowing for some indication of whether the deceased was pregnant at the time of death. However, the full implementation took considerable time across all states. This is why our data is particularly noteworthy; we examined the information starting in 2018, coinciding with the full implementation of that process nationwide.

Having outlined everything, how can these figures be enhanced? What should follow?

The foremost message is the need to continue our investment in public health infrastructure. It is evident that we aren’t progressing, and in fact, the statistics surrounding pregnancy-related fatalities are worsening. Therefore, a change in our approach to this issue is imperative.

Specifically, we must boost investment in innovative strategies to improve the quality of care throughout pregnancy and the extended postpartum phase. At the state level, it is crucial to address policy discrepancies and strive to comprehend why some states perform significantly worse than others.

It is a troubling time because the public health framework designed to monitor these fatalities is under threat. Funding for research is experiencing severe cuts. Pregnancy is being deprioritized. Such actions and reductions jeopardize any initiatives aimed at improving maternal health outcomes, which are vital for informing state-level policy and advocating for enhanced access to comprehensive pregnancy care.