Maternal deaths in the United States have surged to their highest level in nearly 60 years, with rates that are far more dire for Black mothers compared with other racial groups, according to new federal data.
In 2021, 1,205 women died of maternal causes, according to a report from the National Center for Health Statistics released by the Centers for Disease Control and Prevention (CDC). That’s a 40 percent increase over 2020, when 861 women died. In 2019 and 2018, there were 754 and 658 deaths, respectively. A separate report by the Government Accountability Office (GAO) cites COVID-19 as a contributing factor in one-quarter of maternal deaths in 2020 and 2021 combined.
The 2021 data, which is the most recent data available, represents a U.S. maternal mortality rate of 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020, 20.1 in 2019, and 17.4 in 2018.
As in past years, Black pregnant women died at significantly higher rates than their white counterparts. In 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for white women at 26.6 deaths per 100,000 live births. In 2020, the maternal mortality rate for Black women was 55.3 deaths per 100,000 live births, compared with 19.1 for white women. The rates for Black women in 2019 and 2018 were 44.0 and 37.3 deaths, respectively, while the rates for white women were 17.9 and 14.9 deaths, respectively.
Black women also continued to die at rates significantly higher than Hispanic women. In 2021, the maternal mortality rate for Hispanic women was 28.0 deaths per 100,000 live births. The rates for Hispanic women in 2020, 2019 and 2018 were 18.2, 12.6 and 11.8 deaths, respectively.
The report considers maternal deaths, as defined by the World Health Organization (WHO), as deaths from any cause related to or aggravated by pregnancy or its management during pregnancy and childbirth or within 42 days of termination of pregnancy. However, the U.S. maternal mortality crisis exists far beyond the parameter of 42 days. In September 2022, the CDC examined maternal deaths up to one year after childbirth, including deaths resulting from mental health conditions. Based on data provided by 36 states on 1,018 pregnancy-related deaths from 2017 to 2019, the agency concluded that about a third of the women died during pregnancy or on the day they delivered, and that about another third died before their baby reached age six weeks. The remaining third died between six weeks and their baby’s first birthday.
A CDC analysis of 3,410 pregnancy-related deaths from 2011 through 2015 shows that the leading cause varied by time relative to the end of pregnancy. Researchers found that during pregnancy, “other noncardiovascular and other cardiovascular conditions” were the leading causes of death; on the day of delivery, hemorrhage and amniotic fluid embolism were the major causes of death. Hemorrhage, hypertensive disorders of pregnancy, and infection were leading causes of death during the first six days postpartum. From six weeks postpartum (43 days) through the end of the first year (365 days), cardiomyopathy was the leading cause of death. It is worth noting that the American Hospital Association reports that mental health conditions account for nine percent of pregnancy-related deaths, and suicide accounts for 20 percent of postpartum deaths.
The depth of the maternal mortality crisis is further illustrated when one considers that the U.S. has the highest rate of maternal deaths in the industrialized world, notwithstanding our advanced healthcare system. As a point of comparison, in 2020, France, the United Kingdom and Canada had rates of 8, 10 and 11 maternal deaths per 100,000 live births, according to the WHO. The WHO reports that the U.S. maternal mortality rate rose 78 percent between 2000 and 2020, while dropping in most other countries. Over the past decade the U.S. birth rate declined by approximately 20 percent as the maternal death rate rose.
Why Is This Happening?
While the reasons for the U.S. maternal death crisis are wide-ranging and complex, there is no denying that systemic health and social inequities put minority pregnant women, and Black pregnant women in particular, at a disproportionately high risk for adverse health outcomes. Factors that tend to increase maternal mortality in the U.S. include lack of access to medical care, economics, underlying medical conditions, and implicit bias and structural racism in the healthcare system. Much like the circles in a Venn diagram, these factors often overlap. The COVID-19 pandemic exacerbated them.
While not meant to be exhaustive, below we discuss the fundamental causes of the U.S. maternal mortality crisis.
Lack of Access to Medical Care (Maternity Care Deserts)
A recent report by the March of Dimes found that between 2020 and 2022, 36 percent of counties in the United States were “maternity care deserts,” meaning there are no hospitals or birth centers offering obstetric care and no obstetric providers.
Key findings from the report include:
- More than 2.2 million women of childbearing age live in maternity care deserts. Another 4.7 million women live in counties with limited maternity care access.
- Two in three (61.5 percent) of maternity care deserts are in rural counties.
- Fifty percent of women who live in rural communities, as compared to seven percent of women in urban areas, must travel greater than 30 minutes to reach an obstetric hospital.
- More than 146,000 babies were born in maternity care deserts. An additional 300,00 babies were born in counties with limited maternity care access.
- Counties with low access to telehealth were 30 percent more likely to be maternity care deserts.
The report does not mince words as to the correlation between maternity care deserts and pregnancy-related deaths. It states: “Recommendations to improve maternal health outcomes and prevent maternal death include incorporating comprehensive care for women with high-risk comorbidities before, during and after pregnancy as well as providing education on warning signs of complications during pregnancy. Both recommendations require continuous access to health care which may be difficult for people residing in maternity care deserts.”
Economics
Hand-in-hand with lack of geographical access to maternal healthcare is lack of economic access. In 2021, Medicaid financed 41 percent of all births in the United States, according to the Kaiser Family Foundation. From 2020 to 2022, Medicaid covered nearly 50 percent of births in maternity care deserts, compared to 40.1 percent in counties with full maternity care access, according to the March of Dimes.
Federal law requires states to provide pregnancy-related Medicaid coverage for 60 days after childbirth. While some women may qualify for continuation of Medicaid coverage for reasons other than pregnancy, there is no doubt that those who lose coverage may still experience a range of health issues after 60 days postpartum. These include hypertensive disorders, diabetes, and other chronic conditions, all of which tend to be more prevalent among people covered by Medicaid than those with private insurance, according to The Commonwealth Fund. The Commonwealth Fund further notes that the postpartum year is also an important time to monitor for and treat behavioral health conditions, which by some estimates are among the leading causes of maternal deaths.
In a positive development, a provision in the American Rescue Plan Act of 2021, which was signed into law by President Biden in March 2021, gives states a new option to extend Medicaid postpartum coverage to 12 months. The Kaiser Family Foundation reports that as of August 9, 2023, 36 states (including the District of Columbia) have implemented the extension.
Underlying Chronic Medical Conditions
In the United States, one in five women of reproductive age reportedly have two or more chronic medical conditions, and many maternal deaths result from missed or delayed opportunities for treatment, according to a 2022 report by The Commonwealth Fund. A report published by Review to Action, which examined data from maternal mortality review committees of nine states, found that chronic medical conditions were among the most common class of patient factors that contributed to maternal deaths from cardiovascular and coronary conditions, cardiomyopathy, infection, embolism, preeclampsia and eclampsia.
Chronic conditions that can affect maternal health outcomes include obesity, high blood pressure (hypertension), diabetes and heart conditions. The CDC reports that about 42 percent of U.S. adults are considered obese, nearly half have high blood pressure, about 11 percent have diabetes and 38 percent have prediabetes.
Implicit Bias and Structural Racism
Racism negatively affects the health of millions of people, according to the CDC. Indeed, research has shown that racial and ethnic disparities in maternal health outcomes persist, even after controlling for other factors like socioeconomic status, education and access to care. A recent landmark study of two million California births published in January 2023 by the National Bureau of Economic Research found that maternal mortality rates were just as high among the highest-income Black women as among the lowest-income white women.
Bias and discrimination within the healthcare system can create communication challenges between providers and patients which can end with tragic adverse outcomes. Look no further than today’s headlines for stories of Black pregnant women who were dismissed and ignored by their healthcare providers until they died (or nearly died). They include:
- Yolanda Mention was discharged from the hospital after giving birth despite having dangerously high blood pressure. Just a few hours later, she returned to the emergency room (a 60-minute drive from her home) with even higher blood pressure and an excruciating headache. But the ER staff made her wait for hours without seeing a doctor, even after they took her blood pressure twice and discovered that it was alarmingly high, and even as her husband banged on the intake desk and demanded that she be seen. More than five hours after she arrived in the ER, a blood vessel burst in Mention’s brain. She died a few days later.
- Shamony Gibson gave birth to her second child via C-section. A few days after being discharged from the hospital, she experienced chest pain and shortness of breath. Gibson went back to the hospital twice, but her concerns were dismissed. Doctors kept asking her if she was on drugs. Just 13 days after giving birth, she died of a pulmonary embolism, which is a blood clot that travels to the lungs. Blood clots are a known risk of C-sections, according to The American College of Obstetricians and Gynecologists (ACOG).
- Kira Johnson gave birth to her second son via C-section. Less than two hours later, her husband noticed blood in her catheter bag. Over an hour later, a “surgical emergency” CT scan was ordered, but the scan never happened, and she wasn’t taken back to the operating room to find the source of the bleeding until much later despite her husband’s pleas for help. By then, it was too late to save Johnson. She died of a postpartum hemorrhage.
- Ali Lowry was one of the luckier moms. She lived. She had internal bleeding after a C-section. It took medical staff hours to act on the warning signs. By the time she was airlifted to another hospital for lifesaving surgery, Lowry’s heart had stopped, and her delivery hospital had nearly run out of blood. Lowry needed a hysterectomy to stop the bleeding.
Even famous, rich, powerful and extraordinarily well-educated Black moms struggle to have their concerns taken seriously when they are pregnant. Take tennis star Serena Williams. In 2022, Williams penned a powerful essay for Elle detailing how she almost died after giving birth to her daughter via C-section in 2017. Williams, who had a history of pulmonary embolism, recognized that she was experiencing the symptoms the day after her daughter was born. As she gasped for air, Williams told a nurse that she needed a CAT scan with contrast and a heparin IV (blood thinner) immediately. The nurse dismissed her concerns and told her that she just needed to rest and that the medications she was on were making her “talk crazy.”
Williams — who described herself as being so ill that she required a “fog of surgeries” — persisted until the nurse finally called the doctor, and the doctor ordered the scan. “I fought hard, and I ended up getting the CAT scan. I’m so grateful to her. Lo and behold, I had a blood clot in my lungs, and they needed to insert a filter into my veins to break up the clot before it reached my heart,” she wrote. Williams also got the heparin drip that she knew she needed. “Being heard and appropriately treated was the difference between life or death for me,” Williams wrote.
Then there’s the case of Shalon Irving. Irving was an epidemiologist at the CDC and a lieutenant commander in the U.S. Public Health Service Commissioned Corps who held a B.A. in sociology, two master’s degrees and a dual-subject Ph.D. Her work focused on eradicating disparities in health access and outcomes. She also had the benefit of excellent health insurance. Following a C-section delivery, a nurse visited Irving at her home every other day to treat her incision and recorded — with no further action — that she had dangerously high blood pressure. Irving also had chronic pain, persistent headaches and swelling in her legs. She visited her doctor twice and was sent home the first time with no treatment and the second time with a prescription. That night, three weeks after giving birth, Irving collapsed and died from complications of high blood pressure. “There’s no manual for overcoming the death of a child, especially when you know that her death could have been prevented if her complaints had been heard,” her mother, said during a public health symposium held at the Johns Hopkins Bloomberg School of Public Health, where Irving earned her master of public health degree.
The Impact of COVID-19
The GAO cites COVID-19 as a contributing factor in at least 400 maternal deaths in 2021, accounting for much of the 40 percent increase in maternal deaths as compared with 2020.
It is first worth noting that physiological changes that occur during pregnancy — such as decreased lung capacity and weakened immune system — put pregnant women at increased risk for adverse outcomes from COVID-19. Beyond that, the GAO found that the pandemic exacerbated key social factors that contribute to maternal health outcomes — such as access to care, transportation or technology; the living environment; and employment. For example, women from racial and ethnic minorities and other socially disadvantaged groups faced barriers to accessing maternal care because the pandemic caused reductions in services, such as transportation, and increased childcare challenges, according to the report.
Similarly, the report notes that women from low-income neighborhoods were generally at higher risk for severe maternal morbidity or death pre-pandemic. Research shows that pregnant women who lived in these neighborhoods during the pandemic were more likely to test positive for COVID-19 than others, in part, because they were not able to maintain social distance to prevent infection. Also, some women were essential workers who could not work from home or had more people living in their household, and thus faced increased exposure as compared with other groups.
Also, at a time when there was a lack of or misinformation about COVID-19, and healthcare guidance was frequently changing, there was a mistrust among pregnant women in general. This issue particularly affected Black women and may have worsened disparities, according to the report.
Can Legislation Prevent Maternal Deaths?
On May 15, 2023, in honor of Mother’s Day, U.S. Sen. Cory Booker (D-N.J.) and U.S. Reps. Lauren Underwood (IL-14) and Alma Adams (NC-12) reintroduced the bicameral Black Maternal Health Momnibus Act, which is a series of 13 bills that will:
- Make critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition.
- Extend WIC eligibility in the postpartum and breastfeeding periods.
- Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity.
- Increase funding for programs to improve maternal healthcare for veterans.
- Grow and diversify the perinatal workforce to ensure that every mom in America receives maternal healthcare and support from people they trust.
- Improve data collection processes and quality measures to better understand the causes of the maternal health crisis in the United States and inform solutions to address it.
- Support moms with maternal mental health conditions and substance use disorders.
- Improve maternal healthcare and support for incarcerated moms.
- Invest in digital tools to improve maternal health outcomes in underserved areas.
- Promote innovative payment models to incentivize high-quality maternity care and non-clinical support during and after pregnancy.
- Invest in federal programs to address maternal and infant health risks during public health emergencies.
- Invest in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies.
- Promote maternal vaccinations to protect the health of moms and babies.
Similar legislation was put forward in 2020 and 2021. In 2021, the first bill from Momnibus, the Protecting Moms who Served Act, to support veteran moms, was signed into law by President Biden.
The fight to end the U.S. maternal health crisis continues …