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Maternal Deaths, and Disparities, Become a Grassroots Cause

Mary Caffrey
Rates of maternal deaths have climbed over a generation in the United States while falling in other developed countries. African American women are more than 3 times more likely to die in childbirth than white women. A new federal law and efforts in states like New Jersey seek to turn the tide.
Since 1990, it has become safer to have a baby in Germany, France, England, and Japan, but that has not been the case in the United States, where the rate of mothers who die of pregnancy-related causes has skyrocketed over the past generation to 700 a year, or 2 a day. The crisis is acute among African American mothers, who are 3.5 times more likely to die in childbirth, or shortly afterward, than white women, according to the CDC.

Tennis star Serena Williams was almost among those numbers a year ago, when she suffered shortness of breath after a C-section and struggled to get hospital staff to take her complaints seriously. Her story pulled the tale of rising maternal mortality and morbidity—and huge racial disparities—from the obscurity of medical journals to the front pages of America’s largest newspapers. High-profile investigations in USA Today and The New York Times featured stories of new mothers whose deaths stemmed from preventable causes, like hypertension, and discussed a landmark 2015 study in Lancet that showed how poorly US maternity care compared with the rest of the developed world.

Maternal mortality and morbidity—an estimated 50,000 women experience injuries in childbirth each year in the United States—is a complex problem rooted in the lack of consistent healthcare during and before pregnancy. Mary-Ann Etiebet, MD, lead and executive director of Merck for Mothers, said the connection between lack of insurance and maternal mortality is being studied, and the need for healthcare before conception is being recognized.

“From our programs, we’ve learned that many women have not seen a provider since childhood and that for many women, pregnancy is a window of opportunity to establish a connection with the healthcare system,” she said in an email. “Without consistent primary care, many women may enter pregnancy with unmanaged chronic conditions, such as diabetes, and hypertension, that can contribute to complications during pregnancy, childbirth, and beyond.”

It all led to a rare bipartisan vote in Congress on a new federal law that President Donald Trump signed on December 22, 2018, which will promote better data collection to tackle the problem.

The American College of Obstetricians and Gynecologists (ACOG) hailed the passage of the law, which will provide funds to establish and support Maternal Mortality Review Committees (MMRCs) at the state level. These groups would be required to review every pregnancy-related death and develop recommendations to prevent future deaths. It also provides $12 million a year in new funds for 5 years for states to fund these committees.

“The passage of the Preventing Maternal Deaths Act has been a long-held goal for ACOG and is a crucial step to reversing our country’s rising maternal mortality rate,” the group said in a statement. “No more pregnant and postpartum women should die from preventable causes.” 

Now, the hard part begins for physicians, state-level policy makers, advocates, and health plans. Understanding how to fix the maternal health crisis starts with a question: has care for pregnant women become worse over the past generation, or are we finally realizing just how bad it’s been?

Katy B. Kozhimannil, PhD, MPA, associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health, where she is director of research at the University of Minnesota Rural Health Research Center, believes it’s the latter.

In an interview with The American Journal of Managed Care® (AJMC®), Kozhimannil said the data on maternal mortality have not been very good historically. CDC only began tracking pregnancy-related deaths in 1986; these are defined as “the death of a woman while pregnant or within 1 year of the end of a pregnancy—regardless of the outcome, duration or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Especially in the early years of tracking, data may have been inaccurate, since CDC depends on MMRCs in the states to report deaths and injuries.

When a mother dies in childbirth, Kozhimannil said, “It’s such a silencing experience that no one wants to talk about it when it happens. It’s something that should spark outrage, but it’s just so soul crushing.”

As family members mourn, they may fail to see themselves as part of a larger pattern, Kozhimannil said. And even when MMRCs exist, lack of staffing can stall data collection, as is the case in Minnesota. The panel there has not met in 2 years, she said.

The federal law and national attention to maternal mortality is generating action in the states, including an effort in New Jersey led by First Lady Tammy Murphy. Members of the General Assembly recently introduced a 14-bill package to address maternal mortality and racial disparities; despite the state’s relative wealth, New Jersey ranked 47th among the 50 states in maternal mortality on a recent report, America’s Health Rankings.

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