The High Rate of Pregnancy-related Mortality and Morbidity in the U.S. Is a Scandal
Learning that one is pregnant is a source of joy for some, anxiety for others, and anguish for still others. It is the role of healthcare providers to try to ease the stresses and strains of reproductive health-related milestones like pregnancy. Sadly, the U.S. does about the poorest job of ensuring positive reproductive health outcomes among high-income countries and the situation is likely to worsen unless major steps are taken.
The first thing to know is that the rate of pregnancy-associated deaths in the U.S. is obscenely high. According to the Centers for Disease Control and Prevention (CDC), the maternal mortality rate in 2020 was 23.8 per 100,000 live births, compared to 20.1 in 2019 (the last years for which data are available). Worse, the rate for non-Hispanic Black women in 2020 was almost three times higher than for white women at 55.3, also showing a significant increase over 2019 rates. (Please note that while Critica uses the term “pregnant person” to acknowledge the fact that women are not the only people who can be pregnant, the CDC uses the term “maternal” to describe its pregnancy-related data).
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This U.S. rate of pregnancy-related mortality is almost three times higher than most other high-income countries. According to data from the Commonwealth Fund, almost no women die in the Netherlands from maternal complications. Despite the fact that we spend far more money on healthcare per capita in the U.S. than most other developed countries, our maternal mortality rates are dismal, especially for people of color.
Most Pregnancy-related Deaths Are Preventable
Making these data even more frustrating is the fact that most pregnancy-related deaths are preventable. In its most recent Maternal Mortality Review (MMRIA), CDC defined pregnancy-related deaths as occurring during pregnancy, delivery, and up to a year postpartum and found that 84.2% were preventable. A closer look at these data is instructive.
For white and Hispanic women, mental health conditions were the most common underlying causes of pregnancy-related deaths, accounting for 34.8% and 24.1% respectively. However, for Black women, only 7.0% of pregnancy-related deaths were attributable to mental health conditions; for them, conditions affecting the cardiovascular system were the most common underlying causes of death.
The striking difference between Black and white women in underlying causes of preventable pregnancy-related deaths points once again to the well-described disparities in access to high-quality healthcare in the U.S. That Black women die from pregnancy-related cardiovascular conditions, most of which the CDC deems as preventable, at these alarmingly high rates in the 21st century is unconscionable and demands much more attention than it is getting by healthcare policy experts.
In terms of the mental health conditions responsible for pregnancy-related deaths, suicide and substance use disorders are most common. In an excellent article in The Conversation published last November, Rachel Diamond of Adler University noted that “30% of preventable pregnancy-related deaths happened between 43 and 365 days postpartum—which is also the time frame suicide most commonly occurs.” Diamond further noted that Medicaid covers 40% of births in the U.S., but it was not until 2021 that states could extend benefits up to one year postpartum and so far only 27 states have done so. “Continued Medicaid expansion would reduce the number of uninsured new parents and the rates of maternal mortality,” Diamond wrote.
Diamond also noted that “At this time, 24 states consider substance use during pregnancy to be child abuse, and 25 states require health care professionals to report suspected prenatal drug use.” This criminalization of substance use during pregnancy likely impedes pregnant people from getting medical help for their condition and may contribute to preventable pregnancy-related deaths.
Restricted Abortion Laws Associated With Suicide
The association between pregnancy and mental health-related deaths is likely to get worse. A recent study in the journal JAMA Pediatrics reported that enforcement of laws restricting abortion access is associated with a 5.81% increase in suicide rates for women of reproductive age compared to pre-enforcement years and compared to women of post-reproductive age and to deaths from motor vehicle crashes. It is important to note the limitations of this study: as explained by the authors, individual level data are not involved here, so we do not know that any particular individual died by suicide because of difficulty obtaining an abortion. Rather, we have a specific association here between onset of enforcement of laws restricting abortion and increased suicide rates among women of reproductive age at the group level.
Although we need to be cautious interpreting the data from this study, they are reinforced by other data showing that restrictive abortion laws are associated with increased maternal and infant mortality rates. We know from the epic Turnaway Study that having an abortion itself does not increase suicidal ideation or suicidal behavior. Thus, there is at least suggestive evidence that restrictive abortion laws create an environment that is associated with increased despair among pregnant people and elevated risk for suicide.
Two law professors pointed in the New York Times last December to the rising trend for misinformation and disinformation about abortion. “The ultimate goal seems to be ensuring that women are unclear about their options to obtain an abortion or contraception, in their home state or elsewhere,” wrote Michele Goodwin and Mary Ziegler. This will inevitably contribute to an atmosphere of fear and confusion that has the potential to worsen the already increasing risk for pregnancy-related mortality in the U.S.
Multiple Strategies Needed
We need urgently to address the issue of preventable pregnancy-related deaths in several ways. First, and most obviously, affordable high-quality healthcare must be accessible to every pregnant person, with special attention given to remediating the clear racial disparities that currently exist. That black women are dying during pregnancy, delivery, and the postpartum period at nearly three times the rate of white women should strike everyone as among the most glaring examples of the terrible state of the American healthcare system. Extending Medicaid to cover the entire first year after delivery should be a priority for all states.
Second, increased attention must be given to mental health conditions during pregnancy and its aftermath. For example, the American College of Obstetricians and Gynecologists (ACOG) recommends comprehensive screening for depression and anxiety in the peripartum period. It is essential that people who screen positive have access to affordable, high-quality mental healthcare. That means access to behavioral health providers in a timely fashion—not after waiting weeks or even months for an available appointment. At the same time, substance use disorder during pregnancy needs to be decriminalized by all states in favor of the appropriate policy that it represents a mental health condition that requires treatment.
Finally, pregnant people need access to accurate and reliable information about every aspect of reproductive care, including contraception and abortion. Given the possibility that restricting abortion access increases suicide risk, accurate information about these topics could serve as one way of preventing pregnancy-associated deaths.
As we contemplate the statistics provided in this commentary showing the high rates of pregnancy-associated deaths, especially among Black women, in the U.S. and the fact that 84% of these deaths are deemed preventable by the CDC we must pause and ask ourselves if we can allow trends like these to continue to exist and probably worsen. We do have at our disposal the medical technology and the financial resources to ameliorate the high rate of pregnancy-related deaths. There is no reason why the U.S. should be lagging so far behind other high-income countries on these measures. Urgent attention to these aspects of reproductive health is clearly mandatory if we are to consider ourselves a fair and democratic society.