A report released this spring by the National Center for Health Statistics summarized the strikingly high rates of maternal deaths in the US. In 2021, the US rate of maternal deaths that occurred while pregnant or within 42 days of being pregnant was 32.9 per 100 000 live births—more than 10 times the estimated rates for other high-income countries including Australia, Israel, and Spain, which all hover between 2 to 3 deaths per 100 000 live births.
Moreover, the report found that maternal mortality rates increased every year from 2018 to 2021 for all racial and ethnic groups included in the analysis. Overall, 1205 people died of maternal causes in the US in 2021 compared with 658 in 2018.
Deaths are particularly high in certain US populations, according to the report, most notably among Black women, whose mortality rate is 2.6 times that of White women. Hispanic women’s mortality rate surpassed that of White women in 2021 for the first time.
Without better data collection, the rates for other US populations can’t be quantified accurately, which experts say is needed to design interventions and allocate resources across all communities and populations. For example, data regarding American Indian women are rarely highlighted even though they have a high prevalence of poor outcomes. In Asian populations, data disaggregation is needed to understand and interpret the true trends in different ancestral subgroups.
To make sense of US maternal mortality, Kirsten Bibbins-Domingo, PhD, MD, MAS, editor in chief of JAMA and the JAMA Network, recently spoke with Joia Crear-Perry, MD, an obstetrician-gynecologist (ob-gyn) and the founder and president of the National Birth Equity Collaborative; Monica McLemore, PhD, MPH, RN, a professor in the Department of Child, Family, and Population Health Nursing at the University of Washington School of Nursing; and Audra Meadows, MD, MPH, an ob-gyn and a professor of obstetrics, gynecology, and reproductive sciences at the UC San Diego School of Medicine.
This interview has been edited for clarity and length.
Dr Bibbins-Domingo:Let’s start by discussing how we are in the situation of these very high maternal mortality rates.
Dr Meadows:We got here from a number of different avenues. There are some clinical factors that we look at, but there are also larger systemic factors that we think about. The health care system that a birthing person is entering matters, the timing that they’re entering into that health care system, the health care that they receive before becoming pregnant, and then their treatment during their pregnancy and delivery matter as well.
Dr Bibbins-Domingo:One thing that people often point to is that we have an issue of accessibility to health care in the US and high rates of uninsurance compared to other places. But that doesn’t feel like the only set of factors that we’re talking about, because we also see these [deaths] happening when issues of access to care is not the primary issue. Dr McLemore, what do you say when people ask you, “How did we get here?”
Dr McLemore:First of all, it has to be said that these deaths are preventable. I would add that, in addition to the clinical factors and the insurance factors, there’s a workforce factor that needs to be considered, and then we have to move away from the patient-level factor.
We’ve blamed patients historically for their deaths. They come to pregnancy older and sicker and fatter, and they’re not in the best condition. That’s actually not an individual problem. It’s a societal and a structural problem. Whether or not people have access to green spaces or to healthy foods or to insurance or to clean water—these are policy and structural decisions.
Then the workforce piece, I think, is really important. We’ve done a lot of research looking at structural racism and how mistreatment and bias really show up. We miss signs and symptoms of deterioration. We miss places where we actually could have acted more upstream. And we really are not paying attention to the one thing that we should be paying attention to, and that is the birthing person.
So to me, there’s a workforce piece, there’s a patient-level factor piece that we need to move away from because it’s not really the root cause, and then there’s a societal piece that these are preventable deaths.
Dr Bibbins-Domingo:You’re right. We tend to think of this 1 patient at a time, 1 person at a time and sometimes it’s reasonable to start there. But it oftentimes puts us in this trap of blaming a person for the sets of things they did or didn’t do before they were pregnant or when they’re pregnant. And it doesn’t help us to necessarily think through what clearly the numbers speak to are the larger trends, which require some more systemic types of solutions. I really love that you said preventable because, especially as we see these rates rising, we shouldn’t be trapped into thinking we should expect a rate of people dying in the US who are pregnant.
Dr Crear-Perry:As a medical student and as a resident I was taught in the late 1990s that there were 3 biological races. I had no reason to question that we had different outcomes because if you perceive that the reason that people are dying in childbirth is because they’re innately broken, because there is a biological basis of race, then you make policies based upon that belief.
I was also taught that [Black women] have higher rates of C-sections because we have an anthropoid pelvis vs White women having a gynecoid pelvis. All these things were codified in textbooks. So even when you try to unlearn those things, you still have beliefs, behaviors, and policies where people show up in hospitals from Bogalusa, Louisiana, to San Diego, California, and people perceive that they have different rates of hypertension because of a biological basis of race. Until we unlearn the harmful eugenics and white supremacy and patriarchy that we were taught in medical school, we will continue to harm patients.
Dr Bibbins-Domingo:I think one of the things that’s really striking is that we’re seeing these trends get worse over time. And while we know that having access to care is better than not having access to care, we see time and time again stories of people who have access to care, who have the means to get care, people who are recognizable. And we assume they must have access to good clinicians, good care in the medical setting.
Dr McLemore:I wrote about this shortly after Shalon Irving died. I have to say her name because this was a dual PhD, somebody working at the CDC [Centers for Disease Control and Prevention] on maternal morbidity and mortality issues, who died a week after she had her daughter. This is a Black woman who was part of the Uniform Armed Services and had great insurance.
Or we think about the near misses—Serena Williams and Beyoncé—people who had pregnancy-related complications and told those stories publicly. The social aspect of Black skin is that you have an equitable relationship with racism. People think about it biologically, but actually it’s social in terms of how you are treated by our system.
I think about Sha-Asia Washington in New York City who died. One of the other things we need to really talk about around maternal morbidity and mortality is that the timing matters. The most preventable deaths happen in the postpartum period. And it’s estimated between 40% and 60% of maternal deaths happen in the postpartum period. Everybody wants to make sure lactation is good and we’ve got family bonding and the baby’s doing okay. We take our eye right off the postpartum person.
We end up in a situation where people are not being heard and not being believed. Then you get multiple visits to health care providers in emergency departments and office visits. But we’re still missing it. And so I think it needs to be named that even within maternal deaths, there is a window of time where they’re even more preventable. And we actually could do something about that with appropriate staffing, with access to care.
We’d also be remiss not to talk about midwives and doulas. Pregnancy is a normal physiologic condition. It’s not a disease state. We spend a lot of time focusing on the episode of birth and perhaps maybe we need to build a health system and a workforce that can engage with people outside of that.
Dr Crear-Perry:I was thinking about how we hyperfocus on babies in this country. We are not the worst in the industrialized world just because Black and Indigenous women are dying. A lot of White women are dying in the United States of America who, if they lived in Norway, if they lived in Sweden, would live.
You have a system that values people fundamentally differently, if you think about the fact that we only count maternal deaths up to 6 weeks and we know people are dying up to a year later, if you think about the fact that Erica Garner died from cardiomyopathy 6 months after having her baby. And she wouldn’t even be counted as statistics—they only go up to 6 weeks. The biology does not even match how we collect the data and statistics.
For years, I would say between 700 and 900 women a year die in childbirth. I would complain that we are the only industrialized country that has a range because we had not released an actual number in this country from 2007 to 2019. So we finally got an accurate number and now it’s getting worse. The reason we say their names is because when you just say things like “700,” “900,” “1200,” we don’t acknowledge the humanity, the actual person that was a whole human being [like Tori Bowie] who represented the United States of America in 2016 in the Olympics and was a champion and then died in her home in childbirth. Blaming her, shaming her, trying to figure out what was wrong with her is exactly why we have the worst outcomes in the industrialized world.
Dr Bibbins-Domingo:The point that’s really hitting home for me is the proportion of these deaths that are happening in the postpartum period. It always strikes me that that is where somebody is also particularly vulnerable to our highly fragmented health care system. How do you think about this system of care?
Dr Meadows:The system of care is broken. It needs a lot of improvement and attention to improvement. There are a few different places where we need to enter into that, like public health. When you have systems in place of good public health and public health improvements, you can see improvements in maternal outcomes and reductions in maternal deaths.
I want to ensure that women can walk through any doors and have the same chance of receiving optimal care and optimal experiences as anyone else. The systems of care have to be set up to be able to know that that is or is not happening. Currently, as it stands, many systems don’t have that ability within OB departments. We don’t even know exactly how many maternal deaths maybe contributed to what’s happening in our own facilities. We don’t have data that’s able to show us what’s happening in a more upstream approach with severe maternal morbidity and some of those health conditions that we know are leading to maternal deaths. We haven’t been able to look at our data.
Oftentimes we will say in the health care system that we have done well for a particular metric and for our population. But what we’re not saying is we’ve done well for all populations. We have to have that data and we have to be able to stratify that data by different demographics.
And we have to have leadership to support having the resources to do that. It’s really important because if we’re not able to look at different groups by age, by race and ethnicity, by demographic geography, by who’s new to this country, by who is coming in newly to our health care systems, then we’re not able to tell that story. We’re not able to really be able to adjust what we’re seeing on a national level because we’re not getting at it on the ground with the nuance of what’s happening in our health care systems.
Dr Bibbins-Domingo:What do we need to pay attention to in the next year, in the next 5 years, in order to make strides in reversing these trends?
Dr McLemore:Well, first of all, we haven’t used the words reproductive justice yet. We need to think about reproductive health rights and justice, and that means a human rights approach to understanding that we can actually make all of this different.
That’s number 1. Number 2 is that we’ve had the Momnibus, which is an omnibus set of bills introduced by nurses in Congress. It has money in it for the health care perinatal workforce. It has money in it for better data. It has money in it, and it keeps dying on the Congress floor. So when people ask me why voting rights are a reproductive justice issue, I say because it determines the allocation of resources that we need to fix this problem.
And then the last thing I would say is, as we start to think about the election that’s coming up and where we are politically as a country, we also have to remember that our Congress is polarized, but our citizenry is not. This is the year anniversary of the loss of the federal protections of Roe v Wade. We actually have an opportunity to reimagine health services for pregnant-capable people. That’s one of the weird gifts, believe it or not, that Dobbs has afforded us. We can now think differently about all the golden nuggets that we never wanted to touch, because now we’re in an entirely different landscape.
What does care for pregnant-capable people look like regardless of how said pregnancies end? I would like to push us to think differently about how we can use that as an opportunity to maybe rebuild or reimagine a health system that actually takes care of the needs of everybody, grounded in reproductive justice.
Dr Meadows:I really want to continue to underscore what is working. We’ve seen some improvements. At the same time, there needs to be folks who are reimagining care and putting in place the structure for that reimagined care. At the same time, there need to be people who are seamlessly thinking about the policies to support sustainability of that reimagined care and of the care that’s happening right now, the positive parts of it. I’ve been at conferences before where you’ll hear folks say, “We just need to tear down the system and start over.” There are parts that probably do need to be completely overhauled, but there are parts that can continue to function so that we can support everybody from today into the future.
Dr McLemore:I think we’re missing the mark as scientists and as researchers if we are not also capturing the assets and the things that are actually working. Because if that’s not informing our interventions we’re going to create some sharp angles where we’re missing important data that could be very useful for a paradigm shift.
Dr Bibbins-Domingo:As we’re working toward the transformation, every single day we walk into our clinical settings, we teach the next generation. We have to be doing this work every single day. And I think a lot of what we are trying to do with raising awareness about this issue is to have people think about what they’re doing in the various steps that they take every single day in order to think about how they can make a difference here.
Dr Meadows:And just thinking about the reimagining piece, there are questions that arise. One of them is, why are there so few birth centers? Sometimes someone enters a high-risk facility and becomes high risk. They may not enter high risk. We have to start to think about where people are giving birth and what structures are in place. The majority of people delivering in these higher-risk institutions are not high-risk patients and potentially they’re not in the right spaces.
Dr Crear-Perry:I get in trouble by my fellow ob-gyns for talking about midwives and doulas all the time, and I think the reason is because what the midwives and doulas have been able to do is articulate the racism inside their field. We are just now as physicians starting to talk about racism inside of our field. We haven’t even addressed the racism within our own institutions and organizations. Until we start doing that, people are going to still only want midwives and doulas.
Dr McLemore:We would be remiss not to talk about either Dr Kimberly Gregory or Dr Karen Scott, Black women ob-gyns who have developed patient-reported experience measures of obstetric racism. If you can actually measure obstetric racism, then you can consider it as an adverse event independent of clinical events that occurred during pregnancy and childbirth.
And I think that that is super important.
Dr Crear-Perry:It is. And CDC will let you list it as a risk factor for death now. So that’s huge.
Dr Bibbins-Domingo:Is that right?
Dr Crear-Perry:We had to fight hard for that, but yes. Now when you do the remarks [on the death certificate], you can list racism as one of the causes. What we find is in places like Mississippi, they never list it; in places like in Massachusetts they list it on every case. But it allows at least for a conversation within the [maternal mortality review] committee.
Dr Meadows:We don’t have systems set up to even collect patient-reported experiences regularly and routinely. We can do better.
Dr Bibbins-Domingo:We are speaking about a topic that could leave one overwhelmed. After talking with the 3 of you, I’m feeling quite hopeful that if we can think about shining a light on this area, these are preventable deaths. This is a pattern that can be different. We need more people engaged in this conversation to understand where we are, but also to think about what the possibilities are for the future.
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Published Online: July 3, 2023. doi:10.1001/jama.2023.11328
Conflict of Interest Disclosures: Dr McLemore reported receiving book royalties from a related text and consulting fees from the National Birth Equity Collaborative (Scholars Program) and owning stock options in CLEO. No other disclosures were reported.