Preventing maternal mortality: We need data to truly understand maternal health in the US

As a practicing obstetrician, I was struck by the irony of this year’s theme for Maternal Health Awareness Day, observed Jan. 23: “Know Why.”

The American College of Obstetricians and Gynecologists (ACOG) has set this theme to focus on why the U.S. maternal mortality crisis is worsening, highlighting that “to eliminate preventable maternal mortality, we must know why it happens.”

This call to action could not be more timely or urgently needed. Many were shocked when the CDC released a report last fall showing that 84% of pregnancy-related deaths were preventable. We learned that overall, the leading cause of deaths are complications related to the heart, high blood pressure and CVD, together accounting for 29% of all pregnancy-related deaths. This is crucial information at a time when we’ve also seen hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, double over approximately the last 15 years.

But as critical thinkers and advocates for women’s health, we also need to keep in mind what’s missing from this most recent report. It turns out that what is missing is equally important, because as a country, we still struggle to accurately measure outcomes for pregnant women and their babies. The CDC report included outcomes for only 36 states that voluntarily reported their data. What about the rest?

We are struggling with missing data, inconsistent reporting across states, and potentially even politics interfering with our ability to understand the scope of the problem. Last September, I sat in the audience at ACOG’s Texas district meeting, where Dr. Carla Ortique, vice-chair of the Texas Maternal Mortality and Morbidity Committee (MMMRC) was slated to present the data from the state’s anticipated maternal mortality report. She stood at the podium and had to explain that she wouldn’t be able to give her planned talk, as state officials had withheld the report in an unprecedented decision. We all sat in shock, having just heard another speaker highlight the freshly released data from the CDC demonstrating that 84% of pregnancy-related deaths in the U.S. are preventable.

With so much work to be done, everyone in the room understood the implications of withholding the Texas data. Texas’ maternal mortality is above the national average, and the state has an urgent need for resources and improvement. Yet state officials unilaterally delayed the publication of the 2022 report by months. Initially, they said it would be delayed until summer 2023, well past the timing needed for both the midterm elections and the 2023 Texas legislative session, causing some to conclude that the report’s delay was strategic and politically motivated.

Ultimately, one of our major professional societies, the Society for Maternal-Fetal Medicine, threatened to sue the state of Texas for illegally delaying the report’s release. It was finally made public last month. Its findings were disturbing, but not surprising: 90% of pregnancy-related deaths in Texas were deemed preventable. Disparities in outcomes persist, with non-Hispanic Black women having a pregnancy-related mortality ratio approximately twice that of non-Hispanic white women and more than four times that of Hispanic women (with final estimates forthcoming). We also learned that severe maternal morbidity increased to 72.7 per 10,000 women, compared with 58.2 in 2018, and that preeclampsia-associated severe morbidity increased by 37% between 2017 and 2020.

How does this fit into the national picture? The real irony of the upcoming Maternal Health Awareness Day’s “Know Why” campaign is that we lack the data to truly understand maternal health data across states, let alone across the entire nation. We must view this as not only an opportunity for awareness, but also for action.

We often speak about the rising maternal mortality rate, but then we fail to dig into its underlying causes. We lack standardized reporting systems, such that different states track different outcomes using entirely different systems. Texas’ MMMRC is doing some innovative work compared with many states in that they formally track not just mortality but also major morbidity, disparities between races and the contribution of discrimination to pregnancy-related deaths, which was estimated at 12% in this year’s report. While the delay by state officials was unacceptable, the content of the report is quite exhaustive and informative.

Looking across states and reporting systems, not all states are so comprehensive in their approaches. While the CDC’s national data tell us that Black women are about three times more likely to die from a pregnancy-related cause than white women, according to the Guttmacher Institute, only nine states formally track racial disparities in outcomes. In only six states is it required that a maternal mortality review committee (MMRC) report make recommendations to address racial disparities. Only 14 states formally track the preventability of death in their MMRCs, and only five states track morbidity data, which can provide critical insights into the serious complications women are facing during pregnancy and the postpartum period.

We have so far yet to go in “knowing why.” As the CDC acknowledges in its report of data from 2018 to 2020, “it is likely that some of the variation in state rates is due to the marked differences in the quality of state maternal mortality data. These differences may result in underestimates of maternal deaths in some cases, and overestimates in others.”

As we continue learning from the information we have, we see consistent themes emerge. The majority of pregnancy-related deaths in this country are preventable, and there are persistent, significant disparities in outcomes, with the highest death rates among non-Hispanic Black and American Indian/Alaska Native persons. We should “Know Why” in every state, to the greatest extent possible. Every state should be tracking crucial outcomes such as disparities across race and ethnicity, major maternal morbidity and the preventability of pregnancy-related deaths. And finally, we need to ensure transparency and timely data reporting at the state level, as delays in reporting data such as those in Texas cause delayed intervention, ultimately leading to more preventable deaths. Only by understanding the root causes and truly “knowing why” can we begin to effect change and reverse the longstanding inequities and adverse outcomes needlessly experienced by too many women today.

References:

• Cameron NA, et al. J Am Heart Assoc. 2022;doi:10.1161/JAHA.121.023791.
• Delayed Texas maternal mortality report to be released next week, state says. https://www.texastribune.org/2022/12/09/texas-maternal-mortality-report/. Published Dec. 9, 2022. Accessed Jan. 9, 2023.
• Maternal deaths and mortality rates: Each state, the District of Columbia, United States, 2018-2020. https://www.cdc.gov/nchs/maternal-mortality/mmr-2018-2020-state-data.pdf. Accessed Jan. 9, 2023.
• Maternal Health Awareness Day. https://www.acog.org/community/districts-and-sections/district-iii/programs-and-resources/maternal-health-awareness-day#:~:text=January%2023%20is%20Maternal%20Health,about%20promising%20maternal%20health%20initiatives. Accessed Jan. 9, 2023.
• Maternal mortality review committees. https://www.guttmacher.org/state-policy/explore/maternal-mortality-review-committees?gclid=CjwKCAiAwc-dBhA7EiwAxPRylIggq33hdVALX2-hT0oxhJjb8HsqVPw6BlREYL6eamseNObQlr7LFBoCqQcQAvD_BwE. Accessed Jan. 9, 2023.
• Texas Maternal Mortality and Morbidity Review Committee and Department of State Health Services Joint Biennial Report 2022. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Joint-Biennial-MMMRC-Report-2022.pdf. Published December 2022. Accessed Jan. 9, 2023.
• The U.S. maternal mortality crisis continues to worsen: An international comparison. https://www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis-continues-worsen-international-comparison. Published Dec. 1, 2022. Accessed Jan. 9, 2023.
• Trost SL, et al. Pregnancy-related deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html. Accessed Jan. 9, 2023.
• Working together to reduce Black maternal mortality. https://www.cdc.gov/healthequity/features/maternal-mortality/index.html. Published April 6, 2022. Accessed Jan. 9, 2023.