WHO report reveals significant setbacks for maternal health

A 15-year-old girl in Chad has a one in 15 chance of dying related to pregnancy.

Chad has the highest maternal mortality globally, in staggering contrast to the one in 16,000 risk that a 15-year-old child in Australia or New Zealand has, the region with the lowest risk. The WHO report released last week contains innumerable sobering facts such as this one, that seem as though they more easily could have come from a 1923 report than from 2023.

In the United States, too, progress has seemed to reverse course in the last 20 years. While the U.S. maternal mortality is below the Sustainable Development Goal of 70 per 100,000, standing at 21 per 100,000 today, it has risen a staggering 77.9% since 2000. Unfortunately, the U.S. was highlighted in the WHO report for being one of only eight countries globally with a significant increase in the maternal mortality rate between 2000 and 2020, and one of only five that had an increasing rate between 2000 and 2015. While a supplementary Sustainable Development Goal for countries with a low maternal mortality rate was to achieve equity across different population groups within each country, the U.S. has continued to fall short of that metric, with Black women in the U.S. experiencing a mortality rate almost three times that of white women.

Clearly, we have much work to do. One of the main themes common to both global and U.S. maternal mortality is that of preventability, with the majority of global maternal deaths being preventable, and a staggering 84% of pregnancy-related deaths in the U.S. deemed preventable today.

The WHO report defines how we might address some of these preventable deaths, dividing the approach between what it deems to be the proximate causes of mortality and the more distal ones. Among the proximate causes are direct obstetric causes of death such as postpartum hypertension, preeclampsia and hypertensive disorders of pregnancy, pregnancy-related infections and complications of unsafe abortion. In addition, we must consider distal but important causes of death, such as health system failures, poor quality of care, social determinants of health putting some subpopulations at greater risk, harmful gender norms and biases, and lack of access to safe and affordable sexual and reproductive health services.

How can this translate to the U.S. landscape, and what progress — and opportunity — do we have today? In terms of addressing the proximate causes of maternal mortality, we’ve seen broader implementation of patient safety bundles through the American College of Obstetricians and Gynecologists’ Safe Motherhood Initiative, shining a spotlight on how to systematically improve key drivers of maternal morbidity and mortality such as sepsis, hypertensive disorders and postpartum hemorrhage. We’re also seeing a new focus on implementing innovative technology to enhance health in ways that we haven’t seen before: ACOG’s Redesigning Prenatal Care Initiative is one such example, which will include telehealth and remote patient monitoring as options for routine pregnancy care, recommendations for which are anticipated later this year. Additionally, there is some hope on the horizon for innovation in prediction — and therefore prevention — of pregnancy complications such as preeclampsia, a leading cause of pregnancy-related mortality. With encouraging early results in biomarker screening, a recent publication highlighted hope for the development and implementation of new biomarkers to predict pregnancy complications.

On the other hand, considering the distal causes of maternal mortality, such as those impacting access to care, the U.S. has made both some forward strides as well as taken some steps back in the post-Roe environment today. In the former category, we’ve seen improved outcomes in states that have expanded Medicaid since the 2012 Affordable Care Act. More recently, since the 2021 American Rescue Plan Act allowing states to expand coverage until 12 months postpartum, we’ve seen 27 states and Washington, D.C., opt to do so. With 64% of pregnancy-related deaths occurring between 7 days and 1 year postpartum, improving access to care for the 40% of women today who receive pregnancy Medicaid has been a clear step forward that many advocates, such as March of Dimes and ACOG, are advocating to extend to all 50 states.

On the other hand, in the midst of this forward progress, we’ve also had to grapple with a potential return to the reproductive health restrictions of 50 years ago, facing decreased access to reproductive health care in the post-Roe world. While too soon to fully appreciate its potential impact, an early report demonstrated a significantly higher rate of maternal morbidity in Texas, a state with highly restricted reproductive health access, as a consequence of the state’s criminalization of reproductive health care. ACOG predicts that the impact of the fall of Roe “will fall disproportionately on people who already face barriers to accessing health care, including people of color, those living in rural areas, and those without ample financial resources,” a sobering analysis in the face of the already unacceptable disparities in care and outcomes faced by these groups.

In order to meet the 2030 Sustainable Development Goals globally, WHO notes that we would need to have unprecedented rates of improvement over the next 10 years globally. While daunting, especially in light of the last 20 years of worsening maternal health in the U.S., it’s all the more imperative that we take the attention that maternal health is receiving today and convert that attention into action. With all of the resources we’re fortunate to have on hand in the U.S., we can and we must find the path to improvement.

References:

• ACOG statement on the decision in Dobbs V. Jackson. https://www.acog.org/news/news-releases/2022/06/acog-statement-on-the-decision-in-dobbs-v-jackson. Published June 24, 2022. Accessed Feb. 24, 2023.
• Emeruwa UN, et al. JAMA. 2023;doi:10.1001/jama.2022.24906.
• Four in 5 pregnancy-related deaths in the U.S. are preventable. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html. Published Sept. 19, 2022. Accessed Feb. 24, 2023.
• Maternal mortality rates in the United States, 2020. https://stacks.cdc.gov/view/cdc/113967. Accessed Feb. 24, 2023.
• Nambiar A, et al. Am J Obstet Gynecol. 2022;doi:10.1016/j.ajog.2022.06.060.
• Nowhere to go: Maternity care deserts across the US. 2022 report. https://www.marchofdimes.org/sites/default/files/2022-10/2022_Maternity_Care_Report.pdf. Accessed Feb. 24, 2023.
• Protecting and expanding Medicaid to improve women's health. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/06/protecting-and-expanding-medicaid-to-improve-womens-health. Accessed Feb. 24, 2023.
• Redesigning Prenatal Care Initiative. https://www.acog.org/programs/redesigning-prenatal-care-initiative. Accessed Feb. 24, 2023.
• Safe Motherhood Initiative. https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative. Accessed Feb. 24, 2023.
• Steenland MW, Wherry LR. Health Affairs. 2023;doi:10.1377/hlthaff.2022.00819.