The U.S. has a maternal death crisis. What can we do?
The latest data paint a truly dire picture, particularly for Black women. Dr. Elizabeth Howell, a leading researcher on disparities in maternal health, talks about where she sees hope.
With a problem as severe as maternal mortality, it can be hard to look away, to talk about anything more than just how bad it is.
And it is. Really bad. The U.S. Centers for Disease Control and Prevention, updated its data earlier this month, reporting 32.9 maternal deaths per 100,000 live births in 2021. Those are deaths during pregnancy or in the first 42 days postpartum. For Black women, that rate was an astounding 69.9 deaths, compared with 26.6 deaths for White women. For all women giving birth over age 40, the rate rose to 138.5 deaths, up from 81.9 in 2018.
Before 2018, the maternal mortality rate in the United States was steadily rising, far beyond rates in much of Europe and Canada, which remained in single digits.
We are in crisis.
This is the outcome of so many broken systems whose consequences converge on the bodies of people going through one of the most precarious moments a human can experience, in labor and delivery. We need to recognize that and also consider what is working—to look toward progress. A way forward.
Dr. Elizabeth Howell sees it—a beginning, at least.
Howell is chair of Penn Medicine’s Department of Obstetrics and Gynecology. She has studied disparities in maternal health outcomes for years, previously at the Icahn School of Medicine at Mount Sinai in New York. Now she leads a department of about 500 people in a health care system that has made closing disparities in maternal health an institution-wide goal.
A portion of compensation for senior leaders at Penn Medicine is determined by progress on a handful of goals related to improving health outcomes. Since September 2020, one has been reducing Black maternal mortality and morbidity, or serious complications. To Howell, it’s been transformative.
“We face the same issues that people face across the country, but we have a really focused effort in our department,” she said, “and I think there's a lot of buy-in about trying to tackle maternal morbidity and mortality, not only within Penn Medicine, but also in the larger Philadelphia area.”
Howell talks fast and, as I ask her about where she’s sees progress, she rattles off a wide array of projects testing new models of care and broadening community outreach, including the Alliance for Innovation on Maternal Health and the work her colleagues are doing with the Pennsylvania maternal mortality review board and within a group convened by the city’s Department of Health to tackle this problem.
It is important to note the significance of doing this work in Philadelphia, a city whose economy is driven by “eds and meds” that also has dramatic health inequities. The birthplace of modern American medicine broadly and of modern obstetrics specifically.
Layla A. Jones last year wrote a powerful story for the Philadelphia Inquirer’s “A More Perfect Union” project about that history—a racist one from the start—and the local legacy that continues to shape Black maternal health across the country.
It is easy to feel skeptical about how the same U.S. health care system that has gotten us here can fix this. Certainly, the groundswell of Black-led midwifery providers, birthing centers and doula practices have an incredibly important role to play. Still, most people deliver babies in a hospital.
People like Howell are working to move the levers of power—to push them—in the right direction. She has the expertise, and she is clear about what’s at stake.
A member of Howell’s own family complained of shortness of breath soon after delivering a baby, she told me. A resident listened to her lungs and dismissed her concern. She struggled to breath through the night. When she finally had a chest x-ray the next day, it showed her lungs were full of fluid—pulmonary edema caused by peripartum cardiomyopathy. She was treated successfully and received follow-up care from a cardiologist, Howell said.
“The story of not being listened to has been told over and over again by Black women (and many others) in the setting of maternal health,” Howell told me. “My family is lucky.”
Our conversation has been edited for length and clarity.
How are we doing? The latest overall maternal mortality rate is nearly double what it was in 2018. The Associated Press also reported partial data from 2022 saying the rate was falling back to pre-COVID levels—as if the pre-pandemic rate wasn’t also atrocious. I found myself feeling frustrated by the mixed messages of these headlines. How are we doing, really?
Howell: I have the same response that you do, that it's frustrating this year. There's always these time lags [for data collection and reporting]. And so it's hard for us to understand everything, but that report was concerning, right? That kind of increase—and you saw the rate for Black women that had really skyrocketed as well.
Some of this is Covid, probably, but we don't know.
There's much more public awareness around this issue. More people understand it's a crisis and we need to put resources and attention toward trying to solve it. NIH [the National Institutes of Health] is in the space now funding research. PCORI [the nonprofit Patient-Centered Outcomes Research Institutes] is in the space. And all that is good. We're doing better in that sense.
That doesn't mean we're doing better in our statistics. That's really hard to see.
You are really diligent in your work and in your public messaging to make sure that morbidity, or the severe outcomes other than death that a birthing person can experience, remains part of the conversation. Why?
Howell: If you think about the 1,200-plus maternal deaths a year, that seems like a small number to people, even though these are young women, so any one of these deaths is super concerning—but still. The morbidity discussion is so important because, for every death, it’s estimated that about 100 birthing people experience one of these severe maternal morbidities. The CDC defined that category by really significant things that have major short-term and long-term implications, so something like organ failure or eclampsia, or hemorrhaging when a person has to go back for a hysterectomy and loses their uterus to control the bleeding.
I think in the old days, we used to say, ‘Oh, this is so sad. This woman lost her uterus.’ Now we realize, oh my gosh, this is post-traumatic stress disorder also. This field is also acknowledging the mental health implications of these events, and what it does to not only a mother or a birthing person's own mental health, but to their ability to care for that infant, their ability to breastfeed that infant, the ability to connect with that infant.
And especially with the most recent pregnancy-related mortality data [which includes outcomes up to one year postpartum]—the CDC said that 23 percent of the deaths were mental health-related, and that was a combination of suicide and overdose deaths.
We always knew that postpartum depression was a particularly important issue, that it impacts women from all different racial and ethnic backgrounds, but those with less resources are the ones that are often impacted the worst, because they don't even have the ability to get the care. I think that mental health threat is becoming more and more important. People are understanding it not only as an underlying cause of death, but also as a secondary effect—you know, a person has a significant morbidity during their delivery and hospitalization and has a really hard time, and then that depression ensues postpartum.
Researchers are starting to frame the perinatal period as a distinct stage of development, and some are looking at this as a critical window in a person’s lifespan that can shape their mental and physical health for the long term. When you consider that Black women already face dramatic health disparities before pregnancy, and then the system in which they are cared for during this critical time in their life is woven through with inequity, in terms of quality and access to care—what does that mean for their health over time? We talk a lot about the immediate ramifications of these disparities, but then there’s the long-term picture, too.
Howell: That’s exactly how I think about it. And I think about that [maternal-infant] dyad and that intergenerational transfer of effects—it's critical if we're ever going to reduce health disparities.
What are the underlying causes of these maternal deaths and severe complications—and what aren’t they? Sometimes I hear maternal mortality discussed as an issue of poverty or framed as being about individual choices and preconception risks—specifically I’m thinking about those who point to weight and diabetes.
Howell: The idea that it’s the individual is completely wrong. It's about the systems in which we grow up. People have shown this over and over again. You think about where people live, and you're telling them to eat healthy food—what's their access to that and what does that mean for rates of diabetes, et cetera, right?
People need to acknowledge and accept that race is a social construct. Then you start to realize, okay, it's not about race. It's about racism and the structures and how people are—their chances and opportunities. One of the ways I looked at this in my work was to look at the ways quality of care contributed to outcomes, because I would always hear those exact same things—factors outside of the hospital were the real contributors.
The research I did with my team [in New York] really started to document, systematically, the ways in which quality of care contributed to disparities. The fact that people go to different hospitals and that some hospitals have more resources and have better outcomes—risk adjusted outcomes—than others. That's part of the story. Then even within the same hospital, when people have access, there are differences.
When I think about health equity in this space, I think about a multi-pronged approach because it's a complex issue. And so no one single solution is going to solve it.
I will acknowledge part of this issue is that, you know, women are older when they’re having children, and we know that complications rise as a result. We know that comorbidities are higher now than they've been before. And we know that puts people at a higher risk for some of these things. But remember, it's this continuum.
Even if these early factors are higher, there are things you can do to try to prevent the endpoint of having a death or a severe event. That's important to recognize as well.
I think what you’re saying is that even if someone comes in with higher risks, that doesn’t mean there’s nothing you can do to prevent poor outcomes or to ensure a positive one, right?
Howell: Exactly. And another key message is the care continuum—preconception, antenatally, during delivery, postpartum. Those are all four points in which we could be intervening to try to improve outcomes.
I was talking to someone recently—a smart man, a senior scientist in a different field—about maternal health generally and about Black maternal mortality specifically, and the various societal factors that contribute to it, and he said to me, “Isn’t this all a result of the rugged individualism of American culture?” The subtext of the question was, how do we even begin to fix this? Do you face that kind of apathy at all—the idea that this is too big and complicated to solve?
Howell: I don't accept that. I just don't accept that. We wouldn't be doing that if it were White males suffering from this. So, no way.
Right. So, how do we get beyond that, to get more people to act?
Howell: Our CEO [Kevin Mahoney] is a perfect example. He has the will. It’s having people in leadership in different places, caring enough about this issue and having access to resources to help us make a difference. We have a lot more work to do, but I feel like he has created an environment and supported this work so that we can continue to do this.
The national attention that President Biden and Vice President Harris have put on this issue and the resources they've put towards it, the fact that we have more funding from the administration for maternal mortality review committees— there are a lot of things that are happening at the government level. That’s the will we’re talking about.
We need a lot more of it. We need every CEO of every health system to care and to really want to put resources behind it.
How do you scale up that kind of commitment? It can seem like such a dire outlook, especially when you see some CEOs choosing not to improve their maternity units at all but to close them altogether, particularly in rural counties. Where do you see hope in this picture?
I'm very much a proponent of building an evidence base. We have a really broad portfolio of maternal health equity research. Then we do different things—like standardized induction. I have a junior faculty member working on this, seeing if we standardize induction, can we make sure there's not differential rates in cesarean?
It's building that research base of, what are the things that actually work, not only overall improving outcomes, but narrowing disparities and then trying to implement them and disseminate them.
The same junior faculty member, Rebecca Feldman Hamm, worked on hemoglobin in pregnancy. The American College of Obstetricians and Gynecologists used to have differential recommendations for when we classify a patient as being anemic. A White pregnant patient would be treated if they had a hemoglobin level less than 11 [g/dL]. If it was a Black patient, it was lower [10.2 g/dL].
She thought to herself, this doesn't really make sense. I wonder what really happens to Black women when they come in to labor and delivery when they're in that 10.5 range, do they have worse outcomes? She basically found that they were more likely to have blood transfusions and more likely to come in anemic. She published this. ACOG took this and changed its guideline.
[ASIDE: This change just happened. In 2021. This work found that Black women were more likely to come in to labor anemic, compared to non-Black patients, and that all patients who had a hemoglobin level less than 11 grams per deciliter were more likely to need a blood transfusion. Read more here. ]
This is what I mean about a complex problem. You’ve got to do a bunch of things. So we're looking at delivering postpartum care in the NICU. We have people looking at emergency department visits and postpartum readmissions. We have a lot of people doing stuff around labor. We're part of the American Heart Association’s big health equity grant. . . That has turned into a large proposal around cardiovascular morbidity, because we know Black women are more likely to have those complications and to die from them.
These are a big deal in Philadelphia. This is the example of the woman coming to the emergency room six weeks, eight weeks after delivery, having shortness of breath, and the doctors not even knowing she delivered two months ago. So they're not thinking about cardiomyopathy.
Communication failures are a huge part of this, too. So education on implicit and explicit biases is important. And also shared decision making, because the qualitative work we've done with women from all different racial and ethnic backgrounds, including White women, suggest that there are communication failures across the board. We need to do a better job of listening to patients and their symptoms.
All of that is really fascinating. And then I also think about the point you’ve made about differences from hospital to hospital. Is there a resource that tracks these disparities from facility to facility? Do we know how this place-based disparity around maternal outcomes compares with other hospital-to-hospital differences in outcomes?
Howell: So, there are huge groups of researchers that have looked across the United States at variations, like the Dartmouth Atlas and others. Most of that is on cardiac outcomes and other major things. So you see his idea of variation and what it means. The point of the work that we did is trying to show that maternal health is similar. There's huge variation, and it does matter for the patient.
[ASIDE: The Dartmouth Atlas is a well-known and reputable source of data on unwarranted variation between hospitals on all sorts of measures—end-of-life care, surgical outcomes, neonatal care, hospital readmission rates and much more. I couldn’t find any maternal health measures on their website. I’ve asked them if they’ve reported on any or have any in the works—I’ll let you know what I hear.
Howell went on to say here that there’s more work to do before it’s really feasible to take this large-scale approach to maternal outcomes, related to defining high-performing versus low-performing hospitals in this context and adjusting for the degree of risk among the patients they serve.]
It seems like there’s so much catching up to do. A lot of the things that you're talking about in terms of data collection and dissemination and a multi-level approach are things that have been done in other areas of health care. It's as if this problem of maternal mortality and morbidity has been growing in the shadows. Is there a light on it now?
Howell: I think we're there in ways we never were 10 years ago. And that spotlight is helping to make leaders—this is on their radar now. This is where we needed to be probably years and years ago. But now we're here, so yeah. Let's embrace it.
Backtracking on even the most basic health provisions: I’ll write about this more soon, but here’s the story. Yesterday, a federal judge struck down a provision of the Affordable Care Act that requires most health insurers to cover a broad array of preventive care services with no out of pocket costs. I’ve written lots about this provision in the past, including recently in regard to maternal mental health.
As Nathaniel Wiexel of The Hill notes, Judge Reed O’Connor previously struck down the entirety of the ACA before it was upheld by the Supreme Court. His latest decision almost certainly will be challenged by the Biden administration but could end up before the Supreme Court. If it holds, it will have a broad impact, especially for birthing people and kids.
If you’ve had a baby in the past 10 years, you’ve benefited from this provision in myriad ways. Free breast pumps and lactation support. No-cost screenings for gestational diabetes, postpartum depression, or preeclampsia. No-cost screenings for your kids, including for autism, blood lead levels, vision, hearing, general development through infancy and beyond. Then there are the well visits for the whole family. Oh, and mammograms, pap smears, STI screenings, colonoscopies, immunizations, blood pressure screening, tobacco cessation counseling, and coverage of statins for those at high risk of high risk of heart attack or stroke—all things that we want as many people as possible to receive, not only to preserve people’s health but to save money at a population level, by preventing disease or the development of more serious health needs over time.
This point should be apolitical.
Exceeeepppt that the provision requires coverage of birth control and the revolutionary pills that prevent H.I.V., the latter being the matter in question in this case.
From The Hill story:
O’Connor’s decision was not unexpected. He ruled last year the preventive services mandate was unconstitutional, but at the time waited to decide on the scope of remedy.
O’Connor also invalidated ObamaCare’s HIV treatment mandate, saying it violated the Religious Freedom Restoration Act by forcing the plaintiff, a Christian employer and well-known GOP donor, to pay for insurance that covers HIV prevention drugs.
The company’s owner argued HIV drugs, known as PrEP, promote homosexual behavior that conflicts with their faith and personal values.
It should go without saying that one person’s access to health care should not be determined by another person’s faith, but here we are.
Required reading: This brilliant story from Rebecca Traister had me raging and left me cheering:
What if you wrested away issues that Democrats have long ceded as fundamentally feminized, fringe, radical, or dangerous and presented them as unapologetic centerpieces of a forward-looking, morally robust economic agenda?
Read that last part again—a “morally robust economic agenda.” That’s the vision that Traister lays out here. After the month we’ve seen (and since Shirley Chisholm set the stage in 1969, truly), it has become crystal clear that this is what the United States needs.
A vision for turning school shootings into a problem solved: A commenter called this latest essay by
a “sermon,” and that's a perfect way to describe it. After her daughters' school went into lockdown and her hope, Martin writes through her grief toward hope—that one day she can tell her children about how adults acted to stop gun violence:I would like my daughters to have never huddled under their desks or behind the bookshelves. But even more, now, I would like to teach my daughters that there was a moment when this country honored life. I would like say: for some people, not us, but for some people, guns are precious. They have fond family memories of hunting or they see them as a symbol of something core to their love of America and its values. Even though we don’t share these memories or this association with guns, we understand that some people do. And we are so grateful that these people—the ones who hold guns as precious—understand that children and educators, that every human life, is so worthwhile that they choose to create wise limitations around the guns they love so that people can live. They got to keep their symbol and it became even more precious because of the wise limits surrounding it. We got to have our children.