Category: Maternal Health

Pregnancy-Related Deaths Among American Indian or Alaska Native Persons: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019

Maternal Mortality Review Committees (MMRCs) are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy (pregnancy-associated deaths). MMRCs have access to clinical and nonclinical information (e.g., vital records, medical records, social service records) to more fully understand the circumstances surrounding each death, determine […]

Maternal Mental Health Summit with APA, HHS, including Heidi Murkoff

The Center for Faith-based and Neighborhood Partnerships at the U.S. Department of Health and Human Services and the American Psychological Association co-sponsored this summit to promote maternal mental and physical health. The goal of “Maternal Health: Partnering for the Wellness of Racially Marginalized Communities” was to 1) educate and heighten awareness to faith and community […]

Survey: 1 in 4 Pregnant Women Feel Ignored or Dismissed by Health Care Providers as Maternal Health Disparities Persist

Pregnant women who are Black, live in a rural area or have a household income under $50,000 experience significant disparities in maternity care, a What to Expect survey found.
In May and June 2022, What to Expect surveyed 1,406 women who were either pregnant or had given birth within the last 12 months about their maternity care. Key findings:

1 in 4 pregnant women have felt ignored or dismissed by a maternity care provider: 10 percent by their primary provider and 19 percent by another provider.
Women who earn less money tend to live farther away from their providers. A woman making less than $50,000 a year is five times more likely to live more than 30 miles from her maternity care provider than a woman who makes more than $125,000.
Black women are more likely than white women to have delayed first prenatal appointments. They are also three times more likely to have their first prenatal appointment at 16 weeks or later.
Black and Hispanic/Latina women are getting their first ultrasounds later than white women. White women are 14 percent more likely than Black women to have their first ultrasound during the first trimester. Black and Hispanic/Latina moms-to-be are two times more likely than white moms-to-be to have their first ultrasound after 12 weeks.
Higher-income women have better virtual access to their practitioners. Women with a higher household income ($125,000 or more) are 32 percent more likely to have access to their practitioner through a virtual patient portal than women with a household income of less than $50,000.
Every mother deserves a safe pregnancy, and while pregnancy-related deaths are rare, in the United States, they’re not rare enough: women in this country are more than twice as likely to die from pregnancy- or childbirth-related complications than women in other high-income countries.[1]

Disparities in care are a major reason why the U.S. is falling short when it comes to maternal health. And What to Expect’s findings are a stark reminder that the quality of prenatal care a mom receives in this country varies enormously depending on where she lives, her income and the color of her skin.

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The survey revealed some good news, namely that the vast majority of pregnant women do receive prenatal care. Eighty five percent of the moms-to-be we surveyed have had at least one prenatal appointment, while an additional 11 percent have their first appointment scheduled. Ninety six percent say they feel confident they’re receiving the prenatal care they need, and the overwhelming majority felt that their pain management wishes and birth plans were respected by their labor and delivery team.

1 in 4 pregnant women feel dismissed
While these numbers are encouraging, the survey also identified areas where care can be improved. For example, 1 in 4 pregnant women report feeling ignored or dismissed by a maternity care provider: about 10 percent by their primary provider and 19 percent by another provider.

The survey also shed light on some of the disparities in care that pregnant women and new moms experience based on their race, socioeconomic status and geographic location.

Below, some of the most significant findings from the survey.

Black women are getting prenatal care later
It’s no secret that there are vast disparities in maternal health care based on a woman’s race, which is one reason why the maternal mortality rate is so much higher for Black moms in the U.S. Our survey reinforced that there are clear disparities in when and how Black and Hispanic/Latina moms-to-be receive care, as well as how they’re treated by practitioners.

Although it’s generally recommended that women make an appointment with their practitioner as soon as they find out they’re pregnant, with a first prenatal visit ideally happening in the second month of pregnancy, Black women are more likely to have these initial appointments later, our survey found.

White moms-to-be are most likely to have their first prenatal appointment by 8 weeks (70 percent), significantly more than Black moms-to-be (59 percent). Black women are also twice as likely to have their first prenatal visit at 13 weeks or later when compared to white women.

delayed prenatal appointments
This trend continues in the later weeks of pregnancy: 9 percent of Black moms-to-be have a first prenatal visit at 16 weeks or later (compared to 3 percent of white moms-to-be), and 4 percent of Black moms-to-be don’t receive prenatal care until 21 weeks or later (compared to only 1 percent of white and Hispanic/Latina women).

In addition to delayed prenatal visits, our survey found that Black and Hispanic/Latina women are receiving first ultrasounds later, too. Ultrasounds are an important piece of prenatal care — in early pregnancy, they confirm fetal heartbeat and the baby’s position in your uterus, and later on, they screen for fetal growth and placenta location.

Among the women we surveyed, the first ultrasound is most commonly scheduled between weeks 6 and 12. But 10 percent of Black and Hispanic/Latina women report having their first ultrasound later on, during weeks 13 to 15.

White women feel better about their prenatal care overall
White women report more favorable prenatal care experiences in other ways, too. For example, they are more likely to receive written materials on a variety of topics during their first prenatal appointment, including information about genetic testing, office visits/scope of care, prenatal classes and the flu vaccine.

And while 69 percent of white moms-to-be say they are allowed to bring their partner with them to prenatal visits “all the time,” only 64 percent of Black moms-to-be and 53 percent of Hispanic/Latina moms-to-be report the same.

earlier ultrasounds
The survey also identified differences in where expectant moms receive care and how they get to appointments. Black moms-to-be are less likely to have their first prenatal appointment at a doctor’s office, and more likely to have it at a facility like a walk-in or stand-alone clinic: 12 percent of Black mothers had their first appointment at a community health center or walk-in clinic, compared to 5 percent of Hispanic/Latina and only 2 percent of white moms.

What’s more, Black women are more likely to rely on someone else for help getting to prenatal appointments. They are five times more likely to take a taxi or rideshare to their prenatal visits (5 percent vs. 1 percent for white women) and more likely to rely on someone else to drive them (39 percent vs. 28 percent for white women), for example.

And when it comes to how they feel about the prenatal care they’re receiving, 76 percent of white moms-to-be report feeling confident about the quality of care they’re getting, compared to just 65 percent of Black moms-to-be who feel the same.

Black moms also have more complicated pregnancies
A number of pregnancy-related complications disproportionately affect Black women, and our survey seemed to support this. About one-third of the women we surveyed (32 percent) say their pregnancy is considered “high risk,” but this rate was higher for Black moms (at 39 percent).

Of those new moms we surveyed whose labor was induced, the majority were induced because their practitioner recommended it (56 percent), followed by a maternal health issue (43 percent). But Black moms were most likely to have labor induced because of a health issue with their baby (33 percent vs. 16 percent total).

Black moms were also more likely than other ethnicities to need an emergency C-section, a procedure that comes with more risks for both mothers and babies.

Moms with higher household incomes report better maternity care experiences
Although racial and ethnic disparities remain highly concerning when it comes to maternal health, other factors can also result in differences in care. Moms with higher household incomes report better maternity care experiences overall.

For example, married moms-to-be, those living with a partner and those with household incomes above $75,000 are more likely to have their first appointment earlier when compared to single and lower-income parents.

And although 96 percent of the moms-to-be we surveyed say they feel like they can speak freely with their maternity care provider, 100 percent of expectant mothers who earn $125,000 or more say they can. Women from households earning more than $125,000 a year are also more likely to feel like their practitioner “always” listens to their concerns.

Women who earn $125,000 or more annually are more likely to have their first ultrasound in the first trimester compared to those who make less than $50,000. And at postpartum visits, practitioners are more likely to discuss breastfeeding with women from households earning more than $125,000 a year compared to moms earning $50,000 or less.

During the pandemic, telehealth experienced a surge in popularity. But women with higher household incomes appear to have more virtual access to their practitioners: they are 32 percent more likely to have a virtual patient portal they can use to communicate with providers, and 50 percent more likely to have had a prenatal visit conducted using telehealth. That’s potentially problematic, since a woman who makes less than $50,000 is also five times more likely to live more than 30 miles from her maternity care provider than one who makes more than $125,000, our survey found.

telehealth access
Race and ethnicity intersect with socioeconomic status, too. Forty one percent of the Black mothers we surveyed report a household income of less than $50,000 a year compared to 24 percent of white mothers – making Black women even more vulnerable to experiencing various maternal health and health care disparities.

Location also plays a role in the type of care moms receive
Millions of Americans live in “maternity care deserts” with limited access to prenatal care. Although most of these “deserts” are in rural parts of the country, about one-fifth are in urban areas.[2] Living further from your maternity care provider or having less access to them can make it harder for moms-to-be to keep up with prenatal appointments, as well as make emergency care less accessible. Our survey found some notable differences in care depending on where moms live.

Of the mothers we surveyed, Black and Hispanic/Latina women were more likely to live in urban settings than white mothers, who were more likely than other groups to live in suburban or rural areas.

Women in rural areas were significantly more likely to live more than 30 miles from their practitioners, as well as more than 30 miles from their hospital or birthing center. However, urban and suburban moms were more likely to use patient portals to connect with their practitioners than rural moms.

distance and prenatal care
Although some might assume that people living in rural areas don’t receive as quality care as those in other settings, our survey found that’s not necessarily the case. Although accessibility can be an issue, women living in rural settings were more likely to feel that their practitioner “always or sometimes” listens to their concerns compared to moms living in urban or suburban areas.

Moms living in urban areas were seven times more likely to feel like their pain management or birth plans were “not very well respected.” Women living in urban areas were also five times more likely than suburban moms to report not receiving breastfeeding support in the hospital, and suburban moms were significantly more likely to have their first prenatal visit at 8 weeks or earlier.

Similarly, suburban moms were most likely to have discussed key prenatal topics with their practitioner during their first appointment, and they were also more likely to receive written information about various prenatal health topics compared to moms living in rural or urban areas.

Moms who hire doulas are still the minority, though Black moms-to-be use them more than others
Doulas are trained professionals who provide emotional and physical support during pregnancy, childbirth and the postpartum period. While hiring a doula remains the exception rather than the norm, Black moms-to-be are turning to these skilled birth attendants more than other groups, our survey found. This could be in part because it’s becoming increasingly known that doulas may help Black, Indigenous and People of Color (BIPOC) mothers by reducing the maternal mortality rate and improving birth outcomes.

Only 9 percent of moms reported using a doula or other type of prenatal or postnatal delivery room support, and rural moms-to-be were the least likely to plan on or to use a doula. Black women were the most likely to use or intend to use a doula (14 percent vs. 10 percent total). And Black women with BIPOC providers were also more likely (14 percent) to use or plan on using a doula compared to white moms with white providers (9 percent).

#BumpDay continues to raise awareness about maternal health disparities
Happily, the majority of women we surveyed shared positive experiences about their prenatal care. Most moms-to-be feel respected and listened to, and say they are getting care throughout their pregnancies.

However, the results of this survey are a reminder that many women still experience significant prenatal care disparities that can have implications on their health and the health of their babies, particularly Black and Hispanic/Latina women, as well as women with lower household incomes.

Every mother deserves a safe pregnancy, and the quality of your prenatal care should never depend on where you live, your ability to pay or the color of your skin. That’s why What to Expect holds #BumpDay every year to raise awareness about the need for equitable care for every mom, everywhere. Learn more about the critical issues impacting moms and find out how to participate in #BumpDay on July 20.

Methodology: #BumpDay survey fielded by What to Expect May-June, 2022. Respondents were U.S. women, age 18+ pregnant or with a baby 0 to 12 months old, totaling 1,406 respondents.

WHO recommendations on maternal and newborn care for a positive postnatal experience

Overview This guideline aims to improve the quality of essential, routine postnatal care for women and newborns with the ultimate goal of improving maternal and newborn health and well-being. It recognizes a “positive postnatal experience” as a significant end point for all women giving birth and their newborns, laying the platform for improved short- and long-term […]

Healthcare Utilization and Costs Associated With Perinatal Depression Among Medicaid Enrollees

Abstract Introduction: Differences in healthcare utilization and medical expenditures associated with perinatal depression are estimated. Methods: Using the MarketScan Multi-State Medicaid Database, the analytic cohort included individuals aged 15-44 years who had an inpatient live birth delivery hospitalization between January 1, 2017 and December 31, 2018. Multivariable negative binomial regression models were used to estimate the differences […]

The U.S. Maternal Mortality Rate Surged by Nearly 20% in 2020

The rate of maternal mortality in the U.S. increased by nearly 20% from 2019 to 2020 in a potential indication of the COVID-19 pandemic’s impact on maternal health outcomes.

Data in a new report published Wednesday by the Centers for Disease Control and Prevention shows the overall maternal death rate in the U.S. rose from 20.1 deaths per 100,000 live births in 2019 to 23.8 deaths per 100,000 in 2020, marking an 18% increase. The rate has increased by nearly 37% since 2018, when there were 17.4 deaths for every 100,000 live births.

In total, 861 women in 2020 reportedly died either during or within 42 days of the end of their pregnancy, compared with 754 women in 2019 and 658 in 2018.

The report’s findings are based on data collected from the CDC’s National Vital Statistics System, and encompass maternal deaths linked to a pregnancy or its management. Deaths from accidental or incidental causes are not included.

Maternal mortality rates in 2020 went up across multiple age and racial groups in the report; notably, however, an “observed increase from 2019 to 2020 for non-Hispanic White women was not significant,” researchers said. The overall surge was fueled heavily by a spike in the rates for both Hispanic and Black women. Black women had the highest maternal mortality rate of the three racial or ethnic groups included, at 55.3 deaths for every 100,000 live births. That rate was nearly three times higher than the 19.1 deaths per 100,000 births among white women – a larger disparity than in 2019 – and more than three times higher than the rate of 18.2 deaths per 100,000 among Hispanic women.

Yet the maternal death rate among Hispanic women saw the largest increase from 2019 to 2020, rising by 44% over that year compared with an increase of 26% among Black women.

By age, women 40 and older had both the highest mortality rate and the largest increase from 2019. The maternal mortality rate for women 40 and older was 107.9 deaths for every 100,000 live births in 2020, a 43% increase from 2019 and 7.8 times higher than the rate of 13.8 per 100,000 live births for women under the age of 25. A rate increase among women under 25 was not statistically significant.

For years, the U.S. has had what can only be described as a poor record in maternal health outcomes when compared with other wealthy nations. A 2020 analysis by The Commonwealth Fund found that the 2018 U.S. maternal mortality rate of 17.4 deaths for every 100,000 live births was more than double the recent rates of a majority of other developed countries studied.

Tracking data from the CDC shows 82 deaths among pregnant women with the disease reportedly occurred in 2020. And though the latest figures do not delineate whether deaths occurred in connection with COVID-19, they come amid concern about both the direct and indirect health risks the COVID-19 pandemic has posed for pregnant women.

The CDC warns that pregnant or recently pregnant people are more likely to become severely ill from COVID-19. A CDC study published in November and focused on Mississippi also found a higher mortality rate among women with a coronavirus infection during pregnancy – none of whom had been fully vaccinated – compared with females of reproductive age who had a coronavirus infection.

The pandemic additionally disrupted maternal health care, leading to the alteration or cancellation of prenatal visits, hospitals enacting restrictions on who could be with a mother during delivery and even the shuttering of some birth-related services, at least temporarily. The number of home births rose by nearly 20% in 2020, from more than 38,000 in 2019 to more than 45,000.

Data also points to elevated levels of issues like depression and anxiety among many pregnant women during the pandemic.

“When we think about all of the stressors that a person felt even prior to the pandemic, adding all of these other things on top, it’s no surprise that we see an additive effect of the pandemic causing feelings of unsafety,” says Kristina Wint, senior program manager for reproductive and maternal health and wellness at the Association of Maternal and Child Health Programs. “Many people think that televisits is something that has been filling in the gaps, and it absolutely has, but they are just a Band-Aid on a broader and bigger issue on how (we can) ensure that people are able to access the care that they need.”

Maternal Deaths Rose During the First Year of the Pandemic

The number of women in the United States who died during pregnancy or shortly after giving birth increased sharply during the first year of the coronavirus pandemic, according to a new study, an increase that health officials attribute partly to Covid and pandemic-related disruptions.

The new report, from the National Center for Health Statistics, found that the number of maternal deaths rose 14 percent, to 861 in 2020 from 754 in 2019.

The United States already has a much higher maternal mortality rate than other developed countries, and the increase in deaths pushes the nation’s maternal mortality rate to 23.8 deaths per 100,000 live births in 2020 from 20.1 deaths in 2019. Maternal mortality rates in developed countries have in recent years ranged from fewer than two deaths per 100,000 live births in Norway and New Zealand to just below nine deaths per 100,000 live births in France and Canada.

Black women in America experienced the most deaths: One-third of the pregnant women and new mothers who died in 2020 were Black, though Black Americans make up just over 13 percent of the population. Their mortality rate was nearly three times that of white women.

The mortality rate for Hispanic women, which has historically been lower than for white women, also increased significantly in 2020 and is now almost on par with the rate for white women. Death rates increased among all pregnant women older than 24, but particularly in those 40 and over, whose mortality rate was nearly eight times that of women younger than 25.

“Our maternal morbidity and mortality is the highest in the developed world, and the trend is continuing despite our awareness of it, despite our maternal-mortality review committees, despite attention in the press,” said Kara Zivin, a professor of psychiatry, obstetrics and gynecology at the University of Michigan who studies access to care during and after pregnancy. “Whatever we’re doing is clearly not enough to address either the overall rate or the disparities.”

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Although the new report is sparse on details — no maternal mortality figures were provided for American Indian/Alaska Native women, who have higher pregnancy-related deaths than white, Hispanic and Asian/Pacific Islander women — experts said some of the deaths were most likely related to the coronavirus pandemic. Pregnancy puts women at risk for more severe disease if they are infected with the SARS-CoV-2 virus, which causes Covid, and vaccines were not available for them in 2020.

Dr. Chaniece Wallace died in 2020 from pregnancy complications after delivering her first child.
Dr. Chaniece Wallace died in 2020 from pregnancy complications after delivering her first child.
Credit…Chaniece Wallace Memorial Facebook Page
“We actually said when the lockdown started that we anticipated an increase in maternal deaths, both due to Covid and the responses to Covid,” said Dr. Denise Jamieson, an obstetrician at Emory University in Atlanta and a member of the Covid expert group at the American College of Obstetricians and Gynecologists, adding that she was not surprised by the increases.

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In addition to the greater risks faced by pregnant women who have Covid, she said, “we hadn’t figured out how to deliver obstetric care safely in 2020.”

“Our health systems weren’t set up yet to manage telehealth,” she said, “and there were other barriers: Kids were home from school, and parents couldn’t get away for medical appointments.”

Many doctors had stopped seeing patients in person, hospitals were often crowded and patients avoided emergency rooms filled with Covid patients.

Pregnant women who develop Covid face a higher risk of requiring intensive care or mechanical ventilation. And despite the relative youth of pregnant women, they face a higher risk of dying, studies found. Health experts have been urging them to be vaccinated, but their vaccination rates have remained low.

Black Americans overall suffered disproportionately from the pandemic, with higher hospitalization and death rates than their white counterparts, but the racial disparities in maternal mortality predate and extend beyond Covid, and stem from structural health inequities that have complex root causes.

Stress, mental health problems and substance abuse increased during the pandemic and might also have contributed to worse outcomes, said Dr. Mary D’Alton, chair of the department of obstetrics and gynecology at Columbia University Irving Medical Center.

New programs that provide enhanced services for patients, such as doulas, who can support and advocate for patients, are positive advances, she said.

“We also have to educate our providers on listening to patients,” Dr. D’Alton said. “My dad was a primary care doctor and he used to say, ‘Mary, if you want to know what’s wrong with the patient, ask them and they’ll tell you. But first of all, you’ve got to listen to them.’”

“Pregnant women’s complaints are often dismissed, and that is probably much more significant for Black and brown women,” she added.

Generally speaking, the leading causes of pregnancy-related deaths are cardiovascular conditions, other medical conditions and infections. Research has found that cardiomyopathy, a disease of the heart muscle; blood clots to the lung; and hypertensive disorders of pregnancy contribute to a higher proportion of pregnancy-related deaths among Black women than among white women.

One of the new mothers who died in 2020, whose story was widely reported, was Dr. Chaniece Wallace, a Black physician who was the chief pediatric resident at the Indiana University School of Medicine in Indianapolis.

Dr. Wallace developed a pregnancy complication called pre-eclampsia and her baby girl was delivered early by cesarean section in October 2020. But Dr. Wallace went on to develop additional complications, and she died just days after giving birth.