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What is it?
The dismal state of maternal mortality and morbidity in the U.S.
The U.S. is the only industrialized nation where the maternal mortality rate is increasing. From 2000 to 2017, the global maternal mortality ratio decreased by 38%, while the U.S. ratio increased by 58%. The majority of these pregnancy-related deaths were preventable.
Maternal mortality ratio across industrialized nations
Maternal deaths per 100,000 live births in 2017 among women ages 15-49
The major clinical causes of pregnancy-related deaths in the U.S. include:
- Heart disease
- Obstetric emergencies
- Severe bleeding
- High blood pressure
Severe maternal morbidities are even more prevalent than pregnancy-related mortalities. These “near misses,” such as hemorrhages or organ failure, can result in long-term clinical and psychological complications. Estimates from the CDC and the Alliance for Innovation on Maternal Health indicate that 60,000 to 80,000 patients experience severe morbidities every year. Morbidity incidence is increasing faster than mortality at a rate of 190% vs. 62% between 1993 and 2014.
Social determinants of health exacerbate clinical challenges
Clinical causes of pregnancy-related mortality and morbidity are just one part of the story. A host of non-clinical factors, such as restricted access to care, also impact outcomes. Many low-income patients cannot afford private insurance but do not qualify for Medicaid, particularly in non-expansion states. Patients who do have coverage are often under-insured and unable to afford costly copays, limiting access to quality care.
Additionally, reductions in government funding of social services and benefits, including recent federal restrictions to the Supplemental Nutrition Assistance Program (SNAP) and fair housing protections, layer added financial strain on patients who struggle to afford health care. These restrictions to key social programs compound the impact of community-wide social determinants of health that are common in low-income neighborhoods.
Black and Native American patients face the greatest risk of death
Maternal mortality and morbidity is a nationwide crisis that impacts every community regardless of its demographic makeup. However, some groups fare significantly worse than others. Black and Native American patients have much higher pregnancy-related mortality rates than their white counterparts. The mortality rate for Black patients is 3.3x the rate for white patients. For Native American patients, it’s 2.5x the rate. Any maternal health intervention must center on the needs of Black and Native American patients and communities (and others, including transgender and gender non-conforming patients) who are most at-risk of adverse outcomes.
Pregnancy-related mortality ratios per 100,000 live births
Centers for Disease Control and Prevention, 2011-2015
Recent studies indicate that Black women experience worse outcomes compared to white women, regardless of educational attainment and socioeconomic status. In fact, Black women with a college degree are more likely to experience severe morbidities than white women without a high school education.
Less research has been conducted on the experiences of Native American patients, who are often overlooked in national media attention on the maternal health crisis. But for both groups, the root cause of these disparities is structural racism.
How does it impact clinical leaders?
The media and policymakers are increasingly sounding the alarm about U.S. maternal health outcomes. Currently, patients face inadequate access to prenatal and postpartum care. In 2016, nearly 64,000 women received no prenatal care, and over 181,000 began care in the third trimester. In 2018, 40% of women did not attend a postpartum visit. Without comprehensive care, clinical leaders can’t identify and care for risky comorbidities like gestational diabetes or perinatal mood disorders. This leaves patients at increased risk for escalation and long-term complications, as patients who experience severe maternal morbidities are more likely to have heart disease or a stroke later in life. And the babies born suffer too. Pre-term birth and low birth weight reduce early childhood survival and long-term health outcomes.
Yet quality reporting regulations don’t require hospitals or health systems to track or publish maternal health outcomes by race. Clinical leaders at organizations without strategic investments in maternal health equity won’t be prepared when this crisis eventually falls under their purview. Leaders must be ready to take a swift, comprehensive approach—or risk worsening outcomes and quality scores across care coordination, patient safety, and patient engagement.
Conversations you should be having
Connect with an array of organizational stakeholders and leaders to identify specific initiatives to combat maternal health inequity in your community. For more on this topic, keep an eye out for our future publications. We will provide tactical examples that hospitals and health systems can use to improve performance and advance equitable outcomes.
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Creange A, et al., “Maternal Mortality and Morbidity in the United States: Where Are We Now?” Journal of Women’s Health; “Maternal Mortality,” World Health Organization, September 2019; “Maternal Mortality from 2000-2017,” World Health Organization; “Pregnancy Mortality Surveillance System,” CDC, February 2020; “Pregnancy-Related Deaths,” CDC, May 2019; Advisory Board interviews and analysis.
“Nearly Dying in Childbirth: Why Preventable Complications Are Growing in U.S.,” NPR, December 2017; “Severe Maternal Morbidity in the United States,” CDC, January 2020; Advisory Board interviews and analysis.
“Pregnancy Mortality Surveillance System,” CDC, February 2020; “Pregnancy-Related Deaths,” CDC, May 2019; “Racial/Ethnic Disparities in Pregnancy-Related Deaths,” CDC, September 2019; “Severe Maternal Morbidity,” NYC Health, 2016; Advisory Board interviews and analysis.
Neiger R, “Long Term Effects of Pregnancy Complications on Maternal Health: A Review,” Journal of Clinical Medicine, July 2017; “Optimizing Post-Partum Care,” ACOG, May 2018; Osterman M, “Timing and Adequacy of Prenatal Care in the United States, 2016,” CDC, May 2018; Glass H, “Outcomes for Extremely Premature Infants,” June 2016; Advisory Board interviews and analysis.