Recent media reports have coupled a startling set of facts with an equally startling explanation.
Women who want to start or grow their families face greater risks during childbirth than their mothers did. Over the last two decades, the number of American women who die each year from a pregnancy- or childbirth-related cause has skyrocketed by more than 50 percent. The risks for black women are more than three times higher than for white or Hispanic women, regardless of income or education.
The most common explanation? Hospitals have been failing to protect pregnant women. But as maternal health researchers who have been studying this trend, we believe an essential piece of the story is missing.
The Centers for Disease Control and Prevention’s newly released annual report on U.S. deaths indicates a larger challenge than maternal mortality: death rates are rising for all women of reproductive age, not just those who are giving birth. This suggests we need to widen our lens.
The public image is that these deaths are caused by a hemorrhage or other acute condition that suddenly arises during labor and leads to a terrible tragedy. That certainly does happen, and clinicians and hospitals have been taking steps to address these emergencies with new guidelines, and the use of simulations to better handle obstetric crises. While it’s clear that some hospitals could be doing more, this type of response is fundamentally what we’ve structured the U.S. health care system to do — apply abundant resources to better treat emergencies in hospitals.
Although these efforts are essential, they address just part of the problem. The same CDC research that documented the rise in maternal deaths also examined the timing of these deaths. Only about one-third of them occurred during labor and delivery or in the following week. Roughly one-third occur during pregnancy and another third between one week and one year after birth.
That means we have to look at care in the community as well as in the hospital if we truly want to prevent maternal deaths.
In the U.S. each year, an estimated 700 women die from pregnancy- or birth-related causes. Each one of these deaths is heart-wrenching. Yet they constitute only about 1.3 percent of all deaths each year among women of reproductive ages, generally set as ages 15 to 45. Compare their death rates to those among women younger than 15 or older than 45 and an even more disturbing pattern emerges. In the U.S., the death rates for women under 15 and over 45 have been decreasing for decades. But between 2010 and 2016 (the most recent years for which data are available), the death rate for reproductive-age women increased an average of 14 percent. For women between the ages of 25 and 34, the death rate increased by 20 percent.
More data on the trends we describe here are available at Birth by the Numbers.
This wider picture shows that the well-being of all women of reproductive age is on the decline and, contrary to the headlines, it’s not only because of their pregnancies. Over the past decade, the number of maternal deaths associated with life-threatening conditions that are specific to pregnancy, such as postpartum hemorrhage, pre-eclampsia, and infection, have actually been declining. At the same time, life-threatening conditions that are chronic in nature and not directly caused by pregnancy, such as cardiac disease and mental health conditions, have been rising.
In addition to these insidious conditions, a recent CDC report attributed the lion’s share of avoidable deaths to broader failures of social support: not seeking timely care, not following medication plans, abusive relationships, unstable housing, and substance use.
Efforts by clinicians and hospitals to improve maternity care are essential. But we can’t solve the problem of maternal deaths unless we acknowledge that women’s health isn’t something to be concerned about only during pregnancy and then disregarded after the baby is born.
At a minimum, policymakers should resist recent efforts to drop maternity benefits from core health insurance coverage. But they also need to revise current state policies that expand Medicaid coverage for women only during pregnancy and then drop them 60 days after giving birth.
Once we focus on the health of all reproductive-age women, we’ll see that the current concern with deaths during pregnancy was the equivalent of a canary in a coal mine warning of a much larger problem.
Eugene Declercq, Ph.D., is a professor of community health sciences at Boston University School of Public Health and founder of Birth by the Numbers. Neel Shah, M.D., is a professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and director of the Delivery Decisions Initiative at Ariadne Labs. Both are directors of the March for Moms.