The United States has the highest maternal mortality among high-income countries, with approximately 700 deaths yearly and more than 80% of these deaths considered preventable.1,2 Maternal mortality is prevalent in minority populations, with non-Hispanic Black women experiencing 55.3 deaths per 100,000 live births in 2020, nearly 2.9 times the rate for non-Hispanic White women (19.1).3

Racial and ethnic disparities in obstetrics have been well-documented and are attributed to a number of risk factors, including implicit bias,4 hospital quality,5 cardiovascular conditions,6 obesity,7 and metabolic disease.7 Limited progress has been made in remediating the preventable causes of these maternal health inequities.8

The American College of Obstetricians and Gynecologists (ACOG) and other organizations have been taking steps to address this issue by working with health care professionals, policymakers, and leadership organizations to issue clinical guidance that meets the highest standards of patient care.


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Lisa Satterfield, MS, MPH, CAE, CPH, senior director of Health Economics and Practice Management at ACOG, and Jen Villavicencio, MD, MPP, FACOG, lead for equity transformation at ACOG and an obstetrician-gynecologist with a specialty in complex family planning, shared their insights on strategies to reduce maternal mortality.

Q: What steps have medical organizations taken to best address the maternal mortality issue among women, specifically for women in minority communities?

Satterfield: While the effort to eliminate preventable maternal deaths requires a multifaceted approach, one thing that will have a major impact is increased access to health care. ACOG has been the leading voice advocating for Congress and the administration to extend Medicaid coverage beyond the current 60 days after delivery to 1 year postpartum.

Medicaid pays for more than 40% of US births and 65% of births to Black individuals.9 Additionally, more than half of all maternal deaths occur postpartum — between 1 week and 1 year after delivery.2

Thus, expanded coverage will have a tremendous impact on eliminating health care inequities. Congress has already created a simpler pathway for states to [extend Medicaid coverage] and many have already taken advantage of it.

Q: How has the overturning of Roe v Wade affected maternal health, particularly in regard to care for women in underserved communities?

Dr Villavicencio: Now that Roe v Wade is overturned and abortion bans and restrictions have taken effect in various states across the country, we can expect to see the US maternal mortality crisis, once again, exacerbated.

It is a horrifying prospect that many more individuals could die because they will be forced to remain pregnant against their will or needlessly suffer untreated pregnancy complications as clinicians and institutions grapple with what constitutes a lawful medical exception.

While clinicians, hospitals, communities, policymakers, and other stakeholders in this country have turned their attention to the crisis of maternal mortality in the past few years, the post-Roe environment makes it imperative that maternal health care remain a priority.

To be clear, the worsening US maternal mortality rate cannot be addressed without addressing how each American can access safe abortion care if, and when, they need it. The overturning of the longstanding protections for abortion access will serve only to set us back in the fight against rising maternal mortality.

The maternal mortality crisis and the current reproductive health care crisis mimic each other in that, once again, the greatest harm will fall on communities of color, people without robust financial resources, and people who live in rural areas where access to care is already limited.10

Currently, non-Hispanic Black and Indigenous individuals have higher rates of pregnancy-related deaths and the COVID-19 pandemic only increased the rate of maternal deaths among these populations.11 Racism is an impactful driver of these inequitable outcomes.4,11

Q: How do you approach treating women in minority populations, and what resources do you use to inform your decisions to optimize their care?

Dr Villavicencio: It will be critical for hospitals and health systems to work with their communities to address social determinants of health by developing referral mechanisms and networks to help obstetric providers connect or refer patients to resources for mental health, violence prevention, substance use, housing assistance, economic support, and other medical and nonmedical needs.

Institutions should also work with their state perinatal quality collaborative to identify and implement health care processes that need to be improved. For example, many health care systems throughout the country have already standardized protocols to treat common causes of preventable maternal deaths through the national maternal health quality and safety improvement initiative the Alliance for Innovation on Maternal Health (AIM). Currently, nearly every state is a member of the AIM program, but many more institutions within each state can join.

With the overturning of Roe v Wade, patients living in maternity care deserts will face even greater challenges accessing essential health care.

It will be important for the hospitals that do provide care in those areas to collaborate and form relationships with higher-level facilities to transfer patients with high-risk pregnancies and ensure that consultation and referral are readily available when high-risk care is needed. Additionally, institutions should employ telehealth as a strategy to improve access in rural areas.

Q: What policies or processes have been put in place to address inequities in maternal health?

Satterfield: The Preventing Maternal Death Act, signed into law in 2018, provided funding to bolster existing state maternal mortality review committees (MMRCs), as well as create new ones. Maternal mortality review committees are multidisciplinary committees that perform comprehensive reviews of deaths among birthing people within a year of the end of a pregnancy.

Now that nearly every state has an MMRC, the CDC is working to ensure that they are functioning optimally by helping the committees standardize data collection, promoting best practices, and providing states with resources, tools, and support so these committees can provide the necessary community-level recommendations to help eliminate preventable maternal deaths and health inequities.

Q: What are actionable steps that clinicians can take today to help address the maternal mortality crisis and remain informed on this topic?

Dr Villavicencio: As a first step, clinicians can make a personal commitment to eliminate inequities in women’s health and to confront implicit and explicit bias and racism by recognizing and examining their prejudice and bias and addressing the ways in which health care systems perpetuate inequality. Key to this effort is education and providing opportunities for obstetrician-gynecologists to self-reflect, grow, and improve.

Allison Nguyen is a 4th-year student at Ernest Mario School of Pharmacy at Rutgers University in New Brunswick, NJ.

This is the first article in a 2-part series on maternal mortality. The second article Reforming Institutions, Integrating Health Technology to Address Maternal Mortality Gap is available here.

References

  1. Health and health care for women of reproductive age. The Commonwealth Fund. April 5, 2022. Accessed August 5, 2022. https://www.commonwealthfund.org/publications/issue-briefs/2022/apr/health-and-health-care-women-reproductive-age
  2. Trost S, Beauregard J, Chandra G, et al. Pregnancy-related deaths: data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html
  3. Hoyert DL. Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention. Reviewed February 23, 2022. Accessed August 5, 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
  4. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths – United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762-765. doi:10.15585/mmwr.mm6835a3
  5. Howell EA, Zeitlin J. Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Semin Perinatol. 2017;41(5):266-272. doi:10.1053/j.semperi.2017.04.002
  6. Gunderson EP, Greenberg M, Nguyen MN, et al. Early pregnancy blood pressure patterns identify risk of hypertensive disorders of pregnancy among racial and ethnic groups. Hypertension. 2022;79(3):599-613. doi:10.1161/HYPERTENSIONAHA.121.18568
  7. Teefey CP, Durnwald CP. Strategies to reduce disparities in maternal morbidity and mortality: The role of obesity and metabolic disease. Semin Perinatol. 2017;41(5):287-292. doi:10.1053/j.semperi.2017.04.005
  8. Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt). 2021;30(2):230-235. doi:10.1089/jwh.2020.8882
  9. Solomon J. Closing the coverage gap would improve black maternal health. Center on Budget and Policy Priorities. July 26, 2021. Accessed August 8, 2022. https://www.cbpp.org/research/health/closing-the-coverage-gap-would-improve-black-maternal-health
  10. Rural health. Centers for Disease Control and Prevention. Reviewed August 2, 2017. Accessed August 9, 2022. https://www.cdc.gov/ruralhealth/about.html
  11. Stratton P, Gorodetsky E, Clayton. Pregnant in the United States in the COVID-19 pandemic: A collision of crises we cannot ignore. J Natl Med Assoc. 2021;113(5):499-503. doi:10.1016/j.jnma.2021.03.008