Missing Maternal Mortality

Today's post features a guest blogger and dear friend, Kara Zivin, PhD, MS, MA, Professor of Psychiatry, Obstetrics and Gynecology, and Health Management and Policy at the University of Michigan.

More than any other group in health, epidemiologists decide how to measure the health of the nation. They choose what questions are asked and analyzed, what differences are important, serious, and worthy of comment, even alarm. If you do not ask the questions, the only answer is silence.

– John Marks, “Epidemiology, public health, and public policy,” Preventing Chronic Disease.

In January 2020, the Centers for Disease Control and Prevention released the long-awaited US maternal mortality rate (MMR), data they had not updated since 2007. Among the worst in the developed world, the US had 17.4 maternal deaths per 100,000 live births in 2018, corresponding to an estimated 658 lives lost.

This statistic represents a vast underestimate of the burden of maternal mortality in this country.

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The World Health Organization defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” (emphasis added)

The CDC’s National Vital Statistics System used this WHO definition to generate a number of maternal deaths comparable to other countries.

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If I had died because of my prescription drug overdose during my eighth month of pregnancy—the culmination of months-long treatment-resistant depression, anxiety, and insomnia—would my death have appeared in the CDC statistics?

Would my death have counted?

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What we measure drives what we do.

The WHO definition of maternal death underestimates the true societal burden of maternal mortality. It excludes suicide, overdose, homicide, and accidental deaths. It excludes deaths beyond 42 days postpartum. It excludes deaths during pregnancy and postpartum that doctors or medical examiners may overlook because of inconsistent and unstandardized reporting.

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The CDC implemented a checkbox for pregnancy status on death certificates in 2003 to account for missing data on maternal mortality; it took until 2017 for all states to implement it.

Most states now have maternal mortality review committees.

Data from 14 states shows that mental health conditions are the leading cause of pregnancy-related deaths for non-Hispanic white women.

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Perinatal mood and anxiety disorders can affect one in five women during pregnancy and postpartum. My research team and I estimated that maternal mental illnesses cost over $14 billion per year in the US in 2017. Deaths between 43 and 365 post-delivery account for approximately one-quarter of pregnancy-related deaths.

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Between 1990 and 2015, the global MMR decreased; the US MMR increased by 25% since 2000.

In the US, African American, American Indian, and Alaska Native women have two to four times the risk of maternal mortality compared to white women, an unacceptable disparity reflecting widespread systemic racism.

What attention we pay to maternal mortality typically focuses on causes such as severe bleeding, infection, high blood pressure during pregnancy, and delivery complications.

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In California, maternal drug-related death and suicide are leading causes of postpartum death.

In Illinois, one-fifth of all deaths of pregnant women and new mothers in 2014-2016 involved suicides and overdoses.

In Louisiana, homicide was the leading cause of death during pregnancy and the postpartum period in 2016.

The researchers who led the Louisiana study noted, “relative to the attention paid to obstetric causes of death, rigorous examination of mortality from non-obstetric causes during pregnancy and the postpartum period is rare.”

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We measure infant mortality as an indicator of a country’s health.

Why don’t we focus on the breadth, depth, and true magnitude of maternal mortality?

Alison Stuebe, an obstetrician and gynecologist at the University of North Carolina Chapel Hill notes, “in our current system of care, the baby is the candy, and the mother is the wrapper. Once the candy is out of the wrapper, the wrapper is cast aside.”

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My son and I both survived my perinatal suicide attempt, and ultimately, we thrived.

I recognize my privilege and good fortune to have had access to care and support that allowed me to recover from my illness and become a mother to my son.

I represent a treatment success story; yet less than 20% of women receive any treatment, less than 10% receive adequate treatment, and less than 5% achieve remission.

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Professional organizations, such as the American College of Obstetrics and Gynecologists, and state policymakers support extending Medicaid coverage to one year postpartum rather than 60 days postpartum.

The Black Maternal Health Momnibus Act of 2020 aims “to end preventable maternal mortality and severe maternal morbidity in the United States and close disparities in maternal health outcomes.”

Evidence-based policy approaches that we can implement today can curb preventable deaths associated with mental health and substance use causes and overall maternal mortality.

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New mothers could receive follow-up sooner than the six-week postpartum visit.

We could expand and reimburse psychiatric mother and baby units rather than separating a new mother from her infant if she requires postpartum inpatient care.

Implementing universal maternity leave policies would not only benefit women and families but employers as well; productivity loss represents the largest category of costs associated with maternal mental illnesses.

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In Michigan, in her most recent state of the state address, Governor Gretchen Whitmer outlined that the 2020 budget will extend Medicaid from 60 days to one year postpartum and that the first postpartum visit will move up to three rather than six weeks after delivery.

The state will focus on increasing access to mental health and substance use treatment for mothers.

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Official statistics can inform and guide policy debates, but when data exclude relevant information, policy solutions may become ineffective or inappropriate.

Existing policies in multiple states aim to address maternal mental health, such as awareness and education.

Such campaigns regarding postpartum depression have no proven impact on health outcomes and do not lead to enforceable clinical or policy changes.

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We must also keep a focus on physical health complications, particularly at delivery.

Two-thirds of physical health complications of pregnancy leading to maternal mortality remain preventable.

COVID-19 exacerbates the burden of perinatal mental health and substance use disorders, decreases the likelihood of and access to treatment, and complicates documentation of maternal morbidity and mortality.

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In the years since my son and I nearly died almost a decade ago, I have restructured my research career to identifying gaps and barriers to care for women with perinatal mood and anxiety disorders.

Through this process, I have learned that making a significant dent in the growing burden of maternal mortality and deaths associated with mental health and substance use conditions in particular, will require time, creativity, and thoughtfulness from a variety of stakeholders.

As a society, we should remember that there is no health without perinatal mental health, and act accordingly.

To begin, we must document the full extent of maternal mortality.