When a woman dies in pregnancy, childbirth, or the postpartum period, it means there is an infant who will never know his or her mother. There is a tremendous sense of loss, grief, fear, and blame, as well as new, unexpected responsibility for the other parent and the family’s extended community.
Maternal mortality has been rising in the United States. A report from the Centers for Disease Control and Prevention (CDC) counted 1,205 U.S. women who died of maternal causes in 2021, compared with 861 in 2020 and 754 in 2019.
There are many reasons for the increased risk of pregnancy complications that lead to maternal death, ranging from women getting pregnant at older ages, to inequities in health care, to a rise in chronic health conditions. But about 84% of pregnancy-related deaths are thought to be preventable, according to data from state committees that review maternal deaths.
“Women with pregnancy-related health complications may not always recognize the early warning signs of their illness. And even if they do, the providers may miss or cause a delay in diagnosis, which can lead to more serious or even deadly consequences,” says Monique Rainford, MD, a Yale Medicine obstetrician-gynecologist.
Dr. Rainford discussed the reasons for rising maternal mortality rates in the U.S. and what changes need to be implemented to bring those numbers down.
1. What is maternal mortality?
Maternal mortality (or death) is the term for when a mother dies from a pregnancy-related health issue or an existing condition exacerbated by pregnancy. It can occur at any time during pregnancy or in the 42 days after giving birth. (The 42-day timeframe is part of the World Health Organization [WHO]’s definition and was used in the CDC’s recent maternal mortality report.)
The maternal mortality rate, which is based on the CDC’s numbers (gathered from National Vital Statistics System data), is the number of maternal deaths per 100,000 live births. The 1,205 deaths in the U.S. in 2021 translate into an overall maternal mortality rate of 32.9 per 100,000 live births compared with 23.8 in 2020 and 20.1 in 2019.
Some experts believe a 42-day postpartum period does not accurately capture all pregnancy-related deaths, and more are starting to consider that problems can arise up to a full year after childbirth, Dr. Rainford explains. “Forty-two days is based on the idea that, physiologically, a mother’s body returns to normal about six weeks after she gives birth,” she says. “Most things usually do return to normal, but the medical community has started to realize that there are still many mothers who are not quite back to normal physiologically—or otherwise—at that point.”
2. Why is maternal mortality especially high among Black women?
Black women face a much higher risk of maternal death—there were 69.9 deaths per 100,000 live births among Black women in the U.S. in 2021.
“There are multiple reasons for such a high risk,” says Dr. Rainford, the author of "Pregnant While Black: Advancing Justice for Maternal Health in America."
One is what is referred to as “allostatic load,” the cumulative physiological effects of chronic stress. Studies have shown that Black women’s biological age (a measurement of the pace at which the body has aged) can be up to 10 years older than that of their white counterparts, presumably because of allostatic load, Dr. Rainford says, adding that 10 years makes a significant difference because the risk of maternal death goes up significantly with age. “Furthermore, many believe this earlier health deterioration is due to the chronic stressors of racism.”
Overt and implicit bias from health care providers is also a contributing factor, says Dr. Rainford, citing stories in the news about Black women and families who say doctors ignored their reports of symptoms and requests for help. “Implicit bias, in which a person isn’t aware of their bias, is particularly problematic. For instance, a caregiver may think they are doing the right thing for their pregnant patient, but their implicit bias against the woman’s race affects the care they deliver.”
3. How is age a contributing factor to maternal mortality?
The term “advanced maternal age” is used in obstetrics to describe mothers who will be 35 or older on their estimated due date. The median age of mothers giving birth rose from 27 in 1990 to 30 in 2019, according to U.S. Census data.
While many women 35 or older have healthy pregnancies, the risk of dying in pregnancy increases with age—the rate of maternal mortality in the U.S. in 2021 for women under 25 was 20.4 per 100,000 live births and 31.3 for women ages 25 to 39. For women ages 40 and older, however, the rate was 138.5 per 100,000 births.
“Health risks increase as we age, and, thus, older women are more likely to have health conditions when they get pregnant,” Dr. Rainford says. For example, in women over 35, there is an increased risk of health issues, such as gestational diabetes or preeclampsia, and complications, such as having a Cesarean section, problems in labor, and postpartum bleeding. Women in this age group are also more likely to have multiples (such as twins or triplets), which pose a higher risk of pre-term delivery, among other issues.
While older women can’t eliminate their risk, they can take steps to reduce it, Dr. Rainford adds, emphasizing that nutrition, exercise, sleep, stress management, and appropriate prenatal care all contribute to the mother’s health.
4. How has COVID-19 contributed to maternal deaths?
A quarter of maternal deaths were associated with COVID-19 in 2020 and 2021 combined, according to a report on maternal mortality in October 2022 by the U.S. Government Accountability Office. COVID-19 can pose higher risks to pregnant women, whose bodies are undergoing physiological changes, such as decreased lung capacity and a weakened immune system. And these bodily changes can continue in the postpartum period, Dr. Rainford adds.
The deaths may have been caused by COVID-19 directly or by pre-existing conditions exacerbated by the virus, Dr. Rainford explains. “For instance, if you are pregnant and have chronic hypertension, your risk of dying from a COVID infection increases,” Dr. Rainford says. “But, other contributing factors, including social stressors, can adversely affect your health. And stress affected everyone during the pandemic.”
The CDC recommends COVID-19 vaccines to anyone who is pregnant or breastfeeding, or who is trying to get pregnant or could become pregnant in the future.
The hope is that COVID-19 will be less of a problem with greater immunity to the virus and improved treatments, adds Dr. Rainford. “It is reasonable to expect that the 2022 maternal mortality data will improve compared with 2021, when there was an increase in the number of COVID-related maternal deaths.”
5. What health conditions are driving the high number of maternal deaths?
Chronic health conditions, in general, have become a contributing factor, Dr. Rainford explains. “More women than before are coming into pregnancy with a pre-existing condition,” she says. “That puts them at an increased risk of developing new conditions during pregnancy or worsening existing ones.”
Heart disease and stroke are leading causes of maternal mortality, and cardiomyopathy (a weakened heart muscle) is the most common cause of death one week to a year after delivery. In addition, hypertension, which affects a growing number of Americans, can lead to preeclampsia, a condition marked by high blood pressure, proteinuria (protein in the urine), and/or signs of liver and kidney damage that can develop after 20 weeks of pregnancy. Preeclampsia also poses a higher risk for stroke and other problems after delivery.
Another underlying cause of death is mental health conditions. Perhaps surprisingly, both suicide and homicide are considered leading causes of death both during pregnancy and the postpartum period. “If you develop postpartum depression, for instance, it puts you at a higher risk for suicide,” Dr. Rainford says.
6. How does prenatal care affect maternal mortality?
Early and regular prenatal care improves the chances of a healthy pregnancy. This can start with a visit to the obstetrician before a woman gets pregnant to discuss, among other things, updating immunizations, reviewing medical and genetic histories, and controlling any pre-existing health conditions. A provider will also make recommendations to help ensure the baby will be healthy, such as increasing folic acid intake (this alone provides a 70% reduction in the risk of neural tube defects, which include medical conditions such as spina bifida).
Once a woman becomes pregnant, the first prenatal visit should be scheduled in the first trimester (the first 12 weeks). Follow-up appointments should occur throughout the pregnancy for physical exams, weigh-ins, and blood pressure checks, as well as continued discussions about diet, exercise, and any questions that come up. There may also be blood and imaging tests, including ultrasounds, to assess the health of both the mother and fetus.
The American College of Obstetricians and Gynecologists (ACOG) advises additional visits, as needed, starting in the first three weeks after the baby is born, with a final checkup within the first 12 weeks after giving birth. Some women may require continued medical visits, especially if they experienced any pregnancy complications.
7. What else can women do to help reduce the risk of maternal death?
As soon as a woman knows she is pregnant, she should immediately book an appointment with her doctor or the obstetrics practice or clinic where she expects to receive care, obtain confirmation of the pregnancy, if necessary, and start following her doctor's advice, Dr. Rainford explains.
Sometimes, women will need to do research and advocate for themselves to get the support they need, she adds. "It's important to have a good therapeutic relationship with your medical provider," she says. "Women should pay attention to their instincts when they meet a new provider, especially if anything makes them feel uncomfortable."
She also recommends having a doula—a woman without formal obstetric training whose job is to provide guidance during labor. “Doulas are a form of social support; they're knowledgeable and can help with advocacy,” she says.
If a woman develops a complication when her pregnancy is already underway, she should not hesitate to ask for a maternal-fetal specialist, Dr. Rainford adds. (The CDC has a list of warning signs for complications that may develop during pregnancy and up to a year after delivery.)
“The models of care for delivering a baby are changing,” she says. “Obstetrical care was once mainly the work of physicians, but now advanced practice registered nurses [APRNs] and midwives provide it, too. While these practitioners may be excellent, they may not have training in high-risk pregnancy, so it’s important to know when to ask for help.”
8. What institutional changes are needed to help reduce maternal mortality?
Broader change is needed, Dr. Rainford says. “While women can play a role, I think the responsibility is largely in the hands of institutions to improve the health care they deliver to pregnant women,” she says.
Black pregnant women, in particular, suffer the worst maternal health disparities, she adds. “Even a low-risk Black woman entering pregnancy is significantly more likely to die than a similarly low-risk white woman,” Dr. Rainford says. “Furthermore, high-income non-Hispanic Black mothers have worse maternal and infant health outcomes than low-income non-Hispanic white mothers, which suggests a system failure rather than a woman not taking care of her health.”
Those things need to change, but that shouldn’t make women feel as though they can’t take initiative, she adds. Women can maintain their health and seek out medical care they feel comfortable with, and they can reach out to family, friends, and anyone else they have available to create a support network, she explains.
“The people around you can make a difference in the success of your pregnancy. For example, a friend or family member could say, ‘Let's go for a walk to get you some exercise,’ or, ‘I'm going to prepare a healthy meal for you.’ Or, they can just ask, 'How are you doing? Can I help take care of the other children and give you a break?’ All of those things help support a woman through pregnancy,” she says.