U.S. maternal mortality rates increased in 2021, far surpass that of other wealthy countries

Using data from the National Vital Statistics System, the CDC in a new report confirmed 1,205 deaths due to pregnancy or childbirth in 2021, significantly higher than the 861 deaths in 2020 and 754 in 2019. Among live births, the 2021 maternal mortality rate was 32.9 per 100,000, compared to 23.8 per 100,000 in 2020 and 20.1 in 2019.

Per CDC data, maternal deaths are at a 60-year high, with a sharp decline beginning in the mid 1960s before a steady rise over the past two decades. Preliminary data from the CDC, which includes deaths reported during a 12-month period ending in October 2022, suggests a significant drop for past year, with 830 deaths.

With November and December 2022 data absent, the total for the calendar year is unknown but still likely exceeds that of pre-pandemic years, and follows the overall upward trajectory over the last several decades.

“With advances in medical technology you would think we’d be moving in the other direction but unfortunately we aren’t,” said Mayo Clinic Health System certified nurse midwife Jennifer Meyers. “We’re a very rich nation, but (our death rates) don’t reflect that. And there is a lot that factors into that.”

Racial disparitiesAs with many many health conditions or diseases, Black women are dying at disproportionate rates. The 2021 maternal mortality rate was 2.6 times higher than that of non-Hispanic white women, at 69.9 per 100,000 live births, and 150% higher than that of Hispanic women.

“If you look at how care providers are responding to patient concerns, unfortunately minorities are not taken as seriously as white patients, and unfortunately there are providers who are biased,” Meyers said. “Systemic racism and institutional racism pose certain levels of stress physically and emotionally. Living in a racist society and having to deal with that throughout their lifetime can have negative consequences for those patients.”

To help address the gap, the Black Maternal Health Momnibus Act was introduced in 2021, with a series of bills to tackle obstacles to quality care. This includes investments in social determinants of health such as housing, transportation and nutrition, diversifying the perinatal workforce, supporting those with maternal mental health or substance use issues, improving health care for incarcerated pregnant women or new moms and more.

“It’s something we really need to work on,” Meyers said of addressing the issue on a health care level. “I think a lot of people have a certain level of defensiveness when it comes to that, but we really truly need to be looking at, how are we responding to patients? What are things that we can put in place to better listen to patients when they have concerns? And really identifying some of those biases.”

At Mayo, Meyers said, “an initiative was started to raise concerns of diversity and equality, and they are doing a lot of free programming for providers and nurses who want to participate. So I think that that’s a really good step, really highlighting that there’s more that we can do.”

Mayo Clinic as an enterprise has pledged $100 million over a decade to work toward eliminating bias in medicine, diversifying leadership and providing equitable access to services.

Gundersen Health System’s Office of Population senior consultant serves on the Governor’s Health Equity Council, examining disparities and formulating solutions, and Gundersen’s Diversity, Equity, and Inclusion division is working to develop a strategy to close the health disparities gap and foster a sense of belonging among patients, staff and communities.

For many Americans, health care costs are a heavy burden, and that factors into maternal deaths. The U.S. is a wealthy country, and yet the maternal mortality rate far surpasses that of countries with comparable incomes. In Norway, there were no maternal deaths in 2019, per the Commonwealth Fund’s April 2022 report, and the next highest rate among the 11 developed countries examined was France at 7.6 per 100,000. Only 26% of American women of reproductive age felt their healthcare was good or very good, compared to between 58% and 84% among those in the other countries.

American women also spend more than twice as much on out of pocket medical costs, and nearly half have have skipped or delayed health care due to costs.

“We don’t have high quality health care for every single person in our country,” Meyers said. Even among those with insurance, the deductible may be more than they can afford, leading patients to forgo necessary exams or treatments.

“The No. 1 reason for bankruptcy in the United States is health care costs,” Meyers noted.

Telehealth has helped mitigate some of the financial hurdles to seeking care, as patients don’t need to arrange travel or child care to see a provider. For expectant mothers, Mayo offers the OB Nest prenatal program, which allows low-risk patients to do 50% or more of their standard care appointments at home. Patients are given at-home vital monitoring devices, fetal heart rate Dopplers and education on how to utilize the devices. Patients can share their readings via message, phone, or video.

“They’re able to get high-quality care without having to go in,” Meyers said. The model has proved successful, and Meyers noted hypertensive disorders are often more quickly detected in this format as blood pressure ratings are taken more frequently.

An additional factor in high maternal death rates are geriatric pregnancies, when the mother will be age 35 or older at the time of their estimated due date. According to the CDC study, fatalities across all races increased with age in 2021. For those 40 and older, the death rate was 6.8 times higher than that of those under 25. In 2019, among those 40 and older the maternal mortality rate was 75.5 per 100,000, climbing to 107.9 in 2020 and 138.5 in 2021.

The median age of pregnancy is now 30, the highest on record. In 2000, it was just under age 25.

“Moms are choosing to delay childbearing until later years. Maybe they’re trying to focus on their career first or get to a place of financial stability,” said Meyers. “And it’s difficult because a patient who is 35 years old is not, by any stretch of the imagination, an old person. But when it comes to reproduction, unfortunately, increasing age does bring with it increasing risks such as hypertensive disorders, gestational diabetes and premature labor and delivery.”

Reproductive technology such as donor eggs, IVF or UVI has made pregnancy possible for those in their 40s and even 50s, but potential adverse consequences remain, Meyers noted.

The health status of pregnant women also contributes to complications, Meyers said.

“There is a higher acuity of the patients that we’re taking in. They are coming to us with preexisting health conditions like type two diabetes or prediabetes,” Meyers said. “Obesity unfortunately contributes to complications as well and and we as a nation are becoming more obese.”

According to the CDC, between 1999 to 2000 and 2017 to 2020, obesity rates increased from 30.5% to 41.9%. During the same time frame, the prevalence of severe obesity increased from 4.7% to 9.2%. The National Institute of Health reports that women with obesity have a higher risk of miscarriage, gestational diabetes, preeclampsia and venous thromboembolism, and are more likely to require induced labour or a caesarean section.

Obesity rates are highest among Black or African American women, affecting four out of five, which is in part attributed to racial disparities. Lack of access to nutritious foods, living in less walkable areas and insufficient health care are factors.

Wisconsin’s Nutrition, Physical Activity and Obesity Program is working to promote nutritious eating and physical activity across the state.

For information on pregnancy services, resources and prenatal care cost assistance, visit the U.S. Department of Health and Human Services website page for expectant mothers at rb.gy/kzv5w.