A new study published in the American Journal of Obstetrics and Gynecology reports that rates of maternal mortality in the U.S. may have been overestimated. However, responses from the maternal healthcare community encourage a closer look.
The CDC's most recent report on maternal mortality put the rate of maternal deaths at 32.9 per 100K live births. The new study, published in AJOG on March 12, 2024, suggests that the actual rate is much lower: 10.4/100K.
The authors of the study came to this number after ruling out maternal deaths identified solely by a positive pregnancy checkbox on a death certificate. Instead, they classify a maternal death as one with a pregnancy-related cause mentioned by the physician who was certifying the death. They conclude as a result that "the high and rising rates of maternal mortality in the United States are a consequence of changes in maternal mortality surveillance, with reliance on the pregnancy checkbox leading to an increase in misclassified maternal deaths."
The concern is well-founded. The pregnancy checkbox has led to clerical errors in the past -- in one instance, a 70 year old male was classified as a maternal death.
However, while the CDC and other industry leaders have acknowledged that that data collection can be flawed (and they have refined their methods in recent years to reduce the potential for error), they have rightfully been concerned at the public response to the new study. Dismissing maternal mortality rates as an "overestimation" risks overlooking crucial ongoing issues, as highlighted by experts like Christopher M. Zahn, MD, FACOG, interim CEO and leader in clinical practice, health equity, and quality at ACOG. These issues include the overwhelming percentage of preventable deaths, continuing racial disparities in outcomes, and the various non-clinical factors that contribute to maternal deaths from the prenatal phase through the postpartum period.
Critical readers will note that even under the methodology proposed by the study's authors, maternal mortality rates are still egregiously high for a developed country -- and higher still for Black and Brown mothers. Under the proposed methodology, Black and Brown women still die at 2-3 times the rate of their White peers. There is no mention of preventable causes of death, which the CDC places at around 80%, after an analysis of data from Maternal Mortality Review Committees in 36 states.
It is also important to note that the study authors are concerned with direct obstetrical deaths (the authors do not classify suicides in the postpartum period as being maternal deaths, for instance). To focus solely on obstetrical causes of deaths is to exclude risks represented by comorbidities, behavioral issues, and social health determinants; including substance use, intimate partner violence, food and housing insecurity, education and income level.
There is growing support behind expanding the definition of maternal mortality and morbidity to include these non-obstetrical causes and contributors to death, and the stakes are high. They include reimbursement and support for non-traditional methods of care and assistance programs that have been shown to improve a woman's chance of having a healthy pregnancy; regardless of race, income, or education level.
This study should serve as a call to action -- to support careful death investigation and data validation from state review committees, but also to advocate for the delivery of whole-person care. Obstetrical-causes of death are the tip of the iceberg -- to treat pregnancy as an isolated episode of care and to neglect the health of the mother before and after childbirth is to ignore a tremendous opportunity -- and responsibility -- to improve the lives of women.
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