By Melinda Young

EXECUTIVE SUMMARY

Reproductive-age women in the United States experience the highest avoidable death rate among high-income nations worldwide, according to researchers.

• The maternal mortality rates for U.S. women are three times higher than the rate of maternal deaths in France, which is the second-highest among high-income nations.
• Maternal mortality for Black women in the United States is 55.3 maternal deaths per 100,000 live births — nearly three times higher than maternal deaths among white or Hispanic women in the United States.
• Economic differences alone do not explain the disparate maternal death rates between white and Black American women.

Recent research and reports paint an alarming picture of reproductive-age women’s health in the United States, suggesting societal-level changes and case management attention is needed to reduce avoidable deaths, particularly during pregnancy or recently after giving birth.^1-3

When compared with other high-income countries, women in the United States record the highest rate of avoidable deaths, numbering 198 per 100,000 females. The next highest is the United Kingdom, with 146 avoidable deaths per 100,000 females, according to a new report by the Commonwealth Fund.¹

The maternal mortality rate difference between the United States and 10 other high-income countries is even more dramatic: 23.8 deaths per 100,000 live births. This is more than three times greater than France, which reported the second-highest rate of maternal mortality.

“Frankly, it’s unacceptable,” says Munira Z. Gunja, MPH, senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations in New York City. “It’s gone higher during COVID. A change needs to happen. When we look at other countries that have been successful at reducing or eliminating maternal deaths, it all starts with primary care.”

Even worse, Black women in the United States — with 55.3 maternal deaths per 100,000 live births — are 17 times more likely to die during or shortly after pregnancy than are German women. They also are nearly three times more likely to die while pregnant or within 42 days of the pregnancy’s end than are white women or Hispanic women in the United States.¹

Among women from high-income nations, women in the United States are the least likely to report visiting a regular doctor — and it is the only affluent nation without universal healthcare.⁴

“We’re fixed on maternal care, but it extends beyond it to our primary care system and mental healthcare system, and these cannot be ignored,” Gunja says.

Racial Disparities in Mortality Rates

Recent data show an increased rate of maternal mortality among Black people, says Kamilah Dixon, MD, MA, assistant professor and vice chair for diversity, equity, and inclusion in the departments of obstetrics and gynecology at The Ohio State University (OSU) College of Medicine. Dixon also is the medical director of the Moms2B program in the OSU College of Medicine.

“It’s alarming and disheartening, especially as an OB/GYN, as a Black woman, to see this inequity that we continue to have in this country,” Dixon says. “Clearly, we have a lot of work to do.”

One solution health systems could employ is contacting women during pregnancy and follow up with them for a year after they give birth. The Moms2B program has shown some success, suggesting it can help alleviate disparities in maternal mortality rates.² (See story on Moms2B in this issue.)

The differences in maternal mortality between Black women in the U.S. and white women is not explained entirely by economic differences. “A Black woman who has a college degree has a higher rate of mortality in pregnancy than does a white woman without a high school degree,” Dixon says.⁵ “When we talk about disparity in healthcare, we’d be remiss to talk about it in a vacuum. There is systemic racism in the United States that impacts the health status of our people.”

Dixon finds medical students and residents are particularly concerned with the nation’s high rates of maternal mortality.

“I have students with graduate degrees who are well off, but they share concerns about dying after they deliver because of what they’ve heard about the disparities,” she says.

Problems related to health disparities, including maternal health inequities, are comprehensive enough to require new government policies and solutions. Access to education, quality of medical facilities, neighborhood, social, and economic factors all play a role, says Hossein Zare, PhD, MS, an assistant scientist at Johns Hopkins Bloomberg School of Public Health.

Even when Black women can access proper healthcare resources, their outcomes remain poor, partly because society consistently limits the efficacy of those resources, Zare noted in a recent paper.⁶

“We are working [with] a group of low-income Black women to help them control their hypertension, and we have increased their knowledge,” Zare explains. “What’s happening in the real world is they have the knowledge, but they don’t have enough money to improve their unhealthy food behavior, and they lack resources to sustain being in a safe place.”

Access to prenatal care is not the only solution to reducing racial disparities. “Increasing access is only one element,” Zare notes.

Maternal Health and Overall Health Status

Other elements include providing people with access to healthy food, better education, and safer communities. For instance, a pregnant woman might know she needs to eat fresh fruit and vegetables, healthy protein, and less processed food. But if she lives somewhere that is far from a grocery store, she might not be able to obtain the food that would benefit her health and pregnancy.

Even exercise can be difficult for women who live in areas where there are no safe sidewalks or parks for walking. “When we are trying to increase health access, we’re not looking at one element,” Zare explains. “We should go back and look at more structural differences of quality and policy that are inside of some populations.”

Maternal health and outcomes are closely tied to reproductive-age women’s overall health status in the United States, says Alison Gemmill, PhD, MPH, assistant professor in the department of population, family, and reproductive health at Johns Hopkins Bloomberg School of Public Health.

“We focus on maternal deaths a lot, but women are dying from other things, too. It’s important to know the full story,” Gemmill says. “I’ve been working on a project that looks at deaths due to suicide, homicide, and drug overdose among postpartum women, and it mirrors the trend among reproductive-age women.”

For instance, as the opioid crisis escalated, it affected postpartum outcomes and mirrored the trend of avoidable deaths among reproductive age women.³

Pregnancy is even a risk for homicide in some populations. “There need to be increased screening in pregnancy and postpartum for these types of stressors and determinants that women experience and that are sometimes escalated during pregnancy and postpartum,” Gemmill says.

Women’s health should be addressed holistically. It also should become a priority, particularly in states where health outcomes among reproductive-age women are the worst.

“One finding is that the gap in mortality rates between the best- and worst-performing states was about 2.5 — a pretty wide range,”³ Gemmill says. “Where you live matters for your risk of death in these reproductive ages. We found a strong correlation between dying from any cause of death in a state and dying from maternal causes.”

This finding suggests structural and social determinants of health, and not just health system factors, are influencing risks of maternal deaths, Gemmill says.

The state in which a woman resides also could increase or decrease her risk of death during pregnancy or postpartum. Maternal mortality data show high rates in nearly 20 states, primarily located in the South and Midwest, but also including some Northeastern and Northwestern states.²

All-cause death rates of reproductive-age women also are highest in the Southern region. “Alabama, Arkansas, Kentucky, Tennessee, West Virginia, Mississippi, and Louisiana were the southern states where mortality rates were the worst,” Gemmill notes. “There’s pretty rich literature that looks at death across the health span and finds these states matter for where you live. It kind of mirrors the patterns we see for infant death, premature death, and life expectancy.”

These statistics suggest health is driven by sociopolitical factors, including educational opportunities, safety, and policies that may affect health but do not directly pertain to it.

For example, recent research showed an association between the abortion policy environment and a heightened risk of maternal mortality.⁷

“There are studies coming out that look at a state’s policy environment and how that shapes people’s health. It does seem to matter,” Gemmill says.

The best-case scenario is for health systems and providers to address social determinants of health and employ case management tactics to help at-risk women of reproductive age to become healthier.

“You want people to be as healthy as can be when they get pregnant,” Gemmill says. “But their health is shaped across their lives. If they’ve been exposed to adverse things like racism or adverse childhood experiences, then that’s what’s causing poor health. Focus on those instead of their behaviors, and think about social structures that cause a poor diet.”

REFERENCES

1. The Commonwealth Fund. Health and health care for women of reproductive age: How the United States compares with other high-income countries. April 5, 2022.
2. Lister RL, Drake W, Scott BH, Graves C. Black maternal mortality — the elephant in the room. World J Gynecol Womens Health 2019;3:10.33552/wjgwh.2019.03.000555.
3. Gemmill A, Berger BO, Crane MA, Margerison CE. Mortality rates among U.S. women of reproductive age, 1999-2019. Am J Prev Med 2022;62:548-557.
4. Shvili J. 10 Countries Without Universal Healthcare. WorldAtlas. May 30, 2020.
5. Deck J. In US, Black mothers die in childbirth 3x as often as white mothers. Global Citizen. Oct. 25, 2018.
6. Assari S, Zare H. Beyond access, proximity to care, and healthcare use: Sustained racial disparities in perinatal outcomes due to marginalization-related diminished returns and racism. J Pediatr Nurs 2022;63:e161-e163.
7. Verma N, Shainker SA. Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate. Semin Perinatol 2020;44:151269.