California May Have the Answer for Lowering U.S. Maternal Mortality Rates
Key takeaways:
The U.S. has the highest maternal mortality rate of all industrialized high-income nations.
Black women are disproportionately affected. They have an even higher rate of maternal mortality than other women.
California has lowered its maternal mortality rate by 50% through a collaborative initiative that other states can use as a guide.
As an industrialized, high-income country, we’d like to think that the U.S. excels in protecting women’s health during and after pregnancy.
Unfortunately, the opposite is true: The U.S. has the highest maternal mortality rate compared to other high-income nations. Certain ethnic and demographic groups, like Black women and women over age 40, suffer even greater maternal mortality when compared to white women.
The state of California has made great improvements in its maternal mortality rate. Below, we’ll explore the factors driving the current U.S. rates and how we can apply California’s efforts to improve U.S. maternal mortality.
What is the current maternal mortality rate in the U.S.?
The World Health Organization (WHO) defines maternal mortality as “the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.”
In the U.S., 861 women died of pregnancy-related causes in 2020. Death occurred at a rate of 24 women for every 100,000 live births. This rate increased from 20 deaths for every 100,000 live births in 2019. Keep in mind these statistics do not capture the deaths of undocumented pregnant women who may postpone prenatal care or give birth at home due to immigration enforcement policies.
Data from state maternal mortality review committees showed that 50% of all pregnancy-related deaths were caused by hemorrhage, cardiovascular conditions, or infection. Black women had a higher incidence of preeclampsia, eclampsia, and embolism while white women had a higher incidence of mental health conditions leading to death.
More than half of the pregnancy-related deaths in the U.S. occur during the postpartum period and include any death occurring up to a year after the end of pregnancy resulting from a complication. These are referred to as “late deaths” and tend to occur from causes like cardiomyopathy. U.S. women experience more late deaths than in other high-income countries.
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Increased maternal mortality in Black women
Black women are 3 times more likely to experience maternal mortality than non-Hispanic white women. The maternal mortality rate for non-Hispanic Black women in 2020 was 55 deaths for every 100,000 live births.
Women of color face discrimination in healthcare and have less access to prenatal care. Even among college-educated Black women, Black mothers are still more likely to die than white mothers who have less than a high school education.
Black women often experience:
Decreased incidence of exclusively breastfeeding
Pressure to have a Cesarean section
Lack of autonomous decision-making during labor and delivery
Unfair treatment or disrespect by healthcare providers based on their race
Maternal mortality by state
States report varying rates of maternal mortality.
Several Southern states report more than 30 deaths for every 100,000 live births. These states include:
Alabama
Arkansas
Kentucky
Oklahoma
However, other states report less than half of those figures. The maternal mortality rate is significantly lower in:
California
Illinois
Ohio
Pennsylvania
Unfortunately, data is lacking across many states because of gaps in the current reporting system. We currently don’t have a national system for reporting maternal mortality. Deaths are reported at the local and state level and must then be reported to federal officials to analyze.
How does the U.S. maternal mortality rate compare to other countries?
The U.S. has the highest maternal mortality rate compared to other high-income countries. In fact, the U.S. rate is 3 times higher than the country with the next highest rate.
The top 3 industrialized nations with the highest maternal mortality rates are:
U.S. — 24 deaths per 100,000 live births
France — 9 deaths per 100,000 live births
Canada — 9 deaths per 100,000 live births
To compare, the rate is 3 or fewer deaths per 100,000 live births in countries like the Netherlands, Norway, and New Zealand.
What drives high maternal mortality rates in the U.S.?
Several factors impact the high maternal mortality rates in the U.S.
Poor access to home visits in the postpartum period: The WHO recommends at least four visits during the first 6 weeks after giving birth. But most U.S. women have a single office-based visit or none during this period. If home visits are not possible, phone, text, or app-based visits are options.
Lack of midwives, obstetricians, and gynecologists (OB/GYNs): The U.S. and Canada have the least amount of midwives and OB/GYNs among high-income nations. They have around 12 to 14 providers for every 1,000 live births, which is about 2 to 6 times less than other countries.
Lack of paid maternity leave: The U.S. is the only high-income nation that does not guarantee at least 14 weeks of paid leave. Several countries provide more than a year of maternity leave.
Why is maternal mortality decreasing in California?
In 2006, California developed the Maternal Quality Care Collaborative (CMQCC) in response to rising maternal mortality and morbidity rates. The collaborative is a multistakeholder initiative to end preventable morbidity, mortality, and racial disparity in California’s maternity care. Through the efforts of the CMQCC, California has decreased its maternal mortality rate by more than half.
The CMQCC illustrates that change requires the combined efforts of many organizations. Collaboration from organizations such as the California Department of Public Health, CMQCC, clinicians, hospitals, and professional societies has improved outcomes for California women.
The CMQCC conducted a thorough analysis of maternal deaths, including demographic data, contributing factors, and opportunities for improvement. Linking causes with potential interventions helped them design a set of toolkits that are now used to address the most common causes of maternal mortality.
What interventions can other states borrow from California to prevent maternal mortality?
The CMQCC identifies four key steps critical to improving maternity outcomes.
Encourage collaboration and communication among all stakeholders
One organization can’t do it alone. That’s why CMQCC is a hub for the stakeholders to generate ideas and leverage resources. The widespread collaboration allows a centralized infrastructure, common agenda, shared metrics, and continuous communication across multiple organizations.
Regular communication is required to share data and generate engagement. Professional societies like the American College of Obstetricians and Gynecologists (ACOG), the California Nurse-Midwives Association, and the California Academy of Family Physicians shared the CMQCC review findings and quality improvement toolkits in their membership letters and at annual meetings.
Speakers from ACOG and the Association of Women’s Health, Obstetric and Neonatal Nurses engaged hospital and nursing staff through presentations, and the California Hospital Association communicated to hospital administrators through newsletters and conferences.
Communication like this is critical when addressing issues that cross many boundaries, like public health and clinical medicine, in both inpatient and outpatient locations.
Collect data properly
Continuous data for benchmarking is essential. However, the system must be easy and not cumbersome for users.
Key attributes of an ideal system include rapid cycle data processing, low burden and cost, flexibility, rapid turnaround, ability to benchmark, and an engaging user interface.
Implement projects that focus on public health and clinical intervention
Initially, California focused on hemorrhage and preeclampsia as the highest priority targets responsible for most maternal mortality. The engagement of collaborative partners allowed large numbers of hospitals and clinicians to participate. The CMQCC developed quality improvement toolkits to guide clinicians and address the top issues. Rapid-cycle data collection through a low-burden system ensured that improvements could be measured and reported.
As the initiative has progressed, other toolkits have been developed to include venous thromboembolism, Cesarean section reduction, and heart disease.
Use public health surveillance data to design actions
When the state identified rising maternal mortality, it used the Title V Maternal and Child Health Services grant to begin the California Pregnancy-Associated Mortality Review project, allowing for data collection and in-depth case reviews. A multidisciplinary committee of perinatal and public health experts analyzed the data and designed specific quality improvement initiatives to address the problems.
Regional coordinators to visit hospitals, educate, and assist were funded through the Title V Regional Perinatal Programs of California.
Are there federal efforts to decrease maternal mortality?
The Department of Health and Human Services (HHS) has issued a proposed rule on Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination based on color, race, national origin, sex, age or disability. The proposed rule would expand the definitinon of sex to include intersex traits, sexual orientation, gender identity, and pregnancy or pregnancy-related conditions.
HHS recognizes the disproportionate impact of heart disease and hypertension that are causing maternal mortality of Black women. Through implementation of this rule, elimination of racial and ethnic bias around pregnancy could help significantly improve maternal mortality for women of color.
The rule would also protect LGBTQI+ individuals, ensuring care for transgender pregnancies.
The bottom line
Maternal mortality in the U.S. is the highest of all high-income nations, and Black women are disproportionately affected. California has made great strides in decreasing maternal mortality, and we can look to their initiatives to guide efforts across the U.S. to improve health outcomes of pregnant women and those in the postpartum period.
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