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For several weeks a year, nurse midwife Karen Sheffield-Abdullah’s job is really detective work. She and a team of other medical researchers from the North Carolina Department of Public Health review hospital records and coroner’s reports of new moms who have died after giving birth.
These maternal mortality review boards look for clues about what contributed to the deaths — prescriptions not filled, postnatal appointments missed, signs of problems missed by doctors — to find out how many of them could have been prevented and how.
Committees are working in nearly 40 US states, and in the latest and largest compilation of such data, released in September by the Centers for Disease Control and Prevention, a staggering 84% of related deaths with pregnancy were considered preventable.
Even more surprising to nurse-detectives like Sheffield-Abdullah, is that 53% of the deaths occurred long after the women left the hospital, between seven days and a year after giving birth.
“We’re so baby-focused,” she says. “Once the baby is here, it’s almost like the mother is discarded. Like a Reese’s peanut butter cup. The mother is the wrapper and the baby is the candy. Once you remove the wrapper, you just discard the And what I really need to think about is the fourth quarter, that time after the baby is born.”
Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic women more likely to die by suicide or drug overdose, while heart problems were the leading cause of death among women black. Both conditions occur disproportionately later in the postpartum period, according to the CDC report.
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The data highlights multiple weaknesses in the system of care for new mothers, from obstetricians who aren’t trained (or paid) to spot signs of mental health problems or addictions, to policies that strip women of health coverage soon after giving birth. to light
Problem number one, as Sheffield-Abdullah sees it, is that the typical six-week postnatal checkup is too late. In the North Carolina data, new moms who later died often missed this appointment, she says, usually because they had to go back to work or because they had other children to care for.
“We really need to stay connected while they’re in hospital,” Sheffield-Abdullah says, and then make sure patients are referred for appropriate follow-up care “within a week or two after delivery.”
Increased screening for postpartum depression and anxiety, beginning at the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation, as is better coordination of care between medical and social, says David Goodman, who leads the maternal mortality prevention team. at the CDC’s Division of Reproductive Health, which issued the report.
A common crisis point in the months after childbirth is when a parent’s substance use problem gets so bad that child protective services take the baby away, precipitating an accidental or intentional overdose by the mother. Having access to treatment and making sure children’s visits take place regularly could be key to preventing such deaths, says Goodman.
The most important policy change highlighted by the data, he says, has been the expansion of free health coverage through Medicaid. Until recently, pregnancy-related Medicaid coverage typically expired two months after delivery, forcing women to stop taking medications or see a therapist or doctor because they couldn’t afford the cost out of pocket.
Now, 36 states have extended or plan to extend Medicaid coverage to a full year after childbirth, in part in response to early work by maternal mortality review committees. For years, data showed that about a third of pregnancy-related deaths occurred within a year of giving birth, but in this report that jumped to more than half, Goodman says, putting even more urgency on the importance of pregnancy. longer term coverage.
“If this isn’t a call to action, I don’t know what is,” says Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, a nonprofit organization focused on national policy. “We’ve known for some time that mental health issues are the most common complication of pregnancy and childbirth. We just haven’t had the will to do anything about it.”
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The latest CDC study from September looked at 1,018 deaths in 36 states, nearly double the 14 states that participated in the previous report. The CDC is providing even more funding for maternal mortality reviews, Goodman says, in hopes of bringing more comprehensive data from more states in the future.
Advocates and clinicians have been heartened by increased awareness and attention to maternal mortality, especially efforts to correct racial disparities: Black women are three times more likely to die from pregnancy-related complications compared to white women. white.
But many of these same advocates for better maternity care say they are appalled by the recent US Supreme Court decision that uproots the federal right to abortion; restrictions around reproductive health care, they say, will erode gains.
With states like Texas beginning to ban pre-pregnancy abortions and making fewer exceptions for cases where a pregnant woman’s health is in danger, some women find it more difficult to get emergency care for a miscarriage. States are also banning abortions, including in cases of rape or incest, on young girls, who face a much higher risk of complications or death from carrying a pregnancy to term.
“More and more women and others who give birth are getting messages that ‘you don’t own your body,'” says Jameta Nicole Barlow, an assistant professor of health writing, policy and management at George Washington University. “Whether it’s through the policy, whether it’s through your doctor who has to abide by the policy, whether it’s through your day-to-day work experience, there’s this recognition that ‘I don’t own my body.’ “
This will only exacerbate the mental health issues women experience around pregnancy, says Barlow, especially black women who are also dealing with the long intergenerational history of slavery and forced pregnancy. She suspects that the maternal mortality figures will get worse before they get better, because of how politics and psychology intertwine.
“Until we address what’s going on politically,” he says, “we’re not going to help what’s going on psychologically.”