US maternal mortality

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Pauline Chiou: Welcome to Global Health Insights, a podcast at the Institute for Health Metrics and Evaluation, or IHME. I’m Pauline Chiou in Media Relations. In this episode, we’re going to be discussing maternal mortality in the United States.

Researchers at IHME and Mass General Brigham conducted a study analyzing 20 years of maternal mortality data from 1999 to 2019, of five racial and ethnic groups in every single state.

What were the findings? Well, we’re going to dive deep into that. But the general findings are that there are still high rates of mothers dying during pregnancy, or within the year after giving birth. The numbers are the highest in the Black population. And we saw the largest increase in the Native American Indian and the Alaska Native population.

Now for this discussion we have authors of the study, Dr. Greg Roth, cardiologist and associate professor in cardiology, and director of the program in cardiovascular health metrics at IHME. And we also have Dr. Allison Bryant, an obstetrician and associate chief health equity officer at Mass General Brigham. And we have Professor Monica McLemore, who was not part of the research in this study, but on top of all the issues surrounding maternal mortality, she’s professor in the Department of Child, Family and Population Health Nursing at the University of Washington, and also a board member of Black Mamas Matter Alliance.

Thank you to all three of you for being part of this podcast, and this important discussion. Welcome.

First, I want to start with the policy impact the study has already had since its publication. Now, since it was published in the Journal of American Medicine Association, or JAMA, several US senators from New Jersey, Georgia, California, have reintroduced a bill to decrease bias and discrimination in maternal health.

They specifically cite the study that was recently published. So Dr. Bryant and Dr. Roth, I’d love to get your thoughts on this. And Dr. Bryant, let me start with you. When you saw that your study lit this spark, to reintroduce this bill, what were your thoughts?

Dr. Allison Bryant: Thanks, Pauline. I would say I think it’s a long time in coming, and I’m glad that this work is sort of energizing some of this work in the policy space, but it really is long overdue.

So I’m excited that folks are thinking about what’s been going on in the country and how really devastating these rates are and what each state can do in terms of legislative action to make change.

Pauline Chiou: And Dr. Roth, this must have been exciting news for you to hear. In general, what does each state need to do? What would you like to see next?

Dr. Greg Roth: Yeah. Thanks for the opportunity to talk about this. It’s important work because we think that creating this evidence base, creating the data to really show where we’ve been and where we’re headed is a key step in leading to change. You know, states are obviously realizing that they can’t ignore this and both at the federal level and at the state level, we expect to see legislation passed that reflects this really important health crisis that has clear implications for what we need to do with our health systems and our public health systems.

Pauline Chiou: And Professor McLemore, you’ve spoken about maternal mortality and you’ve written about it for years. You’ve pointed out most of the deaths are preventable. So talk to us about prenatal and postnatal care and what’s missing, and what these policymakers really need to act on.

Professor Monica McLemore: Well, let me first of all, thank you for having me, and remind everyone that the Black Maternal Caucus, which is led by Rep. Alma Adams and Rep. Lauren Underwood, who’s also a nurse, they’ve introduced the Momnibus three years in a row.

And in fact, it was introduced the Tuesday  before lockdown during COVID-19, and was reintroduced after the insurrection on January 6th. So we’ve actually had legislation that has been pending, so it’s very exciting to have evidence-based, you know, policy that is being reintroduced.

But I don’t want listeners to not think that people have not tried to bring some attention to these issues, including the work of Black Mamas Matter Alliance.

Let me also say in 2018, I published a piece in Scientific American about the preventable Black maternal deaths and that we really needed to do some very structural things to improve outcomes. First of all, we know maternal deaths mostly happen in the postpartum period, or once the pregnancy has resolved. And that is the time where we at least have our eyes on on pregnant-capable people and postpartum people.

So when the reproductive trajectory resets, is the time when we’re at least looking at individuals. And then second of all, I think that from a state by state perspective, especially post-ops, we are really starting to understand the loss or the lack of support for pregnant capable people, regardless of how pregnancies end, and that that is being a real patchwork of policies, procedures, and services that are available to pregnant-capable people.

So I think it’s spawning a broader conversation for us to try to start to synergize and coordinate our efforts.

Pauline Chiou: And to continue that conversation, Dr. Roth, you are a cardiologist, so help us understand the intersectionality between cardiovascular disease and maternal mortality and what Professor McLemore had mentioned, which is the postpartum period and what signs may be missed.

Dr. Greg Roth: Yeah, I mean, this is something really important for people to understand. When we look at maternal mortality in lower-resourced countries outside of the United States, a lot of attention has been paid to bleeding at the time of delivery or infections. And while those are problems in the United States as well, there’s a very large proportion of maternal deaths in the United States that are due essentially to what we think of as vascular diseases, blood clots and high blood pressure that can become dangerous and even life-threatening during pregnancy, and can have problems after pregnancy as well.

And so when we think of the risks that lead to the cardiovascular problems in older adults, blood clots in the heart, strokes, heart failure and those kinds of conditions, we see that a lot of the same risks are driving these terrible events among younger pregnant women, either during their pregnancy or postpartum.

And so there’s a real intersection between vascular or cardiac or heart health, and maternal health. And that’s something that we need to pay more attention to.

Pauline Chiou: Dr. Bryant, is that generally known, in terms of maternal care, throughout the US, or are there signs that are missed all the time?

Dr. Allison Bryant: I think it depends on who you talk with. I think for many of us who’ve been thinking about this problem for a long time, and yes, we have definitely recognized that there are signs and symptoms that we are not hearing our patients tell us. And so that may be different by who the patient is.

But there are probably educational gaps both on the patient and family side. We can do a better job in the health care system, about giving warning signs to individuals about what to call back for, but also on the side of health care providers, and also on the side of policymakers who need to cover health care for that period of time that is so vulnerable for many of our individuals.

Pauline Chiou: Let’s dive into the study. There’s so much to read. And, you know, when your study was published, our department got so many calls from state reporters just wanting to dive into the granular part of their state data.

So let’s talk about the regions and groups, and you compare the first decade to the second decade, when we look at 1999 to 2019.

Let’s just take the Black population to start. Louisiana, New Jersey, Georgia, Arkansas, Texas – those states individually, saw more than a 93% increase in maternal deaths, when you compared those two decades.

American Indian and Alaska Native population, Florida, Kansas, Illinois, Rhode Island, Wisconsin, saw more than 162% increase. So, Dr. Bryant, what is happening here, that things are not getting better?

Dr. Allison Bryant: I think what’s happening here is structural racism is happening here, and it has been happening here for all of this time.

And we have not systematically addressed that, whether within our health care system or our criminal justice system or our systems of education. So we are all on the hook for what we’ve been seeing.

And so I think that, you know, we spend a lot of time in health care thinking about social determinants of health as sort of a proximate cause of poor health outcomes, things like poor nutrition or education or transportation.

But I think we all have to recognize that those things are differentially applied by population, because of policies that have structural racism built in. And so, if we don’t fix those policies, we really can’t expect that we're going to see a difference.

And so I think that largely explains why we have this perpetuation of these inequities over time.

Pauline Chiou: And Prof. McLemore, what are your thoughts about why this is happening, and we did not see an improvement in the second decade of this study?

And I’d also like you to talk about just the simple act of listening.

Professor Monica McLemore: Well, I completely agree with Dr. Bryant, and I want to add two other pieces to this, right. I mean, we know that insurance access improves health outcomes.

And so, when we have employer-sponsored health insurance versus public insurance, versus if you’re lucky enough, the job that offers you benefits, I want to connect the dots around what we say is structural racism showing up in health care.

I also want to sort of bring forward this notion that if we are all in conflict, if the health care team is in conflict, there’s a workforce issue, right?

So, to Dr. Bryant’s point around not listening or not believing people, or not hearing their stories, or having people repeatedly come back for assessments, being sent home because they’re using either a different language or our staffing is oversubscribed, or whatever it is.

These are structural problems, right? So as much as I appreciate the focus on the cardiovascular events, because all of that is true, we also have to look at more upstream factors, right?

I mean, if you’re constantly in a state of weathering, where you’re always in fight or flight, because you’re wondering whether or not you’re going to be heard or listened to, or served or surveilled by the police, or whatever it is, then you’re not going to have superior outcomes during pregnancy and childbirth. That just is not possible.

So this idea that we’re not listening to pregnant-capable people, I would also argue in the same way that my good colleague, Kimberly Seals Allers always says, we have enough, we have a lot to learn from Black maternal lives, in as much as we do Black maternal deaths, right?

And so as we start to think about these data and policies, it’s one thing to be informed by deaths that are occurring, but like where are the innovations that are working?

We talk about midwifery care, doulas, and all this other support, but we also, I think, we focus a little bit too much on deaths, and not the lessons that we could be learning from Black, pregnant-capable people’s lives and listening to them about what they need, about how to engage and to really hear the language and the ideas that they have about improving this problem, I think is the only way we’re actually going to see any real change.

Pauline Chiou: So can you give us an example so we can pursue that line of thought of interventions that are working? You've got the ears of policymakers now, so help us understand.

Professor Monica McLemore: Yeah, I talk about this all the time. One real simple one Dr. Bryant has already suggested, why can’t we extend everybody’s insurance coverage, irrespective of who’s paying for it, in the postpartum period?

If we already know that 42% of the deaths are estimated in that time point? Why can’t we come up with community-based models to know what to be doing in that extra year of extended coverage.

As opposed to just addressing clinical issues, why can’t we address social ones? Why can’t we give people a basic minimum income so they have the money for the food and transportation and all the sort of negative social determinants of health?

There are different, what, three different regional pilot projects to provide people unrestricted money during pregnancy and childbirth, and we see, in those regions, improved outcomes. I mean, it’s not rocket science, right?

Pauline Chiou: Can we look at other countries that are doing it better? I mean, we are the only high-income country with this kind of maternal mortality rate.

Professor Monica McLemore: We can, but there’s another point to be made there, once we do that. The outcomes, you know, despite the fact that we didn’t see the same magnitude of increase in White populations, right?

The outcomes of White people in the United States still are not the best that we can get in the world. Right? So I always caution us to think about this notion that what are the other constellation of services that are in place in other countries, that complicate these data? Right?

Not to say that there is no structural racism in those countries, there is, but there are mitigating factors like having a robust social safety net, paid family leave, insurance coverage throughout, you know, from womb to tomb, that actually are associated with improved outcomes.

So to continue to compare ourselves to White populations in the United States actually isn’t even the best outcomes that we could get globally.

But we have to have the political will, and the courage to actually say we want to care for our citizens and actually do the things that we know that work in other countries, to improve pregnancy-related outcomes.

Pauline Chiou: Dr. Roth, one way to push for better outcomes through policy is really to have better data. And, in terms of data gathering, when you were doing the research, were there data gaps that were apparent, and what would you suggest in terms of getting better data state to state?

Dr. Greg Roth: Yeah, I mean, the first thing is it’s really important to try and get data at the level that decision-making happens. And so one of our goals in health metrics is really to try and align the information, the evidence base that we’re creating, with the decision-makers and what they need.

And so there’s been no lack of data on maternal mortality in the United States, it’s a well-studied area for a very long time.

So what did we do differently? Well, we actually produced estimates at the level of every single state in a way that was consistent and comparable, so that you could easily look from one state to another and know that those numbers were produced the same way, constructed the same way, and could be directly compared to each other.

The other thing is we produced a really long time series, so the state-level estimates that have been produced by the government have been for single years, or for short periods of time. We think it’s really important to understand this long history in data.

And then finally, we looked within states, and so we took that subgroup of race or ethnic populations within every state, and we did the same thing. So they could be compared across states, and also within states.

And I think that’s why we’ve seen so much of a response, both from the media and from government, is because we’re actually finally dialing in on the kind of information that really helps them understand, “Okay, we need to do something about this now.”

So that’s part of adapting our scientific efforts to really inform policy, and I think that’s a key step. We have to imagine how to change policy from the very beginning of the design of our research projects.

But I think there’s still gaps. We see maternal mortality review committees, which are just such an important part of how data is collected in many states, but we don’t see them in every single state. We don’t see consistent, similar reporting from all of those.

So some do a very, very good job, and others, there are gaps or there are resource limitations. And I’ll just point out that, politically, some of these committees have had their reports suppressed in some states.

And in fact, some of these committees have been disbanded or defunded in some states. So there’s an interaction with the political will to support high-quality disease surveillance, which is how we make this evidence happen, and what we actually see happening.

Pauline Chiou: Are you able to identify or help us understand or recognize where these committees, or some of these reports are suppressed or defunded? To anyone on the panel.

Dr. Allison Bryant: I think that there was example, earlier this year in Texas, in which, Texas is a state that has a sort of mandatory release of a report once a year. And there was a delay in the release of that report.

So, ultimately, the state did release the report, but there are concerns that the data were insufficient. But I think that there was some concern that that was indeed politically motivated.

And so, I think we need to move the politics out of this. But that was, I think, one example where we’re concerned that those data were starting to be suppressed.

Dr. Greg Roth: One of the reasons why we’re so glad that we’ve been able to publish in the Journal of the American Medical Association is because we’ve produced a really, sort of gold standard, completely transparent set of estimates.

We do that in the health metrics field all the time, where we follow a reporting guideline and we make all of the information and all of our methods completely available and available on the web.

And so we really want to raise the bar for evidence and we want to make sure that everybody understands that these numbers are accurate,  they’re reliable, they’re robust.

Pauline Chiou: And to your point, Dr. Roth, we make the datasets available to the media and to the public. And so if anyone asks, we can make it available.

Thank you for being part of this very important discussion. We see that it’s generated a ton of interest from policymakers to the media. So congratulations on an impactful study. And Dr. Roth, Dr. Allison Bryant, and Professor Monica McLemore, thank you so much for joining us on this podcast.