Pregnancy-related death in the United States

[00:00:27]

RICK WEISS: Hello, everyone. Welcome to SciLine’s media briefing on maternal mortality in the United States. I am SciLine’s director, Rick Weiss. For those of you who are not familiar with SciLine, we are a philanthropically funded, editorially independent, free service for journalists and scientists. We’re based at the nonprofit American Association for the Advancement of Science. Our mission is simply to make it easier for reporters like yourselves to include research-backed, validated scientific information in your news stories. And that means, not only news stories that are about science per se but any kind of a story that can benefit from having a scientist source or some scientific information in that story, which in our biased opinion is just about any story you can think of. It’s hard to imagine a news story that couldn’t be better with some scientific evidence to back it up. Among other things, we offer a free matching service through which you can get in touch with us, we will find you an expert source with expertise in the topic you’re writing about and who’s also been vetted for their communication skills, and get you connected to them for your story on deadline or as needed. We also have a variety of other free services for you that you can all check out at www.sciline.org.

A couple of quick logistical details before we get started today. We’re going to have three panelists making short presentations of five or six minutes each before we open it up for Q&A from the group. To enter a question, please just look down at the bottom of your Zoom screen to that Q&A icon and click on that, include your name, your news organization, and your question, and let us know if you have a particular one of the three experts for today that you want to direct that question to. A full video of this presentation is going to be available probably by the end of the day, certainly by first thing in the morning. A timestamped transcript will follow about a day later. But if you need the video sooner than that, we can get you a raw copy soon after today’s briefing. So, just, again, write to us in the Q&A box and let us know, and we’ll get that to you.

I’m not going to take the time to do full-blown introductions for all three of our guests. Their bios are on the website. But I will tell you that we will hear first from Maeve Wallace who is an assistant professor and associate director of the Mary Amelia Center for Women’s Health Equity Research at Tulane University’s School of Public Health and Tropical Medicine. She’s going to be speaking to us just basically to present an overall landscape of pregnancy-related death and illness in the United States. Next, we’re going to hear from Dr. Rose Molina, who’s an obstetrician-gynecologist and assistant professor at Harvard Medical School. She’s going to talk to us about the causes and risk factors of pregnancy-related death. And, third, we’ll hear from Ndidiamaka Amutah-Onukagha who is an associate professor within the Department of Public Health and Community Medicine, and the director of the Maternal Outcomes of Translational Health Equity Research Lab at Tufts University. And she’s going to talk about prevention and solution efforts that aim to address the issue we’re talking about today.

Okay. With those introductions, let’s get to it. And over to you, Dr. Wallace.

[00:03:52]

MAEVE WALLACE: Great. Thank you so much. It’s wonderful to be here with you today. I’m going to share my screen. Let me try that one more time. Great. So, yeah. I’m just going to jump right in with a quick overview of some key definitions and epidemiologic trends in what’s happening with related to pregnancy-related mortality in the U.S.

So, here we see, I’ve put three key definitions shown in concentric rings, meaning that these are groups of maternal death that are sort of—definitions of maternal death that encompass one another. So, starting with the most narrowly defined group, this is maternal mortality down in the bottom circle. Maternal mortality is defined as the death of a woman while pregnant or within 42 days from the end of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. So, these are things like hemorrhage and hypertension, obstetric causes of death that are happening while the person is pregnant or within 42 days afterward. A broader group than that is what we call pregnancy-related mortality. And these are the same causes of death and the same timeframe in terms of within pregnancy, but it extends the end of that timeframe out to one year from the end of pregnancy. So, still obstetric causes of death, things like hemorrhage, hypertension, etc., but looking at from pregnancy out to one year from the end of pregnancy. So, that’s the difference between pregnancy-related and maternal mortality. And then the most broadly defined group of maternal deaths include both—include all cases of maternal mortality, all cases of pregnancy-related mortality, in addition to any other cause of death.

So, pregnancy-associated mortality is the death of a person while they are pregnant or within one year from the end of their pregnancy from any cause of death. So, this would include hypertension, preeclampsia, hemorrhage, all of the maternal mortality causes as well as things like suicide, homicide, drug overdose, car accidents, etc., any cause of death will be pregnancy-associated mortality. These are official CDC or WHO definitions. And so, I think even for people in this field, these kind of nuances can get a little bit confusing. And so, if you’re ever talking to someone who’s doing research, just ask them to clarify specifically what are they talking about in terms of if they’re talking about a mortality rate.

I wanted to just quickly too share the definition from the CDC of severe maternal morbidity. And so, these are unexpected outcomes of labor delivery that result in significant short- or long-term consequences to a woman’s health. So, a lot of debate currently in the research arena about what specifically to include.

Right now, the CDC has settled on this list of 21 indicators. So these are things like acute renal failure, cardiac arrest, eclampsia, heart failure, sepsis, shock, etc. There’s 21 conditions here that would be an indication of severe maternal morbidity. So, you may have heard that we’re not doing so well in the United States when it comes to pregnancy-related mortality and maternal mortality. This graph shows our progress or lack thereof, I guess, since the 1980s. We have year on the bottom axis, we have pregnancy-related mortality ratios on the y-axis. So, you can see our rate of death, which is deaths per 100,000 live births, really going up over time.

This data, it looks like it stops around 2018, but I’m sorry to report that the trend continues, we continue to see increases in maternal mortality and pregnancy-related mortality. We have the highest rate of these outcomes among high-income countries in the world. And we unfortunately are one of the only countries that are seeing an increase while others countries are continuing to see decreases in their maternal mortality rates. With respect to who is really most impacted here, this is a really racialized issue. So, we consistently see year after year the highest burden of death and loss experienced by Black women and Native American, Alaska Native women in this country. So, those are the light purple and the dark purple bars shown in this graph which is looking at pregnancy-related mortality ratios over time. Consistently, we can see there very little change in the bars that they’re the highest year to year. This graph shows that same relationship but we’re looking also at age here. So, just showing that for all women. You can see age groups here listed at the bottom and as we go from, you know, the lowest risk group down in your 20s. At more advanced maternal ages, we see increases in the risk of pregnancy-related death for those women in more advanced ages, and especially so for Black and American Indian, Alaska Native women.

[00:08:50]

RICK WEISS: Maeve, I think—there you go, now the age slide shows.

[00:08:54]

MAEVE WALLACE: There’s that slide again that has the age groups at the bottom. You can see the really steep increase in line as we move into those upper ages. Here, again, this is showing the persistent and increasing inequities in maternal mortality. And this is the most recently published data by the CDC showing what happened in 2020. So, we see the blue line is 2018, the green is 2019, purple is 2020. I should note that CDC only started reporting national maternal mortality rates in 2018. The last time they’ve reported prior to that was 2007.

So, 2018 really marked a data quality milestone in which we were finally able to report—or they were finally able to report the national rate. And so, they will be doing so from every year hereafter. And so, we can see since they’ve started reporting, things have only—appear to be getting worse. Things are increasing. And again, it’s that non-Hispanic Black group there that’s always been the highest and continued to increase relative to other women. Here is even more recent data but it’s provisional data from 2021. So, you can see the figure on the left side is the number of deaths in 2021. You can see the last bar there on that. Right here is much higher than the previous years. Again, over on this bar, we’re seeing this same data, it’s just that rates this time. Again, the green is non-Hispanic Black women having a much higher rate and really, again, increasing in 2021. So, looking at more of 2021 what might have been happening, I think you’re all very well aware with the COVID-19 pandemic and the role that this played in maternal death appears to be significant. And, in fact, you can see there in the light purple bars, we have maternal deaths that are not related to COVID-19. So, perhaps not a big increase if COVID-19 had not happened over time from 2018 shown here up to 2021. But the dark purple showing the maternal deaths related to COVID-19 really explaining a lot of that increase that we see in 2021. And the increase exacerbating racial inequity. So, really a much larger increase among Black and Hispanic women relative to white women.

Here is just the data shown geographically. So, we have areas in the country where things are much worse and that’s the Southeast where I live and work. And then some states where rates are a lot lower. So, really, really large variation geographically. Just quickly too I wanted to share some sources of data and some—I’m an epidemiologist so I’m all about this data measurement piece. The primary source of data that we have on maternal death nationally is the National Vital Statistics System. And so, these are death certificates that states submit to CDC, CDC codes them to identify cases of maternal death. As I’ve mentioned previously, CDC just resumed the annual recording of 2018 so that was the first year that we had this.

You might have heard of something called the pregnancy checkbox. So, it’s an element, it’s an item on the death certificate that allows a person to check whether or not the decedent is pregnant or had been pregnant at some point before her death. And so, it wasn’t until 2018 that all states had this pregnancy checkbox and that’s why that was the first year going forward that we were able to report national data. There were some issues before 2019 about was the data quality making it appear like there had been an increase when in fact there wasn’t. But I think there’s definitely been research studies and the CDC themselves have shown that there’s been true increases. And so, these are not just the artifacts of better data collection, they are true increases in mortality.

Some links there if you’re more interested in going into depth on that. A couple of other sources are the Pregnancy Mortality Surveillance System. So, that is death certificates but they undergo an additional review at CDC by medical epidemiologists and other people that review medical records, autopsy reports, other data that might be available to confirm whether or not something is a case of maternal death.

And then finally there are state and local maternal mortality review committees that usually put out reports, data reports profiling what’s going on in their state. This is by far going to be the most complete and detailed data on maternal mortality because they review every piece of data that they have available from medical and non-medical sources, it might include law enforcement records, autopsy reports, media, everything they can find. I’ve included only our own one here in Louisiana. They have their annual reports up there on their page. And then this link to the Guttmacher Institute state policy website which has actually state-by-state information about what the state maternal mortality review committee looks like. If you’re curious about checking out your state. So, thank you. That’s all I have for today.

[00:13:54]

RICK WEISS: Fantastic. Great work laying out the sort of tragic landscape that we’re talking about today and the wonderful resources here. A reminder for reporters these slides will all be available after the briefing so you can look more closely at them and check out that final link which is a great ticket to check out your own state’s situation. And over to you, Dr. Molina.

[00:14:17]

ROSE MOLINA: Thank you. I’m just going to go ahead and pull up my slides. Right. Is everyone seeing this?

[00:14:27]

RICK WEISS: Perfect.

[00:14:28]

ROSE MOLINA: Excellent. Thank you. And thank you so much to Dr. Wallace for that presentation. I’ll be amplifying some of those really important points in this presentation as well. So, just to get us started, we have a national crisis in maternal health. The United States has the worst outcomes for pregnant individuals among high-income countries and continues to have vast inequities by racial and ethnic groups with Black individuals experiencing the worst outcomes regardless of educational level or income.

Over the past years, this crisis has gained national attention with underlying structural racism named as the root of these inequities. However, it has also been traumatizing for people with lived experiences who feel that enough is not being done soon enough to make a real difference. While the U.S. fares poorly among other high-income countries overall, the trajectory of deaths related to pregnancy had actually dropped over the past century due to advances in public health, in medicine, and in obstetrics. As you can see here, this graph shows deaths per 100,000 live births on the y-axis and the years from 1916 to 2018 on the x-axis. And as you can see, the overall trajectory has shown a dramatic decrease but we have noted in recent years, detected alarming signals of worsening outcomes for birthing people in the most recent decades as shown in the callout box from 1990 to 2016.

One of the challenges in tracking pregnancy-related deaths is consistent data capture and attribution of cause of death across all states. As was mentioned in the previous presentation, pregnancy-related deaths are any death during pregnancy or within one year after the end of pregnancy from a pregnancy complication or a chain of events that were initiated by pregnancy or aggravated because of pregnancy. These deaths are causally related to pregnancy or its management. There has also been progress, however, in recent years to better ascertain the cause of death and the relationship to pregnancy.

Most recently, there was a CDC report that was published just a few months ago that included findings from the state maternal mortality review committees that were mentioned previously. This report of 36 maternal mortality review committees looked at all of the data around causes of death and reported out on those. Just briefly, those maternal mortality review committees are multidisciplinary committees that convene at the state or local level and comprehensively review the deaths, have the most access to data to really ascertain the cause of death. And the CDC works with these maternal mortality review committees to improve the review processes and inform recommendations for preventing future deaths. So, according to this report that was published just a few months ago, the leading causes of pregnancy-related deaths from 2017 to 2019 are listed here with mental health conditions, such as suicide and substance use disorder, leading the top, followed by hemorrhage and heart conditions which include coronary artery disease, pulmonary hypertension, and valvular heart disease as the following leading causes.

It’s important to note though that when combining cardiomyopathy which is heart failure and pregnancy-related hypertension with other heart conditions, this group becomes the overall leading cause of death. Additionally, the cause of death varies by racial and ethnic group. Heart conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black birthing people. Mental health conditions were the leading underlying cause of death among Hispanic and non-Hispanic white birthing people. And hemorrhage was the leading underlying cause of death among non-Hispanic Asian birthing people.

We’ve also learned a lot about the timing of these deaths. While childbirth hospitalization is often the most scrutinized, the CDC report found that over half of pregnancy-related deaths occurred in the delayed post-partum period, which is between seven days after birth and one year after birth. There’s increasing attention to the importance of the postpartum period as the time of physical recovery, as well as social vulnerability and stress. However, our health systems are not designed to deliver comprehensive medical and social care during this time and new parents are often found in a gap between pregnancy care and primary care. In addition to the overall increasing rates of pregnancy-related death, as mentioned previously, there are persistent inequities by racial and ethnic groups that seem to be intractable.

Black and American Indian or Alaskan Native birthing individuals continue to suffer death rates two to three times the rates of white individuals. And this difference is magnified by educational attainment. Black individuals who have a college education or a higher have even worse outcomes than White individuals with less than high school education. It is also important to know that these racial and ethnic categories do not capture the totality of ways that social factors and identities yield inequitable outcomes. For example, language and immigration status may be additional lenses to understand inequities in maternal health. Other important risk factors for pregnancy-related death include increasing maternal age, particularly over the age of 40. And other health issues such as high blood pressure, diabetes, and obesity. On a policy level, it is important to note that maternal deaths also vary by state, with some states having twice as high rates as others. There is now growing recognition of racism as a public health emergency and underlying driver of inequitable outcomes. Along with other systems of oppression that preferentially treat some and marginalize others, racism shapes the social and political determinants of health that are directly linked to poor health.

While we are mostly discussing pregnancy-related death in this briefing, it is also important to highlight that severe maternal morbidity is also on the rise. Severe maternal morbidity includes unexpected outcomes that result in significant short- or long-term consequences for health. This can include heart or kidney failure. The increasing rates are mostly driven by increasing numbers of blood transfusions.

Lastly, I also wanted to mention that the experience of care is another important dimension to consider in addition to death and morbidity. We know that people of color experience more mistreatment and discrimination than their White counterparts in the maternity care system. These results come from the Giving Voice to Mothers Study which was the cross-sectional study of over 2000 birthing people from across the United States. They found that 1 in 6 women experienced mistreatment during childbirth with some most common examples being reported that they were shouted at or scolded by a healthcare provider. That healthcare providers ignore them, that they refused their requests for help, or fail to respond to their requests in a reasonable amount of time. So, with that summary, I look forward to hearing from our next speaker and engaging with you all in the discussion later. Thanks so much.

[00:21:55]

RICK WEISS: Thank you, Dr. Molina. Very interesting, and again, not great data to see. So, we’re interested to hear more about this and maybe some hints at solutions. Over to you, Dr. Amutah-Onukagha.

[00:22:18]

NDIDIAMAKA AMUTAH-ONUKAGHA: Okay. Good afternoon, everyone. A pleasure to be here with you all. Thanks for this tremendous opportunity. I’m going to chat about prevention and strategies and how can we really think about how to address pregnancy-related morbidity and frankly, how do we center the role of racism. So, as you’ve heard from my colleagues and my predecessors in this space, we are not trending in the right direction. And I think the conversation we’re going to have today has focused on how we got here and frankly, what are some of the things we can do to move forward. So, as you already heard, when we think about how we’re defining maternal health, maternal health and maternal morbidity are any conditions attributed to and/or aggravated by pregnancy and childbirth that has a negative outcome to the birther’s well-being.

When we’re thinking about maternal mortality, that is defined as the death of a woman during pregnancy, at delivery, or soon after delivery. And so, we can think about these two really important terms and the way that we frame the conversation around morbidity which is illness versus mortality, which is death. So, what I think is most jarring when I give talks like this and when I’m in spaces is that more than 80% of maternal deaths and pregnancy-related deaths were preventable. This data is recently released, in February of this year, from the 36 maternal mortality review committees that my colleagues have spoken about already, but of the nearly 1000 pregnancy-related deaths, more than 80% of them were deemed to be preventable.

So, you’re probably thinking, “How do we have such a high number of deaths that are actually preventable, and what can be done to address this crisis?” Well, before we can talk about solutions, we should think about really clearly what is contributing to maternal mortality and morbidity, what is driving it, what’s the background, and what are the things that are really exacerbating these rates. And frankly, disproportionally burdening people of color and communities of color. One thing that I want to focus on is access to care. So, when we’re thinking about where people access their care and the quality of care, we should be really clear to think about maternal care deserts, maternity care deserts, and these spaces are not opportune for people to get care. We know that a majority of people in rural parts of the country are not able to access care quickly, transportation can be a barrier. So, this exacerbates underlying disparities and inequities when you’re not able to access care or the quality of care varies by geographic location. Those of us that are here in the Greater Boston Area are afforded a tremendous opportunity in that we can go and get really quality care from a number of different places really close by. That may not be the case in other parts of the country, right? And so, this quality of care is different by geographic location. And the problems of chronic diseases, we’ve heard already today around hypertension, diabetes, obesity, high blood pressure, these things really exacerbate morbidity and increase the likelihood of mortality. Clinical support, how birthing people are treated when they enter into the health care system.

And structural racism, which I wanted to just define because I think it’s going to frame a lot of the conversation that we’ll have. But structural racism is a system, it’s an institution where public policies, practices, and cultural representations work to reinforce and perpetuate racial inequities. So, how does that play out in the healthcare system? Well, we know that throughout U.S. history, women of color have suffered tremendous reproductive injustices. I can lift up the work of Betsey, Lucy, and Anarcha, three Black enslaved women who were unfortunately not consented, not treated, mistreated, and have their bodies used for obstetric research by what we used to call the father of modern gynecology, J. Marion Sims.

So, when you’re thinking about this historical context around the birth and the bodies of Black birthing people, then it’s no surprise that structural racism is still showing up today because this is how the field of obstetrics and gynecology started through these procedures being done, this is how we know how to do a fistula repair today, this is how we know how to use a speculum today, this is how so many other cervical and gynecological procedures were perfected on the bodies of these black enslaved women. And so, these reproductive injustices are still playing out today. We know that Black women are three times more likely to die from pregnancy than any other racial or ethnic group.

I wanted to just hold space for a present-day example of structural racism and talk about the case of Serena Williams. I’m sure everyone here knows who she is. She’s a global superstar athlete. What you may not know is that she almost died immediately after having her daughter. The case of Serena Williams is such a clear example for me around structural racism because this is a woman that has tremendous resources, tremendous access but was still disregarded and mistreated by the healthcare system. So, not only did she have a really complicated pregnancy where she was bedridden for six weeks, she had four surgeries, including a C-section. Upon delivery, she had to advocate for herself to be able to get a CT scan because she was having problems breathing. So, she talked to the nurse and she told the nurse, “Listen, I think I need a CT scan. I’m having problems breathing.” This is something she had been treated for pre-pregnancy so it was already documented in her medical records that she had a history of pulmonary embolisms. So, the nurse told her to go lay down, that she was tired, and she was confused. And we know that this shows up in historical literature in the way that Black women’s bodies and Black women’s priorities and healthcare needs are dismissed and under-regarded. So, this was a situation that was really life and death for her. Had she not advocated in the way that she did, she would have died because she had indeed had a blood clot that was forming in her lungs. So, for me, that’s such a beautiful example unfortunately of what structural racism looks like. You cannot have enough income, enough resources, enough education to get your way out of a broken and racist healthcare system. And she says this quote being heard and appropriately treated was really the difference from life and death for her. Now, think about what a stain that would have been on the fabric of this country, for us as a country, and the world frankly to lose a superstar athlete like Serena Williams to preventable complications that were already documented because of the way structural racism showed up in her care.

So, what strategies can we think about to really focus on pregnancy-related mortality and morbidity, right? We know that disparities exist. I am a big proponent of partnering with community organizations at the local, state, and national level. We know that being able to improve access to doula care—I’ll talk about what doulas are in a minute—and the quality of care really improve pregnancy outcomes. I am a big proponent of also enhancing pregnancy-related data collection. My colleagues have talked about that. And also improving maternal community nutrition. And these are some of the things we know can kind of stimy the impact of pregnancy-related mortality and morbidity.

So, what is a doula? Well, doulas are individuals often from local communities. So, I work with a lot of community-based doulas here in the Greater Boston Area who are trained to provide psycho-social, emotional, and educational support to the birthing person. This can be during pregnancy, during the actual labor and delivery, and then in the postpartum period. I’ve also seen bereavement doulas, I’ve seen a tremendous body of work from the doula community around just how amazing the resources and the services they offer are. Now, we know doulas are critical in labor and delivery because they serve as advocates for the patient. They provide comfort, they provide coaching. Community-based doula programs build on the strong relationship that doulas already have with their clients and their birthing people that they work with. But the research also supports the impact of doulas in addressing maternal morbidity and mortality. We know that birthing people that have had doulas are more likely to breastfeed, are four times less likely of having low birthweight babies, and are twice less likely to experience a birthing complication. So, these are some resources that we think are really going to impact that.

I want to move quickly and talk about the work I’m doing here at Tufts University, at the School of Medicine in my newly-founded Center for Black Maternal Health and Reproductive Justice. I started the center in April and really I’m laying out for you quickly here our blueprint and what we think is going to really address maternal mortality in the Black community. How do we plan to combat that and what are some of the things we’re prioritizing? So, the mission of our center here is to foster academic and community-engaged, community-focused research in support of our goals which include conducting maternal health research, and we have a number of studies going on with the focus on Black maternal health and the elimination of these inequities. The center has 6 units, the MOTHER Lab which I’ll talk about in a second, research development and grants, our epidemiology and data unit, our policy unit, our education, and training unit, and a clear focus on community engagement. So, the MOTHER Lab, as was mentioned in my introduction is the largest research lab in the country. I started this lab in July 2020. I’m focused on training the next generation of maternal health scholar activists through research, advocacy, and mentorship.

As the Maternal Outcomes for Translational Health Equity Lab, we have 35 students, undergrads, Masters, Ph.D.s, M.D.s, researchers, social workers, public health professionals, and clinicians from all different backgrounds who are really thinking about how do we focus on the reduction of maternal health inequities as experienced by the Black working people. We have a number of large projects underway. I’ll talk quickly about some of the research that I’m funded to do from NIH. So, I currently have what we call in my world an R01, so it’s a five-year multimillion-dollar grant looking at racial disparities and SMM, severe maternal morbidity, here in Massachusetts. And through that lens, we are looking at the work of community-based doulas, we’re looking at the work of addressing maternal safety bundles with the ultimate goal of creating interventions that can address maternal morbidity and also center the role of doulas while trying to eliminate disparities as experienced in clinical spaces as well. Two other strategies I’ll lift up quickly. The work that’s been done in New York City through the Maternal and Infant Community Health Collaborative where they’re bringing together community-based projects to improve maternal and infant health.

And also, in my home state of New Jersey, which is number 47 as it pertains to maternal mortality, I’m helping think through some of the things that they’re doing on the ground there around how can we create birthing spaces of equity where the resources need to be driven, and how do we create access with the focus on doulas, and essential services across the state. I would be remiss if I didn’t lift up the work that we do that’s community-facing. So, every year, during Black maternal health week, I host a conference on a different theme or a different aspect of it. Next year’s conference is Friday, April 7th, and it’s centering the role of nurses and midwives in addressing maternal health inequities. We know that the nurses and midwives that are at the bedside are critical and they see things that the patient experiences, and they’re so central to our solution-driven approach that we are honoring them by, one, having a full day of free workshops, seminars, breakouts that will be led by nurses and nurse midwives. The conference will be hybrid so if you’re not on the ground here in Boston, you’re welcome to join us virtually. And that’s coming up next year. Here’s all my resources that I used today. Here’s my contact information. Please follow us on social media. And I’m happy to engage in any questions that you have. Thank you so much.

[00:34:21]

RICK WEISS: Thank you for really a thorough presentation there. It looks like a great meeting for some people to cover come spring. And I want to just double-check with you when you say New Jersey is 47th, I take it that means in a bad way or a good way? Forty-seventh.

[00:34:34]

NDIDIAMAKA AMUTAH-ONUKAGHA: Yeah, bad way.

[00:34:36]

RICK WEISS: Okay. All right. I want to remind reporters for Q&A to please go down to that Q&A icon at the bottom of the screen if you have questions, and let us know what you would like to get into. And I will start with a few that we have so far. First question from Meg Evans, a freelance reporter in Illinois. “What explains the lowest mortality rate that happened back in the late 1980s?” Can anyone reach back that far and know what was going on then or why things changed after that?

[00:35:10]

MAEVE WALLACE: I think that was a question that came from the figure that I showed which started in ’87. But the figure that Dr. Molina showed in her presentation went back I think to, what, the ’20s perhaps. And so, actually what you see is that it’s very high back in the earlier part of that century before medical advancements, aseptic practices, things that—just improvements in medical care since the time of World War I and II. And so, we see the huge decline and it’s very, very low in the ’80s. And so, it’s perhaps just looking low and then you get up in the 2000s where we are now and we see minor increases. Of course, it’s still well below what it was back in the ’50s. But, yeah, so I think it was just the nature of the—we see the increase start perhaps back in the 1990s and ’00s.

[00:35:59]

RICK WEISS: Not necessarily something to be proud of that we’re way below the way things were before medicine really knew what it was doing.

[00:36:05]

MAEVE WALLACE: The fact that it’s increasing at all is something to worry.

[00:36:08]

RICK WEISS: Right. Okay. A question here from Rosemary Westwood, WWNO Public Radio in New Orleans. “In the wake of Louisiana’s near total abortion ban, I’ve been hearing stories of miscarriage care that was not handled well. How dangerous can miscarriage be and what is the equity landscape for miscarriage?”

[00:36:35]

ROSE MOLINA: I’m happy to partially answer that. So, I do not have the most recent data post-Dobbs decision in terms of the landscape in specific states in terms of miscarriage care that this reporter was asking about directly. But I will say that miscarriage is a still stigmatized condition of pregnancy that is far more common than any of the things that we talked about today so far. And so, I think I’m shedding a light on miscarriage. Up to a third of women in their lifetime experience a miscarriage. I think is a really important area for, not just research but for bringing this to light in terms of the media. But I don’t have the most recent statistics post-Dobbs decision around the safety of miscarriage management. I will say that it is a very common—it occurs very commonly and certainly if there’s no access to quality obstetric or gynecologic care, certainly there are safety concerns but I can’t comment past the most recent policy landscape after the Dobbs decision.

[00:37:42]

RICK WEISS: Ndidiamaka, it does drive me to wonder whether doulas or midwives have a role to play there. We didn’t really talk about that direct connection but I presume that might be one of the benefits of having those kinds of close caretakers at hand.

[00:37:56]

NDIDIAMAKA AMUTAH-ONUKAGHA: Absolutely. Doulas and midwives I think are critical to any parts of this conversation where we’re looking to either, one, stymie some of the increases that we’re seeing that shouldn’t be happening or, two, provide better resources and service that can do it for birthing people.

[00:38:14]

RICK WEISS: Another question here, “What is the role of pre-existing conditions in maternal mortality and morbidity? Are any researchers or agencies like CDC collecting data on this?”

[00:38:28]

ROSE MOLINA: I would say absolutely. These are important other health conditions that absolutely have impacts on pregnancy-related outcomes. So, hypertension or high blood pressure, diabetes, obesity are important sort of what are called pre-existing conditions. But other health conditions that can magnify the impact of pregnancy and the outcomes that people experience. So, yes, there is—CDC is tracking that and there are many research articles that have looked at the impact of how those conditions can increase the rate of complications or a bad outcome such as even up to death.

[00:39:12]

RICK WEISS: Is there a way to know what the contribution of pre-existing conditions is to the racial disparity that we’ve been talking about today? Is that a factor there versus say the access to care and some of the other issues that were brought up? And if you have any information on that?

[00:39:31]

MAEVE WALLACE: Yeah, I did want to say when I was listening to that question that, while they’re important, we know that they don’t explain entirely the racial inequities, that we still see racial inequity if you were just to analyze data from women who were coming in or people that were coming into pregnancy without any pre-existing conditions, we still see racial inequity there. So, they don’t explain it but certainly, they contribute to it. And we know that a lot of the root causes of maternal morbidity and mortality are the same root causes that we see inequities in preconception or just general women’s health across the life course. And so, of course, you’ve got a condition and then you become pregnant, you’re at increased risk of—it’s sort of doubling. But long story short, it does not explain the racial inequity entirely.

[00:40:21]

RICK WEISS: Question here from Lauren Bavis, from WFYI Public Radio in Indianapolis. “I’m reporting on doulas. So, thank you for including the work of doulas in this presentation. Are doulas getting to the people who need them most? What is keeping doula care from expanding? Ndidiamaka?

[00:40:40]

NDIDIAMAKA AMUTAH-ONUKAGHA: Yeah. Thank you for that question, Lauren. So, yes, doulas are getting to some of the people that need them most. But I would also say that what’s keeping doulas from expanding is a really political quagmire. I mean, doulas are not being reimbursed at the rates that they need to be to be able to provide the extent of the care that they need to, and to be able to have livable wages for themselves and their families. So, that’s a deterrent to people going into this line of work is when am I going to get paid, what’s the reimbursement level, how long is it going to take for me to get reimbursed? So, I think that system’s issue is really keeping doulas out of the workforce in some places. Now, here in Massachusetts, we right now have an open request for information where MassHealth, our public state insurance, is kind of grappling with this and looking for communities and people to provide input, and that’s great. And I think we’ll have a positive outcome here but we’re not seeing that kind of blanket response across the country. So, I think that’s one thing that’s keeping doulas out of the care. The other thing is doulas are, for now, and until we get a handle on the way that doulas are reimbursed and the way that doulas are paid, doulas are a little bit of a luxury for people that have the resources. I have two children. I had a doula with both of mine. I paid out of pocket for both of mine. They were worth every dollar. I would do it with every future pregnancy. But that’s a privilege that people that have resources can afford. Unless you are talking about a hospital-based doula that’s paid as part of that system, doulas are a little bit out of the way for most birthing people. And so, yes, they are getting to some people that need them. Are they getting to the most high-risk people? Are they getting to the most vulnerable birthing people? Are they getting to the most marginalized people? Maybe. But I think we still have a lot of work to do. And frankly, doulas are just now starting to get their just due as for the work that they do in this space. So, it’s a both/and, we need to get them reimbursed and we need to make sure that cost is not prohibitive for most people.

[00:42:42]

RICK WEISS: So, if I can interject a memory from 20-plus years ago when I became a dad. One of the issues that I recall for doulas and midwives is that they were limited in what they could do without the oversight of a doctor. And I wonder if that’s still an issue or has that been worked out?

[00:42:56]

NDIDIAMAKA AMUTAH-ONUKAGHA: Yeah, Rick, that’s a really great issue. And I think this is—and Dr. Molina is an OB-GYN and so she can attest of this as well. I think, you know, some clinicians, not all, because I do work with some amazing clinicians, some clinicians see doulas as kind of in the way, right, like they’re, you’re stepping on my toes, you are on my territory. And so, it’s a little bit of a dance because they are hindered by what they can do and how far they can go. They are not board-certified, they’re not going through that process clinically in the same way that a nurse midwife would or OB-GYN would. So, that is part of the conversation as well.

[00:43:34]

RICK WEISS: Rose, from your perspective, is there anything you want to add to that?

[00:43:39]

ROSE MOLINA: I would just say that I think doulas are critically important members of the team. And I think that some of our experiences around developing relationships with community-based doulas and figuring out what are the best ways to integrate them into the healthcare team as a team member, just like the rest of the healthcare team. I work in an academic medical center and the team is big, we have anesthesiologists, we have pediatricians, we have obstetricians, we have nurses, we have social workers, we have a big team to take care of people during this moment of birth. And I think we need to do a lot more to build in best practices for how do we integrate doulas, particularly community-based doulas who really come from the community and really support people from those marginalized backgrounds who would really stand to benefit in many ways the most, how do we include them in the team, how do we create teaming practices that are inclusive of doulas? I think those are really important sort of next steps. I agree with everything that was said around some of the challenges. There’s a lot of policy-related challenges for payment, but I think this particular issue around teaming with doulas is a critical one. The other piece I would add is thinking about the dimension of language and how culturally concordant doulas can really have a really special place and have particular power in reaching people from different cultural backgrounds, not just different racial backgrounds. And so, that means crossing language barriers, crossing cultural barriers which can be a huge asset to the healthcare team in terms of meeting patients where they are during this critical moment of their lives.

[00:45:24]

RICK WEISS: Yeah, it’s very interesting. Great. All right. A question here from Megan Rose from ProPublica. “Are there efforts to collect more specific data related to abortion restrictions? How soon do you think trends regarding changes in abortion law will show up in the morbidity and mortality data?” Maeve, you were our initial data maven here, if I may, any sense from you about what it’s going to take before we start seeing any evidence of an impact here?

[00:45:53]

MAEVE WALLACE: Yeah, I mean, I don’t think that it will take long. I think it will be—there’s a data lag so CDC hasn’t put out the 2021 data yet officially but we’ll get that soon. And 2022. I think we’ll be able to see it in 2022 data in 2023. And, yeah, related to another question, I think because those abortion restrictions impacted places that were already having bad and worsening trends in inequities, it’s just going to exacerbate those. And so, that will become very apparent pretty quickly I think.

[00:46:32]

RICK WEISS: Anyone else want to address the abortion issue here?

[00:46:35]

ROSE MOLINA: Sure. I would add that there are modeling studies that have been done and recently published that we can get to you afterward that show the impact on maternal death in states that are outlawing access to abortion. And so, I think that it’s critical to know because around half of pregnancies are unplanned, which is a huge number. And so, the impact of these laws is far-reaching. And there are lots of researchers looking into this from a policy perspective, and there are modeling studies out already. Again, modeling studies without sort of the outcomes yet. But, of course, we don’t want to wait for those outcomes to happen if we can make any possible change in the meantime.

[00:47:21]

RICK WEISS: Ndidiamaka, I’m curious short of actual policy changes regarding abortion, are there solutions or approaches one could imagine that might help reduce this added risk we’re talking about if these laws are to remain in place?

[00:47:39]

NDIDIAMAKA AMUTAH-ONUKAGHA: Rick, that’s tall-ordered. I just—the short answer is I’m not sure. I do know that there is a higher demand for obstetric services, right, at the time the United States is already facing a shortage of OBs. And I think this ending of Roe will lead to more births, right, almost 160,000 more births each year which will also lead to additional miscarriages, additional premature birth, additional pregnancy complications. So, it’s hard to say while we’re still under the system that we are right now if there’s going to be anything positive. I don’t see anything positive coming out of that. So, thanks.

[00:48:24]

RICK WEISS: Okay. The question here from Ruth Nasrullah, a freelance reporter based in Houston. “Are data available on pregnancy, mortality, morbidity in young women with disabilities whether due to physical, psychosocial, logistical access, or other issues?”

[00:48:41]

NDIDIAMAKA AMUTAH-ONUKAGHA: I can start this question because we’re doing some of this work now. So, Ruth, I am part of a research team that’s led by Dr. Monika Mitra out of Brandeis University here in the Greater Boston Area. And she is with the Lurie Center for Disability. So, as one of her co-investigators on the study, we are actually looking at the impact of disability in mostly young women of color but also other young women. That study is in its first year. We just got funded to do this. But I’m happy to connect you offline with Dr. Mitra because this is her body of work. But the short answer is yes, there are studies being done looking at that intersection of disability and pregnancy.

[00:49:19]

RICK WEISS: Okay. A lot of questions coming in. Now, we’re going to try to blitz through a few here. Jess Mador from WABE News, Atlanta. “In one of the slides, mental health is listed among the biggest drivers of maternal mortality and morbidity, could you please talk more about this and give some examples of how mental health problems lead to death?”

[00:49:39]

ROSE MOLINA: That was my slide. I’m happy to take that. Yes, mental health is increasingly being recognized as a critical cause of death. And some of the things that I mentioned around substance use disorders so around the increasing rates of substance use disorder, as well as suicide. And that’s why I also emphasized the timing of the deaths. When we look at the deaths across one year after birth, over half of them are in the delayed postpartum period between seven days after birth and one year. So, again, it’s that time of social vulnerability, transitioning to new—the stresses of new parent—Transition back to work or finding a job after not previously having a job can all contribute to mental health stressors. But I’ll also add, the mental health workforce is quite strapped right now, the workforce capacity to meet the need is a huge area of concern. And so, I think that access to mental health providers that people trust, that look like them, that come from their community is really challenging. And having people come forward with mental health issues is also still quite stigmatized in many communities. And so, mental health is a really important driver of, not just morbidity but also mortality around pregnancy. I do want to emphasize that as I mentioned in my slides, when you put together all of the cardiovascular-related conditions, it’s the number one cause of death if you lump them all together. But if you split them apart, then, of course, mental health is a leading cause of death and it certainly merits a lot of attention, particularly in the postpartum period.

[00:51:32]

RICK WEISS: Okay. Question from Phoebe Taylor-Vuolo from WSKG Public Radio in Upstate New York. “Can any of you speak to rural access to maternal health care or any inequities that you see as far as rural maternal deaths?” I’m also wondering whether some of that geographic map that showed so many such a high rate of trouble down in the Southeast has to do with the ruralness of those areas or some other factor.

[00:51:59]

NDIDIAMAKA AMUTAH-ONUKAGHA: Yeah, I’m happy to start this off. Maternity care being delivered in rural spaces is pretty problematic, to say the least. There’s a nice, really well-done piece that came out in August. I was featured in two of the four articles that was written by Nada Hassanein from USA Today. So, just google USA Today, rural health, it’s a really beautiful piece. It’s a four-part series. But it’s talking about how the delivery of care in rural parts of the country is getting increasingly more difficult. So, we know that a third of maternity care deserts are in rural areas, we know that maternity care deserts are growing. And they’re not just in rural areas, they’re also in what is considered urban communities. My hometown, Trenton, New Jersey, is a maternal care desert. We have no obstetric unit in the capital city of the state. Now, that is a result, in my opinion, of structural racism because the places that I was born, my siblings were born are no longer offering those services. You have to travel outside to the city. Some people don’t have cars. I’ve done research in my hometown, talking to friends of mine, talking to people that we grew up with, and thinking about how their pregnancies played out. And you’re talking about a low-income community that has really high complications. And I’ve heard stories from people that I know who almost died from placental abruption, having to travel almost 45 minutes to access services. That’s in an urban environment. We’re seeing those things exacerbated even more.

[00:53:35]

RICK WEISS: We lost Ndidiamaka’s channel there briefly. But I will carry on meanwhile. We have the time for just a couple of more questions. Let’s see. There is an ask here from Emily Capetillo from KOA Radio Denver about a place we can see city- and state-level information on pregnancy-related deaths. I know there was a good marker preference earlier. Any other suggestions beyond that?

[00:54:05]

MAEVE WALLACE: Yeah. So, the Kaiser Family Foundation puts out state-level estimates of maternal mortality. So, you can go and look at. They’re state maternal mortality rates there. I think it’s maternal. Here’s where definitions matter. And the other issue there is as far as getting data of the city or more local levels, it’s really difficult because these are relatively rare counts of death that we’re talking about. And so, estimating a stable rate becomes difficult when you’re talking about a small area, unless you’re looking at a city like Chicago or New York, big cities might be able to—might have a local maternal mortality review committee or provide local estimates of mortality rates. But I think the state is more likely to find. So, google Kaiser Family Foundation maternal mortality by state. And there’s probably a few other sources. CDC of course puts out annual reports which would have a table of state proof.

[00:55:01]

RICK WEISS: So, related to that, we have this question from Sofia Gratas from Georgia Public Broadcasting. “I would really like to know panelists’ thoughts on why maternal mortality committees may not have updated publicly available data. I live in Georgia and our MMRC only has data available through 2017. It seems that if they lead on policy recommendation, they should have better data.” Are these committees or groups not all up to speed on these issues?

[00:55:33]

MAEVE WALLACE: I mean, I think this is the nature of underfunded public health departments. The states across are doing the best they can, as fast as they can. I know here we are about—they put out the 2019—they’ve reviewed the 2019 deaths. So, we’re always a few years behind just in terms of closing out the data here, and then the review process can take a year because of having the depth of data collection as they go for every case, and then the review, getting everybody at the meeting. So, yes, it’s unfortunate that’s behind, especially with such a fast policy-moving climate that we’re in.

[00:56:07]

RICK WEISS: It sounds like this might be a little above average. I think it sounds like the perfect kind of thing to put a little journalistic pressure on and see what’s really going on. Let’s see. I think we have time for maybe one more question in here. And, Rose, this might be perfect for you. “Can you address the research from Harvard that found that pregnant and recently pregnant women are more likely to be murdered than to die from obstetric causes?” That was a Harvard study apparently.

[00:56:36]

ROSE MOLINA: Yes. It’s tricky because of the different terminology and definitions, which is why Dr. Wallace’s presentation was so important. So, pregnancy-associated deaths are different from pregnancy-related deaths. So, associated simply means that the deaths occurred during the time window of pregnancy so around from pregnancy through one year after death. And I believe that study looked at pregnancy-associated deaths and did find very concerning rates of homicide and suicide. But again, it’s the attribution issue that’s a little bit challenging because it’s hard to know whether that was because of the pregnancy or happen just to be temporally associated with pregnancy. I will say though that intimate partner violence—I understand this research or this reporter does work on gender-based violence. I think intimate partner violence was certainly a risk factor for homicide. And so, certainly, an area that needs additional support all the way from screening to connecting people to services who are in relationships that are abusive and violent. But, yes, that study did shed light on the importance of understanding violence as a critical driver of some of these deaths.

[00:57:56]

RICK WEISS: We are just about out of time. And I want to do a round-robin to get the last question for each of you to answer for our reporters. But I do want to remind reporters before you start to log off to please take the extra half a minute as you leave today to fill out the brief survey there which will help us keep producing media briefings that are of the most value to you. But the important and useful, very practical question to end this briefing with, I’d like to ask each of you to say something that either you think the media has been doing well or not so well in covering this issue and/or a take-home of some kind that you think would be of most practical use to reporters as they start to—or as they continue their work covering this particular topic. And so, if I can just go through each of you to address one or another parts of that mixed-bag question. Maeve Wallace, I’ll start with you.

[00:58:48]

MAEVE WALLACE: Sure. Well, I’m an epidemiologist and I deal with data and stats and numbers, and that’s what I publish. And so, I’m always appreciative of journalists that tell the story that you take the stats but then find the story, find someone with the story, or find the story and tell it so well. And I honestly think that the coverage of racial inequity especially in the media around this issue has really helped mobilize congressional action and state and local action as well. So, keep that up.

[00:59:15]

RICK WEISS: Great. Dr. Rose Molina.

[00:59:20]

ROSE MOLINA: I would similarly say that it’s wonderful to see that reporters are picking up on stories and reports and research studies about maternal health. And I think one of the key moments that galvanized the movement was the NPR ProPublica series on lost mothers in 2017. For me personally, that was a really important kind of sentinel series that really threw light on this issue and created a platform for urgent evaluations of maternal health in this country and potential solutions. I would end with just saying I think we need transformational change in our healthcare system to see the equitable outcomes that birthing people deserve. And from our presentations, this is everything from how we collect data and analyze data to acting on the data that we collect, and how we interact with each other in clinical settings but also thinking about the wrap-around social support services, inclusive of doulas that need to be in place for optimal health. It also includes things like housing and child care. I just urge us all, not only to focus on deaths which I know was the topic of this briefing but also to focus on enhancing the quality experience and trustworthiness and trust in the health system during this critical window of pregnancy.

[01:00:41]

RICK WEISS: Thank you. That’s a great reminder. And finally, Dr. Ndidiamaka Amutah-Onukagha.

[01:00:47]

NDIDIAMAKA AMUTAH-ONUKAGHA: Thank you, Rick. I think two things for me. I also echo the sentiment around the ProPublica series. That was really jarring and just so necessary, it’s such beautiful reporting and journalistic work there. And I think the other thing I would say is I really want us to look at the work, yes, we are in a crisis, yes Black and Brown-birthing people are disproportionately impacted, but I think the best thing that journalists can do is to get the context from the experts, which are Black and Brown birthing people themselves. Researchers like myself, researchers like who are here, Dr. Wallace, Dr. Molina, we are also really pivotal to the conversation. And I agree, Dr. Wallace, that this has absolutely shepherded some really important legislation, the Momnibus bill. I’m also hearing the Momnibus 2.0. I’m supporting some of the work that’s happening here in Massachusetts. We have some things that are moving through the state senate and the house of representatives. But talk to people that are closest to the problem, which is Black and Brown birthing people. How do we get their voices elevated, amplified, and into these spaces that can really make this type of transformational change that is needed? The healthcare system is inherently broken and racist. That’s the thing I want to leave us with. And if we are going to start to make these inroads, we need to do it from the people that are closest to it who frankly have experienced it. And even with all my degrees and background, when I was in labor with both of my kids, I experienced micro-aggressions, I was mistreated by the healthcare system. Your education, your accolades are not going to save you in those spaces as a Black or Brown-birthing person. The system needs to be radically transformed.

[01:02:27]

RICK WEISS: Some really strong final statements there and wonderful information throughout this hour. I want to thank our guests so much for a really informative and moving media briefing. I want to thank all the reporters who have tuned in today and for the work that you’re doing to convey this kind of information to the news-consuming public. For all of you, again, as you leave, reporters, please do check out the short survey at the end to help us keep these briefings useful to you. Please all of you follow us on Twitter @RealSciLine, check us out at www.sciline.org. And we’ll see you at our next SciLine media briefing. Thanks, everyone.