Tough Questions

Winter 2018

Why are new mothers dying at an alarming rate in this country?

In 2016, journalist Adriana Gallardo and her colleagues at ProPublica and NPR were tasked with reporting on a worrying trend: Between 2000 and 2015, the number of maternal deaths and near-deaths in the United States rose by 25 percent. And African American mothers are four times more likely to die or nearly die as a result of pregnancy than white mothers. 
But who, they wondered, are these women? And why haven’t we heard about them? 
One reason, they later found, has to do with data collection. It turns out there is no standard means of reporting pregnancy-related deaths. Approaches vary from state to state, leaving researchers and the public alike ignorant of national or even regional trends in the data that could point to a solution. And despite attempts by states to better identify pregnancy-related deaths, for a number of reasons, the data collection is frequently prone to error.
Although the data pose more questions than answers, it’s clear that the United States has far more maternal deaths and near-deaths than any other country in the developed world. In every other developed country, these numbers continue to drop. In the United States, an estimated 700 to 900 women die of complications related to childbirth each year, and at least 60,000 women nearly die of pregnancy-related complications. Probably 70 percent of these deaths and near-deaths are preventable. 
While the data offered little in terms of reasons for this rise, it was the lack of discourse about these mothers that Gallardo found unsettling. The journalist team scoured the Internet and asked for families to reach out with their stories. More than 4,700 people responded. From their research, the team created the awarding-winning Lost Mothers series, for which Gallardo and her colleagues dissected the data and engaged with communities around the country to illuminate the names, faces, and stories behind the trends.
Momentum is building here to find answers. Gallardo visited the University of Pittsburgh’s Oakland campus in May for a maternal mortality forum hosted in part by the nonprofit Healthy Start. Likewise, the Magee-Womens Research Institute and the Jewish Healthcare Foundation (JHF) of Pittsburgh held related symposia in October. JHF just announced it’s partnering with Magee and RAND to develop a center to combat cardiovascular disease in pregnancy, a leading cause of maternal death. And the Commonwealth has established a Maternal Mortality Review Committee. 
We sat down with the CEO of Healthy Start, which is charged with improving maternal and child health in Allegheny County, and three Pitt professors who’ve been appointed to Pennsylvania’s Maternal Mortality Review Committee. We wanted their perspectives on why new mothers are dying at an alarming rate and what can be done to spare families from these tragedies.   —Susan Wiedel

  From left: Braxter, Borrero, Mendez, Shirriel
Pitt Med's Tough Questions panel:

Betty Braxter, PhD
Assistant Professor of Health Promotion and Development
School of Nursing
Sonya Borrero, MD 
Associate Professor of Medicine; Clinical and Translational Science; and Obstetrics, Gynecology, and Reproductive Sciences
Director, Center for Women’s Health Research and Innovation
School of Medicine
Dara Mendez, PhD, MPH
Assistant Professor of Epidemiology
Graduate School of Public Health
Jada Shirriel, MS Chief Executive Officer, Healthy Start 


To paraphrase ProPublica and NPR’s Lost Mothers series: American women are more than three times as likely as Canadian women to die in the maternal period. They are six times as likely to die as Scandinavians. In every other developed country, and many less affluent ones, maternal mortality rates have been falling. The journal Lancet noted that in Great Britain the rate has declined so dramatically that “a man is more likely to die while his partner is pregnant than she is.”

And, though the data are difficult to get a handle on—the United States doesn’t even release an official maternal mortality figure anymore—the situation appears to be getting worse.

What are the data, with all the current limitations, telling us so far?

Dara Mendez (public health researcher): We’ve seen on the national scale the rates have been actually increasing quite a bit, although there are no formal national kind of rubber-stamped estimates. 
We have seen variations by state. Some states have seen tremendous decreases in maternal mortality—California being one example. There are a few [reasons] they point to: They instituted their maternal mortality review committee in, I want to say, 2006. That state also has what would be equivalent to a perinatal collaborative, which is a group that not only takes the recommendations but applies them. Some of the core elements they’ve instituted in California [have addressed] postpartum hemorrhage. There are no . . . national protocols . . . for hemorrhage. 

In addition to hemorrhage, what other conditions are behind these deaths?

DM: Pregnancy-related hypertension or hypertensive disorders, preeclampsia, those are some of the leading causes of maternal death. 
If we’re thinking about morbidity in general, we also see a tremendous disparity, racial difference, there. 
Betty Braxter (nurse midwife): I think we have to look at factors that we know impact healthy pregnancies, and [sedentary lifestyle] is one. And substance abuse issue, which is not something new. We’re just seeing more press now because a different population is being shown as substance abusers who end up dying. [And] we’re now beginning to think of preconception counseling. How do we get people more healthy before they even think about becoming pregnant?

I’m just assuming there’s more obesity in the United States than in, say, Western Europe. Is that correct?

DM: I believe that is correct.

Yet, I’m reading mostly about conditions that arise during pregnancy, not preexisting conditions, related to these deaths. 

Sonya Borerro (internist): Well, they’re related. Prior to entering pregnancy, obesity, existing diabetes, and existing dysregulation around metabolism can all contribute to worsening outcomes during pregnancy. Pregnancy is an incredible stress on the body. These preexisting conditions are exacerbated during pregnancy. So, a lot of attention also needs to be placed on the pre-pregnancy period, although that is incredibly tricky. There is a lot of pushback around the overmedicalization of women’s reproduction. How do we talk about this? We don’t want to elevate the importance of women’s health only because of their reproductive capacity, right? We care deeply about women and women’s health for themselves. 
A couple of years ago, I did a qualitative study with low income women in Pittsburgh. We asked them, “What does it mean to you to plan a pregnancy?” Most of them, if not all of them, talked about the need to have your finances in order, to be married. None of them talked about optimizing health. They also recognized that sort of the social normatives that they felt that they needed to achieve were really elusive in their life. 
What they conveyed to us is that it is socially more acceptable to have an unintended pregnancy than to explicitly state that they were trying to get pregnant, or open to pregnancy, in these sorts of nonnormative circumstances. This just blew me away. Women also talked about the fact that life had taught them that they did not have much agency around their reproduction. So they just chose to let it happen. All of [this flies] in the face of our biomedical paradigm, which is: You should plan all pregnancies. 
We have been recognizing the limitations of this very strict planning paradigm, and that it doesn’t actually meet women’s needs or match their lived experiences or realities. So one of the first things I did was I removed “planning” language from my counseling. I’ve been using “preparing” language. "Would you like to talk about this?" "There are ways to prepare for pregnancy, especially if you are taking some medications or have chronic medical conditions." "Do you feel like that’s relevant to you right now?" Sometimes providers might seem to be imposing our own normative ideas on who should and should not be reproducing and when they should be. That can really erode the relationship. 

What are some contributing factors in the racial disparities in maternal mortality? 

BB: One of the factors that HRSA [Health Resources and Services Administration] called out in international summits this summer was institutionalized racism. And unconscious bias. And some of the interactions have left women of certain ethnic groups, not only by race, but socioeconomic status, less enchanted to come in to be served. Or when the services are provided, they are not at the highest level.
DM: Residential segregation has been one of the main ways in which we’ve measured a form of institutional racism in our empirical research.
In the ’30s and beyond, communities were redlined on a map—not selected for acquiring home mortgage loans or investments. In Pittsburgh, for example, many of the places that were redlined actually overlay with many of the communities that are historically African American. And you can do that for multiple cities.
We can think about housing security. We can think about poverty and the intersections of race, class, and gender in this case around maternal health, and a lot of the work around intersectionality points out that women may be more likely to experience adverse outcomes in general. 
Jada Shirriel (community leader): Some of the work that Healthy Start does nationally is around looking at those redlined areas in different cities across the country, because it was a federal practice. And looking at the health outcomes of women and babies in those communities. And consistently, across the board, you see the disparities in the specific neighborhoods.

What can be done to address racial disparities in maternal mortality and morbidity?

SB: We [providers] use heuristic processes, especially in the time constraints of clinical encounters. This is a natural human cognitive process to stereotype and use shortcuts. We are all guilty of it. And the first step is to recognize situations in which that is happening. We’re doing some implicit bias training in the medical school. And we’re [having] a meeting of the minds to figure out how to continue doing this throughout training. 
DM: There’s been quite a bit of work that we’ve been doing at the health department. There’s a local infant mortality collaborative that has included Healthy Start, University of Pittsburgh scholars, folks within the maternal- and child-health space. We’ve been looking at things beyond just pregnancy and birth, but throughout the continuum. And some of our most recent actions have been around institutional equity. One way that we’ve done that has been work around undoing racism. And really naming racism as a core element that would be contributing to the racial disparity that we see in maternal health, infant health, as well as death. We’ve been working closely with [others] to think about: As practitioners, as researchers, as community organizers that are coming together around these issues, how do we move forward together in a collective impact sort of way?

What is contributing to this disparity at the policy level?

SB: A lot of women, low-income women in particular, become eligible for insurance coverage, Medicaid coverage, during the time of pregnancy, [coverage] which then they often lose 60 days postpartum. 
JS: One of the unintended consequences of these policies that we see in community-based programs is moms come to us repeatedly with subsequent pregnancies that are back to back. So if she loses her health coverage and isn’t able to continue to manage whatever chronic health condition that she may potentially have, then in that subsequent pregnancy, that condition presents itself again. 
[There’s a mindset of a mom’s value] being centered around her capacity to continue to have children. It’s kind of like a backdoor access to things that should be provided anyway. It puts a lot of strain on community-based programs that aren’t necessarily meant to cover basic needs. 

What can be done at the level of the provider, of the community, of the family, to help mothers and babies?

BB: Sometimes [women] just don’t know they have the power to tell the provider, I’m having this dizziness, I’m having these headaches, and to not necessarily accept it if the provider dismisses them.
JS: The mental health aspect is really important. I think that, as a community, we’re doing a better job of making sure that we’re paying attention to mom’s mental health, and the fact that at this perinatal period there is a lot going on. And it’s normal to get help. It’s normal to recognize that this is a huge change and shift. And that we’re not superwoman. Well, we are superwomen, but we still need help.  —Interview by Erica Lloyd
This conversation has been edited. To hear more, tune in to our Pitt Medcast:
Photos courtesy Braxter, Borrero, Mendez, Shirriel.  
Photo Illustration: Elena Gialamas Cerri/Amy P. Kleebank  

Women's Health Prized

To elevate scientific exchange on topics related to early human development and women’s health, the Magee-Womens Research Institute at Pitt hosted its first Research Summit in October, drawing scientists from around the world. During the summit, a research team led by Yaacov Barak, PhD associate professor of obstetrics, gynecology, and reproductive sciences, received the $1 million Magee Prize, established to advance “breakthrough research” in women’s health. Barak and his team are trying to determine how placental defects can lead to congenital heart disease and how fixing those defects might correct or prevent it. —Gavin Jenkins