‘Fourth Trimester’ Focus Is Pushed to Forestall Maternal Deaths
For several weeks a year, the work of nurse-midwife Karen Sheffield-Abdullah is really detective work. She and a team of other medical investigators with the North Carolina public health department scour the hospital records and coroner reports of new moms who died after giving birth.
These maternal mortality review committees look for clues about what contributed to the deaths — unfilled prescriptions, missed postnatal appointments, signs of trouble that doctors overlooked — to figure out how many of them could have been prevented.
The committees are at work in 36 states, and in the latest and largest compilation of such data, released in September by the Centers for Disease Control and Prevention, a staggering 84% of pregnancy-related deaths were deemed preventable.
Even more striking to nurse-detectives like Sheffield-Abdullah is that 53% of the deaths occurred well after women left the hospital, between seven days and a year after delivery.
“We are so baby-focused,” she said. “Once the baby is here, it’s almost like the mother is discarded. Like a Reese’s Peanut Butter Cup. The mom is the wrapper, and the baby is the candy. Once you remove the wrapper, you just discard the wrapper. And what we really need to be thinking about is that fourth trimester, that time after the baby is born.”
Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic women most likely to die from suicide or drug overdose, while cardiac problems were the leading cause of death for non-Hispanic Black women, according to the CDC report.
The data highlights multiple weaknesses in the system of care for new mothers, from obstetricians who are not trained (or paid) to look for signs of mental trouble or addiction, to policies that strip women of health insurance coverage shortly after they give birth.
The No. 1 problem, as Sheffield-Abdullah sees it, is that the typical six-week postnatal checkup is way too late. In the North Carolina data, new moms who later died often missed this appointment, she said, usually because they had to go back to work or they had other young children.
“We really need to stay connected while they’re in the hospital,” Sheffield-Abdullah said, then make sure patients are referred for the appropriate follow-up care “within one to two weeks after delivery.”
Increased screening for postpartum depression and anxiety, starting at the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation, as is better coordination of care between medical and social services, said David Goodman, who leads the maternal health team at the CDC’s Division of Reproductive Health, which issued the report.
A common crisis point in the months after childbirth is when a parent’s substance use problem gets so bad that child protective services takes the baby away, precipitating a mother’s accidental or intentional overdose. Having access to treatment and making sure child visitations happen regularly could be key to preventing such deaths, Goodman said.
The most important policy change underscored by the data, he said, has been the expansion of free health coverage through Medicaid. Until recently, pregnancy-related Medicaid coverage typically expired two months after delivery, forcing mothers to stop taking medications or seeing a therapist or doctor because they couldn’t afford the cost without health insurance.
Now, 36 states have either extended or plan to extend Medicaid coverage to a full year postpartum, partly in response to the early work of maternal mortality review committees. For years, the data showed about a third of pregnancy-related deaths occurred one year after delivery, but in this report, they jumped to more than half, Goodman said, putting more urgency on the importance of longer-term Medicaid coverage.
“If this is not a call to action, I don’t know what is,” said Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, a nonprofit focused on national policy. “We’ve long known that mental health issues are the most common complication of pregnancy and childbirth. We just haven’t had the will to do anything about it.”
The latest CDC study from September analyzed 1,018 deaths in 36 states, significantly more than in the previous report. The CDC is providing additional funding for maternal mortality reviews, Goodman said, with the hope of capturing more complete data from more states in the future.
Advocates and doctors have been heartened by the increased awareness and attention on maternal mortality, especially efforts to correct racial disparities: Black women are three times as likely to die from pregnancy-related complications as white women.
But many of these same advocates for better maternal care say they are dismayed by the recent U.S. Supreme Court decision eradicating the federal right to abortion; restrictions around reproductive health care, they say, will erode the gains.
Since states like Texas began banning abortions earlier in pregnancy and making fewer exceptions for cases in which the pregnant person’s health is endangered, some women are finding it harder to get emergency care for a miscarriage.
States are also prohibiting abortions — even in cases of rape or incest — for young girls, who face much higher risks of complications or death from carrying a pregnancy to term.
“More and more women and other birthing individuals are receiving messages that ‘You don’t have ownership of your body,’” said Jameta Nicole Barlow, an assistant professor of writing, health policy, and management at George Washington University. “Whether it’s through policy, whether it’s through your doctor who has to adhere to policy, whether it’s through your daily work experience, there’s this acknowledgment that ‘I don’t own my body.’”
This will only exacerbate the mental health struggles women experience around pregnancy, Barlow said, especially Black women who are also coping with a long, intergenerational history of slavery and forced pregnancy. She suspects the maternal mortality numbers will get worse before they get better, because of the way politics, policy, and psychology are intertwined.
“Until we address what’s happening politically,” she said, “we’re not going to help what’s happening psychologically.”