Maternal deaths in the U.S. more than doubled during the past two decades, according to a study published last month in the Journal of the American Medical Association. Maternal mortality – defined in the study as a death during pregnancy or up to a year afterward – increased from an estimated 505 in 1999 to 1,210 in 2019.
The study also found significant disparities by racial and ethnic groups. Black mothers died at the highest rates (an estimated 55.4 maternal mortality ratio per 100,000 live births in 2019, up from 26.7 in 1999), while American Indian and Native Alaskan mothers had the largest MMR increase (from 14 to 49.2). The MMR among the white population increased from 9.4 to 26.3.
Maternal deaths have continued to increase during the pandemic. The Centers for Disease Control and Prevention reported earlier this year that there was a 40% increase between 2020 and 2021 in women who died during pregnancy or within 42 days following delivery.
The Kansas Maternal Mortality Review Committee (KMMRC) examines all pregnancy-associated deaths in the state (defined as the death of a woman during or within one year of pregnancy, regardless of the cause). Its new report determined there were 105 deaths in Kansas between 2016 and 2020 that were pregnancy associated. That translates to a pregnancy-associated mortality ratio of 56 deaths per every 100,000 live births.
Of the 105 deaths in Kansas, 29 were pregnancy-related (from a pregnancy complication, a chain of events initiated by pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy), 55 were pregnancy associated but not related, and 21 were pregnancy associated but pregnancy-relatedness could not be determined. More than half of the pregnancy-associated deaths occurred after 43 days postpartum.
The 29 pregnancy-related deaths translate to a pregnancy-related mortality ratio (PRMR) of 15. Based on three-year rolling averages, the PRMRs increased from 11.3 in 2016-2018 to 17.2 in 2018-2020. The leading causes of the deaths were cardiovascular conditions followed by embolism-thrombotic (non-cerebral), hypertensive disorder and infection.
Of the 29 deaths, 23 (79.3%) were considered preventable, with 13 deaths showing a good chance of prevention and 10 deaths showing some chance. KMMRC considers a death preventable if there was at least some chance of the death being prevented by one or more reasonable changes to patient, family, provider, facility, system or community factors.
As is the case nationally, there were racial and ethnic disparities, which raises concerns about implicit bias and access to care. Of the 29 women who died in Kansas, 18 (62.1%) were racial and ethnic minorities and 11 were non-Hispanic whites.
Most maternal deaths do not occur during pregnancy. In fact, a study published in JAMA in June reported that, over the past decade, maternal mortality during labor and delivery decreased in U.S. hospitals across people of all ages, races and ethnicities. In Kansas, 10 of the 29 pregnancy-related deaths occurred during pregnancy.
There are several efforts aimed at reducing maternal deaths in Kansas, with a particular focus on supporting women after their pregnancies. The Kansas Perinatal Quality Collaborative (KPQC) and the Kansas Department of Health and Environment are currently working on the Fourth Trimester Initiative, which is aimed at studying and improving the experience of postpartum mothers and families in Kansas.
Currently, 34 hospitals and birth facilities are participating in the initiative, including Ascension Via Christi St. Joseph and Wesley Medical Center. The initiative centers around implementing the Alliance for Innovation on Maternal Health (AIM) postpartum patient-safety bundle. Additionally, the KDHE Bureau of Family Health developed a Maternal Warning Signs Initiative focused on universal patient and provider education throughout the perinatal period that was disseminated to local public health partners and birth facilities participating in the Fourth Trimester Initiative.
In an important policy change, the Kansas Legislature and Gov. Laura Kelly extended last year the state’s Medicaid postpartum coverage from 60 days following birth to 12 months. Nationally, such an expansion has shown to significantly reduce maternal mortality, particularly among Black women. Other possible reforms include expanding prenatal and postnatal home visitations, addressing social determinants of health, diversifying the perinatal workforce and investing in community-based organizations.
How to help prevent deaths
The Kansas Maternal Mortality Review Committee recommends the following actions to help prevent pregnancy-related deaths:
> Screen and provide brief intervention and referrals for:Comorbidities and chronic illness
- Intimate partner violence
- Pregnancy intention
- Mental health conditions (including postpartum anxiety and depression)
- Substance use disorder
> Improve communication and multidisciplinary collaboration between providers, including referrals
> Increase patient education and empowerment