In this file photo, a mother holds her newborn infant.
Courtesy Alyssa/Flickr
Maternal mortality rates in Oregon more than doubled in the twenty years from 1999-2019. They rose at an even higher rate in the U.S. as a whole. That’s according to a recent study - and the very first to look at rates across ethnic groups state-by-state. The study was published in the Journal of the American Medical Association earlier this summer, a collaboration between researchers at the Institute for Health Metrics at the University of Washington and Mass General Brigham. The highest death rates are among Black mothers, and the highest rates of increase are among Native Americans. We talk with co-author Dr. Allison Bryant, an obstetrician and senior medical director for health equity at Mass General Brigham, about the results of the study and what she sees in her own practice.
Note: This transcript was computer generated and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Maternal mortality rates in Oregon more than doubled between 1999 and 2019. They rose at an even higher rate in the US as a whole. But these overall numbers mask an even more terrible reality: huge disparities among different racial and ethnic groups. Black Americans had the highest overall mortality rate over the last 20 years. Native Americans and Alaska Natives saw the highest increase in that time period. These numbers come from a new study which was the first state by state look at maternal mortality rates across racial groups. Allison Bryant was a co-author on the study. She is an obstetrician and the associate chief health equity officer at Mass General Brigham and she joins us now. It’s great to have you on the show.
Allison Bryant: Thanks so much for having me, Dave.
Miller: There’s a lot in your study that I want to get to, including racial disparities and post birth outcomes and potential solutions. But I just want to start with the top line of your findings. How is it that nationwide maternal mortality rates got so much worse over the last 20 years?
Bryant: I reflect with you on sort of how challenging it is to hear that information. And yet I don’t know that it’s totally surprising. We really have not done the work to reduce rates of maternal mortality and morbidity. We know populations are getting older and sicker, and we are not paying as much attention to things like social need as we should be. There’s the crises like substance use disorder and the COVID-19 pandemic. So it’s not altogether surprising, although it really is tragic.
Miller: I was struck by your words there because I saw in preparation for this conversation a health researcher who was not a part of your study who told the AP “I hate to say it, but I was not surprised by the findings.” It seems like you agree. Was there nothing in the findings that did surprise you?
Bryant: I would say that what I looked at with most interest is really the places that we haven’t been looking as closely at, in particular what’s happening in American Indian, Alaskan Native communities. So that’s a community that oftentimes is small, oftentimes gets othered in more ways than one, oftentimes rolling into a category like “other,” so we haven’t been able to explore what’s happening in that community. And so I think our being able to look at that group separately and on its own and make estimates was revealing, if not surprising about what we saw about rates in that community.
Miller: I want to stick with these disparities for a while. Starting with the broadest question, do you see the maternal mortality rates and the disparities among them as largely being part of overall health disparities in this country? Or are there aspects to maternal mortality rate that are specific to pregnancy and post-birth health?
Bryant: It’s a great question. I think it’s a little bit of both. I think that it’s reasonable for a society to think about what happens to its children and what happens to its birthing individuals as reflective of what happens more broadly in the society as we think about health outcomes. So the maternal mortality rate I think is definitely a reflection of where we are in American health care and American society.
That said, I think that there are things that are specific to pregnancy that can make pregnancy dangerous for some individuals, and can make the postpartum period dangerous for some individuals that we really need to drill down specifically on as we think about intervention. Interventions to reduce these disparities, interventions to reduce these rates will focus both on making sure that every American is healthy and has access to their best health status, but will also focus a little bit on how we treat pregnant individuals on labor and delivery, how we make sure that they have access to high quality care and deliver in the spaces that are right for them. There will be both specific and broad solutions. And so I think it’s a both/and.
Miller: I was struck by the time frame in your study and I may not be alone. I have a feeling that if listeners hear the word “maternal mortality,” they may think about pregnancy and birth. But if I’m not mistaken, the time frame includes maternal deaths both during pregnancy and for a full year after birth. Why extend that full year? What does that tell us?
Bryant: I think there’s two answers. One is sort of the simple administrative answer, which is that’s how maternal death is defined both internationally as well as nationally. If we think about CDC and World Health Organization guidance, maternal death and maternal mortality is defined as those deaths that occur during pregnancy or up until 365 days of the end of a pregnancy. And so I want to be specific, that’s the end of any sort of pregnancy. So whether that is a miscarriage or an ectopic pregnancy or a termination of pregnancy or a live birth, it’s the end of any pregnancy in one year after.
The harder question, which I feel is still entirely valid, is why is that important? And there’s lots of reasons for that. One is that the physiologic, the biologic changes that are associated with pregnancy certainly trail out beyond the actual physical end of a pregnancy, and we want to be mindful of that. But I think also as we think about the contributors to maternal death, I think the social circumstances of individuals change vastly over that first year and there are things that can still be related to pregnancy, to access to care, to parenting that may happen six months down the line that we probably we want to know about to better improve our systems of care for pregnant individuals and postpartum individuals.
Miller: Your study focused on mortality rates as opposed to causes of death. But how much is known about the most common causes of maternal mortality?
Bryant: It’s a great question. The data sources that we use were not able to tell us with any degree of detail or certainty the causes of death. and so we focused really on the numbers over the course of the years that we explored. The work to understand causes of death really happened at the levels of the state, and now sort of rolling up federally at the level of CDC, to really dig down into medical records and social records and criminal justice records of each decedent in each state to really understand what do committees think is the cause of death, and what are the contributor to those causes. And so in the past five to 10 years been able to move that work ahead now that we have some standard definitions, standard ways in which the states are looking at these cases.
CDC has done a great job of pulling some of that information together to understand that probably one of the leading contributors to maternal death across the country is cardiovascular disease, diseases of the heart, diseases that are preexisting or developed during pregnancy, things like hypertension that contribute. But in some communities, it’s actually mental health disorders. Suicide, maybe even homicide, substance use death. Some of those are some of the leading causes of deaths in some communities and in some states.
Miller: Is it fair to say that whether you’re talking about either of those two broad categories of mortality, that in the vast majority of cases we are talking about preventable deaths?
Bryant: That’s the other space that CDC has really been helpful for. The job of each maternal mortality review committee, which exists right now in each of the 50 states as well as in a number of large cities and territories, is to determine causes of death, determine contributors to the death, what we could do to prevent those deaths in the future, but in each case to deliver determine “preventability.” Preventability perhaps is in the eye of the beholder, but I think that we’re getting better at thinking about objective criteria. And as of the last statistics that I’ve seen, probably about two-thirds of maternal deaths in the United States have been deemed preventable. If x, y, and z had happened differently, this death would not have occurred.
Miller: I want to zoom out for a second. I can’t help but think about this if we’re talking about the huge proportion of these deaths that are preventable, it does make me think about the US globally, because the US is so much worse than other developed countries in terms of these numbers. In Australia and Japan for example, there are one or two maternal deaths for every 100,000 live births. In the US, there are nearly 24. And again, I should just say that that’s the US as a whole. And for, for example, Black Americans or Alaskan Natives, the rate is much higher. But why are we so much worse nationally than other rich countries?
Bryant: I think it’s a fascinating question, and sort of leans towards the tragedy of all of this. We know that we could do much better, because we see that our neighboring countries, countries that are high income like we are, have done so much better. And so one of the things that I often reflect on is graphs and statistics that look at the rates of medical spending or spending on health care amongst high income countries. And the United States ranks very highly, per capita we spend a lot of money on health care. And yet if you look at that same sort of graph by social spending, we don’t fare as well in my opinion. We are one of the lower spending countries in terms of the social safety net and other programs that really sort of shore up individuals’ both health status, but also educational status, and transportation, utilities, and all of the things that we know are enablers of health.
To me that is sobering, and to me that is that is reflected in our mortality statistics, that we don’t take well enough care of all of the individuals that live in our societies, particularly those who have come from historically marginalized communities, in terms of all of the things that enable health, even though we provide world class health care. That said, we don’t provide world class health care to everyone who comes in our doors. And so that’s the work of clinical health equity is really making sure that every individual has what they need within the medical system. But we also need help thinking about outside of healthcare, what are we not providing that are keeping people from attaining their best health outcomes?
Miller: It’s striking to see news like we saw this summer in the context of what you’re talking about, I’m thinking about the FDA’s approval of a new blood test that that could lead that many people say will lead to the earlier detection and diagnosis of preeclampsia. How significant is this news?
Bryant: I think it’s great scientific breakthroughs. I think if you sort of follow that story, it’s a very interesting story in terms of thinking about getting from a concept to an idea and testing and sort of out to market. I think we need more stories like that. I think the preeclampsia story is a little bit challenging because we don’t have that many preventive tools for preeclampsia. And once it’s developed, really we know what the “cure” is, which is delivery. And so the clinical utility of predicting who’s going to develop preeclampsia may have some benefits, that means you’ll get someone to a higher level of care on a sooner end. But I think that investing in science is incredibly important, and we need to do that in ways that are truly equitable, that get to everybody who needs it.
And so I think it’s an interesting story to follow. Whether it will have huge public health impact, I’m not entirely certain at this point.
Miller: I guess that’s what I was wondering in the context of your earlier answer where you were talking about enormous existing social inequities that lead to health outcomes. It just makes me wonder if we’re focusing on the right things.
Bryant: Again, I think it would be great to be a both/and. But yes, I would agree with you that if I had to put my billions of dollars in one bucket, it might not be in top tier biomedical advances, although I think that those will pay dividends at some point. But I think that there’s a lot of foundational work that we need to do in this country to make sure that the playing field is level, things like transportation or health literacy or interpreter services access for our individuals. I think all of those have huge payoffs in terms of making sure that people are able to stay healthy, that we don’t spend as much time thinking about.
Miller: You’re in a not unique position of doing research and being an equity leader for this huge hospital system, and just being a doctor, being a clinician. I’m wondering about that last part. How and when do you think about these issues when you’re just sitting with a patient?
Bryant: It’s a great question. I feel privileged to be in each of those spaces, and particularly privileged to be a clinician, because I think that the work that I focus on in terms of health equity and in terms of thinking systematically and in terms of academic products really does come from the 1 to 1 patient relationship. So this is something that comes up for me often in my clinical office, is that I think about it at the baseline. I don’t oftentimes provoke it from my individuals to ask “are you worried about your time in labor and delivery” to my Black patients, for example. But it often comes up in conversation. I identify as a Black female individual, and so I have a number of patients who I think come to see me because I identify in that demographic, and then feel much more comfortable as someone who has perhaps some shared lived experience with them to open up about the things that they are worried about.
I think it’s been fantastic what you all in the media have done to turn these stories outwards so that people know what’s happening. The flip side of that is that the average individual, who is gonna be perfectly fine on labor and delivery, does have a lot of worry and fear sometimes. And so I think it’s great to unpack that in the safe space of our office practice or on labor and delivery. But yes, I think they’re inextricably linked and people are noticing and people are worried.
Miller: I hadn’t thought about that last part. You think that a necessary focus on maternal mortality and on health disparities, it’s led to a more generalized anxiety about labor and delivery that you’ve heard about?
Bryant: Yeah, I do think that there is a correlation. I think part of it is just that we haven’t done as great a job really teaching numeracy and relative risk versus absolute risk. And so I think oftentimes we sensationalize the relative risk, which is perfectly the right thing to do in many academic circles as well as the lay public, I don’t mean to diminish anyone’s understanding. But when we say that Black individuals are three times as likely to die as other individuals on labor and delivery, that sounds incredibly frightening to the average person. And yet the average Black birthing individual has very, very low chance of actually dying in labor and delivery or postpartum. So no doubt, we need to turn our public health focus and programmatic focus. But in the one-to-one, I think that we can be in those spaces reassuring to individuals, especially when we as a health system, like Mass General Brigham, are focusing on this. We’re talking about this on labor and delivery with our staff, we can say we think that we’ve got you, we know what the problems are, we are going to watch out for you, but your risk is low.
But yes, I think that this focus in the media is appropriate, and yet makes a lot of people worried about what’s going to happen to their specific instance when they come in for delivery.
Miller: You mentioned earlier in some of the reasons for maternal mortality, you talked about suicide and overdose. What role does behavioral and mental health care play in this conversation?
Bryant: It’s huge. I think it’s a huge role that we need to be focusing on. And most maternal mortality review committees, certainly including ours, have reached out to make sure that they have that expertise on those committees to understand, if we have an overdose death that occurred at eight months after delivery, what were the contributors? Was there custody arrangements? Were there things about parenting? Were there things about having had great access to mental health and behavioral health care during pregnancy that then fell off because either there was an insurance gap or a caring gap or who knows what? It’s incredibly important that we have those partners at our side to understand the root causes, and then to develop the solutions to improve them.
Miller: Maybe this is too big a question to ask you, but stepping back greatly, what would a more pro-natal, pro-maternal and baby health society look like?
Bryant: It’s a great question and it is huge and it’s enormous. It would look like valuing all of our individuals. It would look like eliminating structural racism and understanding the role of structural racism in the inequities that we see. It would mean thinking about social determinants, social enablers of health, and making sure that individuals have access to those things that make them healthy from the jump, from birth all the way through the entirety of the reproductive life course and beyond. It would look like a reproductive choice. It would look like a number of things that I think that are threats right now to our country that we don’t currently have. And we have so much work to do.
Miller: Well, speaking of reproductive choice, as I mentioned at the beginning, the data that you crunched was basically the first 20 years of this millennium. It went to 2019, meaning before the Supreme Court struck down Roe v Wade. Do you have a sense for how the erosion of abortion protections in many states in this country could affect maternal mortality in the years to come?
Bryant: Yes. I think probably without question, we will see more severe maternal morbidity and maternal mortality as a result of, as you describe, the erosion of reproductive choice in many states. I think that as a birthing individuals are required to or needing to carry pregnancies longer than they intended, either because of personal choice or because of illness of they themselves or illness on the behalf of the fetus, we will see more death, we will see more illness, because we were not able to afford people the full scope of reproductive choice. And that will be inequitable.
Miller: There was an article just today in the New York Times that focused on our neighbor to the east in Idaho, but also other red states, showing that many OB-GYNS are leaving red states, especially rural parts of red states, and going to places where they feel basically that they are not gonna be held criminally liable if they practice medicine. What effect do you think that’s going to have, that in particular, on maternal mortality?
Bryant: I think it’s gonna be part of the story. And that is not to cast any blame or any judgment. I sit as a high risk obstetrician who practices in Massachusetts, and have only ever been in New York and San Francisco and Boston. And so I know that I have a certain kind of privilege and experience, and so I do not judge anyone for the choices that they make. But I do think that what has happened is that those folks who really feel like they are being constrained in the way that they have to practice, which is absolutely what’s happening, and don’t feel like they can practice in those environments, is gonna leave a dearth of well trained individuals in those states. And so I do worry what the effects of that will be on the patients, and frankly the providers who are left behind.
Miller: I mentioned that Oregon more or less mirrors the national numbers in terms of a more than doubling of maternal mortality rates over a recent 20 year period. But Oregon was actually one of a handful of states, I think about eight states in your study, where the maternal mortality rates actually went down from earlier highs in recent years. Do you know what is working slightly better in Oregon and in a handful of other states?
Bryant: I don’t know specifically [about] Oregon, but I do note that with interest, and there are certainly a couple of states like that, California among them as well. I know that in California, there’s been a lot of work, and I think also in Oregon, through the perinatal quality collaboratives. So those are groups that bring together maternity hospitals to think about best practices and how we implement them in our labor and delivery units. So that may point to some of the advantages that states like that may have. Many states have PQCs that are working actively in this space.
But I would be curious to find out also other things like, does Oregon expand its Medicaid coverage postpartum? Are there other things the social safety net that Oregon does well that we might be able to look to as an example? Because I do agree that overall, as compared to the rest of the country, Oregon is doing reasonably well, without as many increases other states have seen in some racial demographics.
Miller: What role can doulas play in this conversation?
Bryant: Yeah, it’s a great point, and we’ve done a lot of work to expand access to doulas. We know that doulas are an evidence based way to be associated with lower C-section rates, improved breastfeeding rates, many things that may affect long term and short term health. And so we have tried to use doulas, or pair individuals at particularly high risk of adverse outcomes with doulas, as a hope that it may start to have closed some of the gaps that we see. I haven’t seen national data or regional data that suggests that doulas are associated with the closure of the racial gap, but we are sort of extrapolating from what we know in general populations.
And I think I’ve heard someone say that doulas are fantastic and I think that they do a fantastic job. But if we in the health care system and the entire country were doing our jobs right, we wouldn’t necessarily need doulas to bridge this gap in the divide between clinical care teams and families, because we’d be speaking the same language, we’d be focused in a very patient and family-centered way. Yet we don’t totally know how to do that in the healthcare system. And so I think that we are blessed with this role group that are these sort of professional caregivers and support people at the bedside. And so I am very pro doula
Miller: I’m not sure that every MD I’ve talked to is as open in saying what you just said, because if having someone who’s there for you, who’s focused on your needs, who can act as a translator or an advocate or a coach or a support, if they can make such a difference, it does seem that that that’s a sign that the medical community could be doing a better job. How universal do you think that feeling is in your community?
Bryant: Yeah, I think that that’s a very fair point. And I think historically, the medical community has not necessarily recognized the value of doulas in the health care workforce. And so I think that that does need to change. And I think it’s bidirectional. There are doctors who get it and there are doctors who don’t. There’s doulas who get it and there’s doulas who don’t. So I don’t want to cast shade on any specific role group. But I think that we need to follow the evidence, and understand what makes our patients care better, and lose some of the ego frankly about thinking that we can do it all, because we haven’t been doing it all, and we haven’t been doing it all well. And so if there is a role group that can step in and close some of these gaps, for sure, we should be welcoming them in our doors. But there needs to be a culture and a sea change in that space.
Miller: What are you most interested in studying next?
Bryant: I think it’s a lot of things. As you mentioned, sort of the temporal changes that have come since our study. So we know from national data that the COVID-19 pandemic certainly worsened maternal care outcomes. And so perhaps continuing this work post-COVID to understand what those inequities look like state by state would be of some value.
And then really digging into this question about what has happened or what will happen once we have eliminated reproductive choice in some of these states that were already burdened with high rates of maternal mortality and high rates of disparities. I think unfortunately what we would see if we projected forward is a worsening of that. And it may be worth doing that to show lawmakers, policymakers, whatever we can do to sort of advocate for change, maybe next steps.
Miller: Allison Bryant, thanks very much for your time today. I really appreciate it.
Bryant: It’s been a real pleasure. Thank you so much.
Miller: Allison Bryant an OB-GYN, associate chief health equity officer at Mass General Brigham and co-author of this new maternal mortality study.
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