The Washington Post
Maternal mortality is finally getting due attention
Mississippi’s House of Representatives passed a bill last week that would extend Medicaid coverage to women a full year after they give birth. This is part of a broader movement among lawmakers in at least nine Republican-led states to do the same. Such a policy change could significantly reduce maternal deaths.
When it comes to maternal mortality, people often think about women dying during pregnancy or delivery. In fact, more than half of maternal deaths occur days after birth. Twelve percent occur in the six weeks to a year after labor.
This is why we need a far greater focus on what happens after childbirth. Pregnancy stresses the woman’s body and exacerbates existing diseases such as high blood pressure and diabetes. I once treated a woman in the emergency room who believed she was having an asthma attack. She had given birth more than two months earlier. As it turned out, her shortness of breath and wheezing were due to new-onset heart failure that probably began during pregnancy but was not diagnosed at the time. If she had been discharged with only asthma medications, she could have died at home.
Heart failure and other cardiovascular conditions account for more than half of later postpartum deaths. Rates of cardiovascular postpartum deaths are particularly high among Black women, making prompt diagnosis and treatment an imperative in combating racial disparities.
The postpartum period also strains mental health, as virtually any parent can attest. One in seven new mothers suffer from postpartum depression, with the highest rates among women of color and those living in poverty.
Then there are preexisting mental health conditions, which are often untreated before and during pregnancy. One study shows that women with preexisting mood or anxiety disorders were nearly six times more likely to suffer illness during and after pregnancy that can result in death.
Another leading cause of pregnancyassociated death is drug overdose, which increased 81 percent between 2017 and 2020. In fact, pregnant women addicted to opioids are at their highest risk of overdose in the seven to 12 months after childbirth.
Given these facts, why hasn’t there been more focus on post-pregnancy health? Part of the reason is cultural. The traditional conception of pregnancy ends at labor and delivery, with the attention thereafter turning entirely to the baby’s needs. This, of course, is flawed for many reasons, including that the health of the mother should be a priority in and of itself.
Another is historical. For many years, the standard obstetrics protocol was for women to visit their doctors only once around six weeks after delivery. Michael Lu, an obstetrician-gynecologist and dean of the University of California Berkeley School of Public Health, says that the tradition is based on when the uterus returns to its nonpregnant size. “Obviously, a woman is a lot more than just her uterus,” he told me. “And that’s why that visit, in practice, is so outdated and archaic and needs urgently to be reimagined.”
Indeed, postpartum women have many ongoing physical and mental health issues that are unrelated to their reproductive anatomy. This is why the American College of Obstetricians and Gynecologists now recommends an initial visit within three weeks of giving birth and then a second at 12 weeks. The World Health Organization also revised its guidelines and advises at least four postnatal health-care contacts.
For this more comprehensive postpartum approach to work, patients must have continuous health insurance coverage. Unfortunately, federal law only requires Medicaid coverage for 60 days postpartum, and many Republican-led states have kept to that minimum standard.
That’s finally starting to change. I’m glad these lawmakers are at last acknowledging that giving new moms a year of guaranteed health insurance is important for their well-being and that of their babies and their families. The last thing that a new mom with hypertension, diabetes, depression or substance addiction should have to worry about is whether she can get care because her insurance lapsed.
Much more still needs to be done. A report from the Commonwealth Fund found that the United States is the outlier among comparable countries when it comes to paid maternity leave. While our peers offer at least 14 weeks, we offer none. In addition, these other countries guarantee home visits, which improve mental health and breastfeeding outcomes and are crucial to identifying families in need of housing, food and other supports. And as another Commonwealth Fund report addressed, restrictions to abortion care — which are increasing in the United States — are associated with higher rates of maternal death.
Ultimately, we must acknowledge that preventing maternal deaths depends on women being healthy before, during and after pregnancy. Indeed, it requires that we improve care for women throughout their lives.