“Fourth Trimester”: Key period for maternal mortality prevention

For a few weeks a year, nurse-midwife Karen Sheffield-Abdullah’s job is detective work. With a team of medical investigators from the North Carolina Department of Public Health, she examined hospital records and coroner’s reports of mothers who died after giving birth.

These maternal death review boards are looking for clues about what contributed to these deaths — prescriptions that were never picked up, missed postpartum appointments, red flags doctors missed — to find out how many could have been prevented and how.

The committees operate in 36 states, and in the latest and largest data collection of its kind released by the Centers for Disease Control and Prevention (CDC) in September, a staggering 84% of pregnancy-related deaths were considered preventable.

Even more troubling to nurse-detectives like Sheffield-Abdullah is that 53% of deaths occur long after women are discharged from hospital, between seven days and a year after giving birth.

“We’re very child-centered,” she says. “Once the baby is here, it’s almost like the mother is thrown away… and what we really have to think about is the fourth trimester, the time after the baby is born.”

Mental health conditions were the leading underlying cause of maternal mortality between 2017 and 2019. Non-Hispanic whites and Hispanics were the most likely to die by suicide or drug overdose, while heart problems were the leading cause of death for non-Hispanic black women.

Both conditions occur disproportionately later in the postpartum period, the CDC reports.

The data reveal multiple flaws in the system of care for new mothers, from midwives who aren’t trained (or paid well) to spot signs of mental health or addiction to policies that disenfranchise women from vulnerable health. .

According to Sheffield-Abdullah, the main problem is that the six-week postpartum checkup is too late. In the North Carolina data, new mothers who later died missed these appointments because they had to return to work or had another young child, she added.

“We really need to stay in touch while they’re in the hospital,” Sheffield-Abdullah said, and then make sure patients “get proper follow-up care a week or two after delivery.”

Another CDC recommendation is more screening for postpartum depression and anxiety throughout the year after delivery, as well as better coordination of care between medical and social services, according to David Goodman, who leads the CDC team. Maternal Mortality Prevention CDC’s Division of Reproductive Health, which published the report.

A common crisis is when a parent’s addiction becomes so severe that the child is taken away by child protective services, following an accidental or intentional drug overdose by the mother. Having access to treatment and making sure children are seen regularly may be key to preventing these deaths, Goodman said.

The most important political change is the expansion of free health coverage through Medicaid, he said. Until recently, pregnancy-related Medicaid coverage expired two months after delivery, forcing women to stop taking medications or see a therapist or doctor because they couldn’t afford the costs without health insurance.

Now, 36 states have expanded or plan to expand Medicaid coverage up to a full year after delivery, in response to early work by the Maternal Mortality Review Committee.

“If that’s not a call to action, I don’t know what is,” says Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, a national policy nonprofit. “We’ve known for a long time that mental health problems are the most common complications of pregnancy and childbirth. We just didn’t want to do anything about it.”

The latest CDC study from September looked at 1,018 deaths in 36 states, nearly double the 14 states that participated in the previous report. The CDC is also funding the maternal mortality review, Goodman said, hoping to capture more comprehensive data from more states in the future.

Increased awareness and attention to maternal mortality has given activists and physicians hope, especially in efforts to eliminate racial disparities: Black women are three times more likely to die from pregnancy-related complications than white women.

But many of these same advocates of improved maternity care say they are shocked by the US Supreme Court’s recent decision to uproot federal abortion rights; Restrictions around reproductive health care, they say, will erode profits.

As states such as Texas have begun banning abortions early in pregnancy and making some exceptions in cases where the pregnant woman’s health is at risk, some women have found it more difficult to seek emergency care for an abortion.

States are also banning abortions — including in cases of rape or molestation — for young girls, who face a much higher risk of complications or death from conception to term.

“Increasingly the message is that ‘you don’t own your body,'” said Jametta Nicole Barlow, associate professor of health writing, policy and management at George Washington University.

According to Barlow, this will only exacerbate women’s mental health issues surrounding pregnancy, especially black women, who face a long intergenerational history of slavery and forced insemination. She suspects that the interplay between politics and psychology will make maternal mortality statistics worse before they get better.

“Until we deal with what’s going on politically,” he said, “we’re not going to be able to help what’s going on psychologically.”

This story is part of a consortium that includes KQED, NPR and KHN.

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