The ‘fourth trimester’ focuses on preventing maternal mortality

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

These maternal death review committees look for clues about what contributed to the deaths — unfilled prescriptions, missed postpartum appointments, signs of problems that doctors overlooked — to figure out how many of them could have been prevented.

The committees are working 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.

More interesting to nurse-detectives like Sheffield-Abdullah is that 53% of deaths occurred after women left the hospital, between seven days and one year after delivery.

“We are very child-centered,” she said. “Once the baby’s here, it’s almost thrown off the mother. Like Reese’s Peanut Butter Cup. The mother is the wrapper, and the baby is the candy. Once you remove the wrapper, you simply throw the wrapper away. And what we really need to worry about is the fourth trimester, the period after the baby is born.

Mental health conditions were the leading underlying cause of maternal death between 2017 and 2019, with white and Hispanic women more likely to die by suicide or drug overdose, while heart problems were the leading cause of death among non-Hispanic black women, the CDC reports.

The data highlight multiple weaknesses in new mothers’ care systems, from obstetricians not trained (or paid) to spot signs of mental problems or addiction to policies that deny women health insurance coverage soon after giving birth.

The No. 1 problem, as Sheffield-Abdullah sees it, is that the typical six-week postpartum checkup is too late. In the North Carolina data, new mothers who died later often missed these appointments, she said, usually because they had to return to work or had other young children.

“We really need to stay connected while they’re in the hospital,” says Sheffield-Abdullah, “then make sure patients are referred for appropriate follow-up care “within one to two weeks after delivery.”

Increased screening for postpartum depression and anxiety, beginning 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. 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 becomes so bad that child protective services take the child away, predisposing the mother to accidental or intentional overdoses. Goodman said having access to treatment and ensuring regular child visits can be key to preventing such deaths.

The most important policy change underscored by the data, he said, is 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 therapists or doctors because they couldn’t afford the costs without health insurance.

Now, 36 states plan to extend Medicaid coverage to the full year postpartum, partly in response to the early work of the Maternal Mortality Review Committee. For years, data showed that one-third of pregnancy-related deaths occurred a year after delivery, but in this report, they’ve dropped to more than half, Goodman said, adding more urgency to the importance of long-term Medicaid coverage.

“If that’s 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 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 analyzed 1,018 deaths in 36 states, significantly more than previous reports. The CDC is providing additional funding for the maternal mortality review, Goodman said, in hopes of capturing more complete data from more states in the future.

Advocates and doctors are heartened by the increased awareness and attention to maternal mortality, especially in efforts to correct racial disparities: Black women are three times more likely to die from pregnancy-related complications than white women.

But many of these same advocates for improved maternity care say they are disappointed by a recent US Supreme Court decision that eliminated the federal right to abortion; Restrictions around reproductive health care will erode gains, they say.

As states like Texas begin banning abortions earlier in pregnancy and making some exceptions in cases where the pregnant person’s health is at risk, some women are finding it difficult to seek emergency care for an abortion.

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

“More and more women and other childbearing people are getting the message that ‘you don’t own your body,'” said Jameta Nicole Barlow, 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 follow the policy, whether it’s through your daily work experience, there’s this recognition that ‘I don’t own my body’.”

This will only exacerbate women’s mental health struggles surrounding pregnancy, Barlow said, especially black women who are dealing with a long, intergenerational history of slavery and forced insemination. She suspects maternal mortality will get worse before it gets better, because of the way politics, policy and psychology are intertwined.

“Until we address what’s going on politically,” he said, “we’re not going to help what’s going on psychologically.”

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

Related topics

Contact us Submit a story tip

Leave a Reply

Your email address will not be published.