Podcast: Maternal mortality rates are spiking. How can the trend be reversed?

Jim Dryden (host): Hello, and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri … the Show-Me State. In this episode, we discuss a disturbing new rise in maternal mortality rates in the United States. That is, those who die during a pregnancy, during childbirth or in the first six weeks after giving birth. The National Center for Health Statistics recently reported that maternal mortality in the United States rose by 40% in 2021, the last year for which numbers are available. The last time the rate of maternal mortality was this high was 1965. While part of that increase was due to the COVID-19 pandemic, Dr. Ebony Carter, the chief of clinical research in the Washington University Department of Obstetrics & Gynecology, and a specialist in maternal-fetal medicine, says there are other important reasons, too. She says cardiovascular problems are the leading cause of pregnancy-related death.

Ebony Carter, MD: So I cared for a patient who had an ejection fraction from her heart of 10%. That number should really be more than 55%. So she was essentially in heart failure with a brand-new, highly desired pregnancy that could kill her.

Dryden: In addition, around 40% of adults in the U.S. are considered obese. Obesity makes complications more likely during a pregnancy and can contribute to heart problems. Plus, nearly half of the people in the U.S. have high blood pressure. High blood pressure puts extra stress on the heart and kidneys. Another risk factor is diabetes. Around 11% of people have diabetes, with almost 40% of the people in the country having pre-diabetes, meaning that a big event like a pregnancy might push them over the edge.

Carter: If you don’t start worrying about the health of a pregnant person and a fetus until they’re pregnant, it’s too late. The active management of pregnancy and improving outcomes actually happens in the before and in the after, right? Actually coming into it with good health and not having diabetes and hypertension and all of these other diseases. And then after you deliver the baby, actually having access to preventative care to try to stay healthy. And we tend to not do that.

Dryden: Plus, a number of women are now having children later in life, which increases the risk of maternal deaths. Carter says the recent opioid epidemic also is a factor. Plus, there are economic and systemic factors that contribute. In the statistics from 2021, for example, the rate of maternal deaths among Black Americans was nearly 70 per 100,000 births, more than double the rate among whites.

Carter: There are certain groups who systematically have less access. And those are the groups, in all of these statistics, that you also see who are having worse outcomes. So indigenous patients had actually the worst widening gap.

Dryden: Carter says the rates have been too high for years, but then came COVID-19.

Carter: With the pandemic, you have this virus that none of us knew what it was, how it worked, how to treat it. And in pregnancy, what we were doing in those early days was taking the lessons of things like flu, where you know that the pregnant body makes these beautiful, amazing adaptations to protect the fetus. And so you tamp down your immune system. That works really, really well for the baby. That doesn’t work so well for the person who is carrying that baby. And so your immune response isn’t as good. And that’s why during flu season, who’s getting really sick with the flu besides older people? Pregnant people. And the same thing happened with COVID. And so you saw patients who were pregnant being significantly sicker than the general population with COVID. We had patients in the ICU during the pandemic. And with each surge — I’m a high-risk obstetrician, I prefer to stay out of the ICU — but in each of those surges, we were rounding in the ICU regularly, often with three to four patients who were there. People who, a few weeks before, were happy, healthy, walking among us, and now are on ventilators because COVID has wrecked their body. And so when I think about those terrible experiences I’ve tried to block from the pandemic, and I put them on top of these statistics, COVID was devastating for pregnant people on top of all of the other issues that I’m happy to talk about that were already happening. But then you see that in 2021, the numbers get even worse, right? And by that point, we know more about the pandemic. We actually have vaccines by this point. You fast forward to now, we probably have more data on the vaccine and pregnancy for COVID than any other vaccine known to man, because mass quantities of people got it. And you still see pregnant people unwilling to get vaccinated. In terms of the pandemic, part of that story, that’s my read, laying it over what I experienced as a clinician caring for patients during that time.

Dryden: But the rate of maternal deaths in this country is about 10 times what it is in comparable, wealthy countries. What are they doing that we aren’t?

Carter: I think there’s several things. One, if you are low income in this country and you don’t actually have access to health insurance, you get Medicaid when you get pregnant. But even then, people come for their first prenatal visit, and we’re rushing to get them emergency Medicaid coverage. Their pregnancy outcomes would have been so much better if they had had access to health care before. So I think part of the problem is that people come into pregnancy in our country really sick, because we haven’t given them access to preventive care beforehand. And that’s part of what’s driving these numbers. And 45 to 60 days after you deliver, in many of the states that didn’t do Medicaid expansion, you get kicked off. And you lose that insurance again, only to be seen the next time you’re pregnant, when all of your diseases are even worse than they were before. So that’s part of what other countries are doing, is actually framing health care as a right and not a privilege and something that’s good for all of society to have. I think the next part of it is the social determinants of health. The access to education and healthy food and shelter and all of the things that it takes to be healthy in life are not fairly distributed among the population. And I think it is a reflection of the social determinants of health. But let’s not start there. The social determinants of health are poorly distributed because of discrimination and racism and sexism. You actually have to go down to the root causes. So when we first started talking, it was like — I mean, we know what to do, right? We know what the solutions for this should be. Some of them are health-care-level solutions, for sure, but I would argue that the vast majority of it are things that we have to commit to do as a country together. And it’s not just in the health-care sector.

Dryden: So it’s more than just, “Some people don’t have insurance” or more than just, “Some people live in a rural area where hospitals are closed.” There’s more going on in your mind than that.

Carter: If you gave me the power to make one intervention that was going to make this better, I think I would choose having health insurance and access for everyone. But to only do that, you would miss the mark. So that would make a dent. That would actually help a lot. It’s not going to do all of it, because it’s actually a multi-pronged issue where there are systems failures at every level that are leading to this.

Dryden: What about convenience in that? That word sounds glib, I know. But my understanding is all around the country, in rural areas especially, hospitals either have closed or have stopped delivering babies. And I’m wondering at a facility like ours, how many times you meet a patient whose first exposure really to health care — other than maybe telehealth — is when they go into labor.

Carter: I think it’s common. And our referral base here in St. Louis is huge. Our transfer system is robust. If I get a call for a transfer, my only question is, “Is the patient stable for transfer?” And as long as they’re stable — and we have a bed, which we usually do — my answer is yes. And we will come and get them by ambulance, by helicopter, by plane. It’s because so many of the patients who get referred to us are out in rural communities and hospitals that have no obstetric clinicians. Like they’re terrified, right? People who aren’t obstetricians, they do not want to take care of pregnant people. People are terrified of pregnancy. And it’s like, “Yes, we will come and get them.” But the way that I manage patients here is very different than when I trained in Boston. In Boston, when you get a transfer, they’re from like 30 minutes away, right? Everything is extremely close. And so I realized that my management here as a physician in Missouri is much more conservative. I ask the question, “How far away do you live from the hospital?” Because if they live four hours away, somebody that I would have sent home who lives 10 minutes away, I’m going to keep them because I want to make sure that they still have access to the care they need if something goes terribly wrong.

Dryden: Other barriers. Local people who don’t have transportation, people who — maybe it was an unplanned pregnancy, they don’t want people to know about it. What are the other reasons why somebody might not get the care before they become pregnant or even after they become pregnant?

Carter: I think one of them is just getting into care. And like I said, we can get patients emergency Medicaid. But often, it’s not immediate. So there’s a delay there. And then it’s also people who come into pregnancy who are really sick. So I cared for a patient who had an ejection fraction from her heart of 10%. That number should really be more than 55%. So she was essentially in heart failure with a brand new, highly desired pregnancy that could kill her.

Dryden: Is there any good news here?

Carter: I think the good news is that we are having the conversation. So these statistics, while they got ridiculously worse during the pandemic, they were already pretty bad. And it’s only been in recent years that we have been having the conversation. But historically, this has not been funded in terms of research or a specific area of interest for the National Institutes of Health, which funds most of the medical research in the country. I feel like putting this spotlight there, hopefully, means the resources go to it to actually make a meaningful difference. The NIH, they’re going to make a decision pretty soon on a program that’s going to bring millions of dollars to reduce maternal mortality in this country. I don’t think that that was necessarily happening five years ago.

Dryden: We’re talking about maternal mortality. What about infant mortality, early birth, things like that? I’m assuming that a person who is at risk for death from a pregnancy is probably also at elevated risk to deliver sooner than is good for the baby or maybe have a problem that is life-threatening to the fetus.

Carter: Pregnancy-capable people who have severe maternal morbidity and mortality, clearly, their infants do significantly worse and are more likely to be born early. And what’s the No. 1 predictor of whether you live to celebrate your first birthday? It’s if you were born too soon. And so I think that this entire issue is really the canary in the coal mine, because if we are unwilling to do what’s necessary to take care of brand-new babies in this country, what does that say for what we’re going to do for everybody else? I think that these statistics bode poorly, not just for maternal health, but also for infant and childhood health.

Dryden: These are big issues. You’ve talked about systems. But what are we doing at Washington University to try to address some of these disturbing trends that we’re seeing?

Carter: I am lucky to work with amazing colleagues who are doing some really interesting and innovative work. And so I’m going to give you a few examples. One is there is a huge doula initiative that’s happening. And so I hope that in the very near future, that all of our patients are going to have access to a doula without any consideration of their ability to pay, because that’s often one of the really big barriers. Another one is our Center for Acceptance, Recovery and Empowerment. So opiate-use disorder, substance-use disorder, is a huge contributor to these issues. And the fact that we have a dedicated clinic that will continue to follow both the patient and the baby long-term, after delivery, is huge. And that’s a huge part of the population that is dying prematurely. We also have the EleVATE initiative. I’m biased. I work with EleVATE closely. It is a community-academic partnership between WashU and the Integrated Health Network that is, essentially, designed and led by Black, pregnancy-capable people. And we have embedded a mental-health intervention in group prenatal care. And really, the preliminary results are amazing in terms of reducing the risk of preterm birth, perinatal depression. There’s an ongoing study across the entire state of Missouri for EleVATE. That’s just a little sampling of some of the amazing programs that are happening here.

Dryden: Do you expect anything to look different a year from now when the statistics come out for 2022?

Carter: I hope that they’re better. And even if they’re better than they are now, they’re still going to be too bad. We have so far to go. And I remember as a kid, my mom worked in minority health. And I remember in the 1980s hearing her use this phrase in all of her speeches, “In the shadow of our finest medical facilities, where kings, queens and shahs travel thousands of miles for the best medical care in the world, Black mothers and babies continue to die.” Here we are, 40 years later, and the same thing is true. I don’t think that we got to this place in a year. We’re not going to get out of it in a year. But I hope that when it’s time for my daughters to reach their reproductive years, as young Black women, they won’t face the same daunting statistics that people who want to have a baby today are facing.

Dryden: So with all this bad news, all these difficulties, what keeps you coming to work every day?

Carter: I’m inspired by the patients we serve. I go home at the end of every day feeling like we’re truly making a difference. And I get to work with patients turned partners, people from the community who are actively helping us to figure out and tackle these issues. I’m inspired by my colleagues who continue to practice under conditions that can sometimes be very difficult. The pandemic was crazy. And I can’t think of a better group of people to have gone through that with this. We were taking care of extremely sick pregnant patients. And I’m inspired by this institution. It’s been an amazing place. I trained here. I’ve stayed as a physician here. And we’re working together to make a difference. And I think we’re moving the needle.

Dryden: Unfortunately, she says the needle needs to move a long way to get the problem under control. And finding solutions will require more than changes only in the ways that health care is provided. Carter says we’re taking baby steps now, but much bigger systemic steps will be required to reduce the numbers of maternal deaths, which currently, as we said, are about 10 times as high as they are in other wealthy countries like Australia, Israel, Japan and Spain.

“Show Me the Science” is a production of WashU Medicine Marketing and Communications. The goal of this project is to introduce you to the groundbreaking research, lifesaving, and just plain cool work being done by faculty, staff and students at the School of Medicine. If you’ve enjoyed what you’ve heard, please remember to subscribe, and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.