PRB

In partnership with Dr. Shalon’s Maternal Action Project, PRB is working to raise awareness of the maternal health crisis in the United States. As supporters of data, our role in this effort is to elevate sound research that shines a light on the causes and complexities of this crisis and how decisionmakers might address it.

Dr. Marie Thoma is a reproductive and perinatal epidemiologist and population health scientist at the University of Maryland. She was part of a revealing study that found that Black women were 3.5 times more likely to die of pregnancy-related causes than white women from 2016-2017. Since that study, Thoma has also examined the impact of the COVID-19 pandemic on maternal death rates.

We talked with her about her recent work, what questions she’s asking now, and why she has hope that policymakers can right the ship on maternal health outcomes in America.

PRB: Your recent research in Obstetrics & Gynecology found that maternal mortality was markedly higher in 2021 than in 2020—both significant years in the COVID pandemic. Can you say what was behind the surge?

Thoma: 2021 was definitely worse. What our paper showed is that it aligned with the emergence of the Delta variant.

In this study, we looked at pregnancy-related mortality, expanding it to the full year postpartum. Maternal mortality is death during pregnancy or within 42 days of childbirth; this one looks at within the full year. So, we looked at that and whether the pregnancy-related death also had a COVID-19 cause code, and we mapped that quarterly in 2020 and then in 2021—and you just see this huge spike in the second quarter of 2021, which aligned with the Delta variant emergence.

PRB: Did anything surprise you about your findings?

Thoma: We found that pregnancy-related deaths increased across all races and ethnicities. But they increased dramatically among American Indians/Alaska Native people in 2021; we looked at it many different ways and always saw this spike. There was an 82% jump from 2020 to 2021. That population is smaller, so there’s more variability in the estimates… but this was way above any kind of random variation that we had seen in earlier periods. I just don’t think you can explain that big of a jump by small numbers or random variation. It also coincided with higher rates of COVID-19 mortality among American Indian/Alaska Native people found in other research, and then you’re combining that with pregnancy, which is a vulnerable time.

We don’t know the cause, but we did examine whether COVID-19 was listed as a contributory cause on the death certificate and how these patterns in pregnancy-related mortality compared to overall deaths due to COVID-19.There were a lot of parallels. Because of the pandemic, there could have been other factors, but we couldn’t tease that apart. In our earlier JAMA paper, we were also able to see the rise in respiratory conditions, obstetric-related viral conditions, which was consistent with COVID-19, but we also saw increases in some of the comorbidities like preeclampsia or diabetes, which could be related to delays in diagnosis and indirect causes from the pandemic or conditions that may also be exacerbated by COVID-19.

PRB: “Maternal mortality,” which we hear about a lot, is during pregnancy and up to 42 days postpartum. Why did you decide to look beyond that, at late maternal death?

Thoma: In the JAMA paper, we saw increases in 2020 in both the late maternal deaths (43 days to one year postpartum) as well as maternal deaths. And there was a lot of emerging literature that suggested that the impact wasn’t just on pregnant people, it could be postpartum as well. There were not only changes to prenatal care that occurred early in the pandemic, like transitions to televisits or access to a birthing partner during labor, but a lot of literature talked about isolation from traditional sources of postpartum care and social support. So conceptually we thought this could have an impact.

In general, I think it’s more recognized that a lot of the deaths are occurring in this later time period postpartum, as well. People are recognizing this is an important and critical time period. The CDC recently released a report from the Maternal Mortality Review Committees, and 53% of deaths were within seven days to one year postpartum. With Dr. Shalon Irving, it was three weeks postpartum that she died from blood pressure complications. Often you just get your six-week checkup, you don’t really see anyone between childbirth and that time or after that 6-week appointment. Before the pandemic, ACOG released recommendations on optimizing postpartum care to extend the number of visits in this period. But, to make it to these visits, people need insurance and paid time off of work (and ideally paid family leave). Many states are now moving to extend Medicaid coverage up to one year postpartum, which is a move in the right direction.

There’s so much we still have to learn about late maternal death. Even how they’re coded leaves unanswered questions. For 42 days and under, the NCHS [National Center for Health Statistics] codes maternal deaths to a specific cause, like cardiovascular disease or diabetes, or respiratory or viral. But if it’s 43 days or later, they all just go to one O-code that just means a late maternal death. There’s still a cause associated, and there’s probably ways we can delve into the data, but that code only tells us the time period and not the underlying cause. So, from the  vital statistics data, we have no idea why people are dying in this period.

PRB: Can you tell us about your future research? What questions are you asking now?

Thoma: Not only do we need to be looking at these extreme events, like maternal mortality and severe maternal morbidities, but we also need to focus on  quality of life during this time, such as postpartum pain and other health metrics, that might not bring you to the hospital but are just as critical in that one year postpartum—that if someone had maternity leave, had access to care, they could really optimize their health. So, I’m looking at this with my students and colleagues, at the other things that affect daily life and daily functioning in the postpartum period. If, as a new mom, you are given support and the time to process and recover, that affects your whole life course. That changes everything.

Whether or not I do this research, with the overturn of Roe v. Wade, many will be examining the impact of state restrictions on abortion access on maternal mortality and severe childbirth complications. We have already been hearing of many pregnancy-related complications due to these restrictions.

PRB: Does your research give you any insight into how we can fix this? How do we end the maternal mortality crisis in the United States? What can we do?

Thoma: We need more research, yes, but what we really need is to put in place the policies that we know can improve these things. We know a lot already; we just have to make it happen and have the policies and support to do it.

The White House Blueprint for Addressing the Maternal Health Crisis is the most comprehensive policy example I’ve seen. It does an amazing job, and it tackles the issue from all angles—housing issues, diversifying the perinatal workforce, mental health. So much went into developing it, and it outlines a lot of the policy initiatives that I think could change this.

I do feel like with this greater general awareness, there does seem to be a momentum to address this, an understanding that the time is now and that we need to make it happen. Working with my students, hearing about the amazing research that others are doing, and these policy initiatives…. The fact that it’s laid out and understood is what gives me hope, that collectively we can move toward the comprehensive reforms we desperately need to improve maternal health in the U.S.

Marie Thoma is an Associate Professor in the Department of Family Science at the University of Maryland School of Public Health. She received her Ph.D. from the Department of Population, Family, and Reproductive Health and her M.H.S. from the Department of Biostatistics at the Johns Hopkins Bloomberg School of Public Health. Follow her on Twitter.